Feasibility and effectiveness of palliative intensity-modulated radiotherapy for carotid sinus syndrome secondary to recurrent head and neck cancer.

A 74-year-old man presented with recurrent syncope 3 months after definitive surgery for hypopharyngeal cancer. The patient experienced dizziness and severe hypotension on the movement of the neck and head. CT revealed disease recurrence with masses encasing the left internal carotid artery. The patient was diagnosed with vasodepressor type of tumour-induced carotid sinus syndrome (tiCSS) and was referred for palliative intensity-modulated radiotherapy (IMRT). Ten days after the commencement of IMRT (25 Gy in five fractions), the symptoms of tiCSS improved, and there was no re-exacerbation of the symptoms till the patient died 56 days after the commencement of RT. Palliative IMRT was feasible and effective for recurrent malignant tiCSS. Given the fact that palliative IMRT is minimally invasive, this option could be widely adapted for patients with such poor general condition and prognosis.

Treatment of syncope in tongue cancer with palliative chemotherapy in the intensive care unit: A case report.

RATIONALE: Syncope caused by head and neck cancer (HNC) is rare. However, syncope caused by tongue cancer (TC) is even rarer. In TC, syncope is caused by tumor-mediated compression of the carotid sinus and stimulation of the glossopharyngeal nerve. PATIENT CONCERNS: In this study, we report the case of a 48-year-old male patient who was diagnosed with advanced TC and bilateral cervical lymph node metastasis. On the third day of admission, the patient experienced recurrent syncope with hypotension and bradycardia. DIAGNOSES: The patient was diagnosed with a well-differentiated squamous cell carcinoma of the tongue along with massive cervical lymph node metastasis and carotid sinus syndrome. INTERVENTIONS: Initially, symptomatic treatment of syncope boosted the blood pressure and increased the heart rate. Thereafter, a temporary pacemaker was implanted. Finally, chemotherapy was used to control the tumor and relieve syncope. OUTCOMES: After chemotherapy, the tongue ulcers and cervical lymph node reduced in size; syncope did not recur. LESSONS: This case shows that chemotherapy may be a valid treatment option in patients with cancer-related syncope; however, the choice of chemotherapeutic drugs is critical. Intensive care provides life support to patients and creates opportunities for further treatment.

Carotid Sinus Nerve: A Comprehensive Review of Its Anatomy, Variations, Pathology, and Clinical Applications.

The carotid sinus nerve branches off the glossopharyngeal nerve just after its appearance from the jugular foramen, descends along the internal carotid artery, and enters the carotid sinus. There have been many studies of the pathway and the course of the carotid sinus nerve and its communications with surrounding nerves. The intercommunication is exceedingly complicated. Acknowledgment of its anatomic diversity can be important in specific operations dealing with this area. Herein we review the anatomy, variations, pathology, and clinical applications of the carotid sinus nerve.

Biomechanical Aspects of Closing Approaches in Postcarotid Endarterectomy.

The carotid bifurcation tends to develop atherosclerotic stenoses which might interfere with cerebral blood supply. In cases of arterial blockage, the common clinical solution is to remove the plaque via carotid endarterectomy (CEA) surgery. Artery closure after surgery using primary closures along the cutting edge might lead to artery narrowing and restrict blood flow. An alternative approach is patch angioplasty which takes longer time and leads to more during-surgery complications. The present study uses numerical methods with fluid-structure interaction (FSI) to explore and compare the two solutions in terms of hemodynamics and stress and strain fields developed in the artery wall.

Fast Von Mises strain imaging on ultrasound carotid vessel wall by flow driven diffusion method.

The elasticity of the vessel wall is important for the clinical identification of rupture-risks. The Von Mises strain can be a potential index for the indication of carotid vessel pathologies. In this paper, a fast clinically applicable real-time algorithm from time-sequence of B-mode carotid images is developed. Due to the compression induced by the normal cardiac pulsation, tissue motion occurs radially and non-rigidly. To obtain an accurate motion field, we developed a variational functional integrating the optical flow equation and an anisotropic regularizer, and designed a diffusion tensor to encourage coherence diffusion. The motion field is smoothed along the desired motion flow orientation. A fast, additive operator splitting scheme, which is ten times faster than the conventional discrete method, is used for the numerical implementation. To demonstrate the efficiency of the proposed approach, finite element models are set up for normal and pathological carotid vessel walls. The results indicate that the proposed diffusion approach obtains an accurate smooth and continuous motion field and greatly improves the follow up strain estimation using a fast differential strain filter. Furthermore, our approach using the Von Mises strain imaging on clinical ultrasound images of the carotid artery is validated. Participants above 65-years in age suffering from different stages of atherosclerosis in their carotid artery are selected. The results are evaluated by an experienced physician. The evaluation results demonstrate that the Von Mises strain has a good correspondence to the presence of certain suspicious areas in the B-mode images. The proposed method is therefore clinically applicable for the real-time Von Mises strain imaging of carotid vessel walls, and can be of great value as a complementary method to B-mode image for the clinical identification of the risk of plaque vulnerability.

Serum atrial natriuretic peptide (ANP) as an objective indicator for the diagnosis of neurogenic shock: animal experiment and human case report.

In forensic medicine, the diagnosis of death due to neurogenic shock is considered to be an aporia, as lacking objective indicators and presenting atypical symptoms in autopsy. Medico-legal disputes and complaints occasionally result from this ambiguity. To explore potential objective indicators of neurogenic shock, we set up a model of neurogenic shock by applying an external mechanical force on the carotid sinus baroreceptor in rabbits. The serum atrial natriuretic peptide (ANP) level was measured by radioimmunoassay in the control group (n = 8), survival group (n = 15) and death group (n = 5) both before and after the insult. The serum ANP level showed a significant increase after the insult in the death group compared with the serum obtained before the insult (P = 0.006), while the serum ANP level after the insult in the survival group and control group was not statistically significant compared with the serum obtained before the insult (P = 0.332 and P = 0.492, respectively). To verify the repeatability of the model and the postmortem behavior of serum ANP, five healthy adult rabbits underwent the same procedure as the experimental group. The mortality rate was consistent with the former experiment (20 %). There were no significant changes in serum ANP level in vitro and in vivo (within 48 and 24 h, respectively). But there was a significant decrease in serum ANP level at 48 h postmortem in vivo (P = 0.001). A female patient who expired due to neurogenic shock during a hysteroscopy was reported. Neither fatal primary disease nor evidence for mechanical injuries or intoxication was found according to the autopsy. The serum ANP level was assayed as a supplementary indicator and was found to be three-fold higher than the normal maximum limit. Combined with the animal experiment, this case highlights that serum ANP has the potential to be an objective indicator for the diagnosis of death due to neurogenic shock.

Carotid baroreceptor stimulation blood pressure response mapped in patients undergoing carotid endarterectomy (C-Map study).

OBJECTIVE: Continuous stimulation of the carotid baroreceptors has been shown to evoke a sustained systolic blood pressure (SBP) reduction in hypertensive subjects. This study conducted a detailed mapping of the SBP and heart rate response to electrical stimulus at different locations in the carotid sinus region in patients undergoing a carotid endarterectomy (CEA). METHODS: The Carotid Sinus Autonomic Response Mapping (C-Map) Study is a multicenter, prospective, non-randomized, acute feasibility study conducted in 10 hypertensive subjects undergoing CEA. Electrode pairs were placed in multiple locations in the region of the carotid sinus for acute stimulation, and the tests were repeated after plaque removal and vessel repair. RESULTS: The configuration that elicited the largest pressure reduction in 8 of 10 patients was with the electrodes arranged longitudinally along the medial (in relation to the bifurcation) wall of the internal carotid artery (ICA) near the bifurcation (11.2±8.1mmHg, p<0.05). There was no difference in average maximum response pre vs. post plaque removal. Spontaneous baroreflex sensitivity increased from 6.0±3.2ms/mmHg pre-CEA to 8.2±5.4ms/mmHg post-CEA (p=0.040). CONCLUSIONS: Endarterectomy surgery did not affect maximal acute stimulation response but improved baroreflex sensitivity acutely. Acute extravascular baroreceptor stimulation (BRS) mapping demonstrated that blood pressure reductions are dependent on electrode location and orientation. In most subjects, the largest SBP reductions were elicited in the region of the medial wall of the ICA. This area can be targeted for future BRS lead design and implant.

Three-dimensional imaging MS of lipids in atherosclerotic plaques: Open-source methods for reconstruction and analysis.

Three-dimensional MALDI imaging MS (IMS) is a growing branch of IMS still requiring developments in methodology and technology to make the technique routinely accessible. Many challenges are simply a matter of producing 3D reconstructions and interpreting them in a timely fashion. In this aim and using analysis of lipids from atherosclerotic plaques from a human carotid and mouse aortic sinuses, we describe 3D reconstruction methods using open-source software that provides high-quality visualization and rapid interpretation through multivariate segmentation of the 3D IMS data. Multiple datasets were generated for each sample and we provide insight into simple means to correlate the separate datasets.

Fístula carótido-cavernosa tratada con compresiones carotídeas / Carotid-cavernous fistula successfully treated with carotid compression

No disponible

Asistolia por compresión del seno carotídeo: una complicación potencialmente fatal de la parotiditis vírica / Asytolia due to compression of the carotid sinus: a potentially fatal complication of viral parotiditis

La parotiditis es una enfermedad vírica aguda, caracterizada por fiebre e hinchazón dolorosa de una o más glándulas salivales, generalmente la parótida, aunque pueden afectarse las glándulas submaxilares y sublinguales. El cuadro clínico inicial es inespecífico, aunque en las primeras 24 h suelen aparecer otalgia y sensibilidad dolorosa en la parótida. Además, pueden aparecer complicaciones a nivel extraglandular, sobre todo a nivel neurológico, testicular, pancreático, articular y cardíaco. Entre estas últimas, las más frecuentes son los cambios electrocardiográficos. También está ampliamente descrita la miocarditis vírica. Presentamos una rara complicación, no descrita en la literatura, de asistolias recurrentes provocadas por la compresión del seno carotídeo, debido a la inflamación local producida por la parotiditis (AU)

Mumps is an acute viral disease, characterized by fever and painful swelling of one or more salivary glands, usually the parotid, and sometimes the sublingual or submandibular glands. The initial clinical picture is non-specific, but during the first 24 h there is otalgia and tenderness in the parotid gland. Apart from the involvement of the salivary glands, neurological, testicular, pancreatic, joint, or cardiac complications may occur. Among the latter, the most frequent are the electrocardiographic changes. Viral myocarditis has also been widely reported. We report a rare complication, not yet described in the literature, of recurrent asytolia produced by compression of the carotid sinus as a result of local inflammation caused by mumps (AU)

Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity.

BACKGROUND: Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity. METHODS: Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG. RESULTS: Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls. CONCLUSIONS: Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity.

Empty fenestration of the internal jugular vein: a rare phenomenon.

Though there are common variations of the internal jugular vein (IJV), fenestrations are extremely rare. The lateral branch of the accessory nerve classically goes through the fenestration. We report a case of an empty fenestration of the IJV that was discovered during clearance of cervical lymph nodes. Original operative and radiographic images are shown.

Carotid-bulb atypical fibromuscular dysplasia in young Afro-Caribbean patients with stroke.

BACKGROUND AND PURPOSE: An atypical form of fibromuscular dysplasia located in the internal carotid-bulb (CaFMD) is thought to be uncommon and is poorly described as a cause of ischemic stroke in the young. This study aimed to obtain a better description of CaFMD in Afro-Caribbean population, who could be particularly affected by it. METHODS: This study included consecutive patients <55 years consulting at Fort-de-France University Hospital Stroke Center (Martinique, FWI) found to have CaFMD as the only cause after a comprehensive work-up. CaFMD was diagnosed when computed tomographic angiography showed a bulbar spur without calcification. RESULTS: Twenty-five patients with stroke and CaFMD were identified. Computed tomographic angiography showed 2 CaFMD patterns: a thin (n=15) or thick (n=10) spur. Three patients initial computed tomographic angiography images showed a mural thrombus overlying the CaFMD. CaFMD was surgically removed from 7 of 25 and 20 of 25 patients who received antiplatelet therapy; after mean follow-up of 25.3±19.5 months, their respective recurrence rates were 0% and 30%. CONCLUSIONS: CaFMD could be a common condition in young Afro-Caribbeans with carotid-territory ischemic stroke. Recurrences were frequent under antiplatelet treatment, while surgical CaFMD removal seemed more effective.

Transphenoidal surgery in acromegalic patients: anatomical considerations and potential pitfalls.

BACKGROUND: Transphenoidal surgery is an effective treatment for acromegalic patients with growth hormone (GH) producing pituitary adenomas. Since acromegaly is a systemic disease which causes multiple bony alterations, we hypothesized that it could affect the sphenoid sinus anatomy. The aim of the study was to determine whether acromegalic patients have sphenoid sinus alterations with potential surgical impact. METHODS: Fourty-six consecutive patients (23 acromegalics-GH group, 23 non-acromegalics-nGH group) undergoing transphenoidal surgery were included in this study. Pre-operative volumetric CT scan of the head was used to assess the following anatomic characteristics: type of sphenoid sinus (sellar, pre-sellar, conchal); number of intrasphenoid septa; number of carotid-directed septa; intercarotid distance; depth of the sphenoid sinus; depth and size of the sella. RESULTS: The sphenoid sinus was of the pre-sellar/conchal type in 26 % of the patients with acromegaly (n = 23) versus 9 % of the patients of the nGH group (n = 23). The number of intrasphenoid septations was significantly higher in the GH group than in the nGH group (P = .03). Interestingly, the intercarotid distance was smaller in GH patients than in nGH displaying a trend toward significance (P = .05). The sphenoid bone was deeper in the GH group as compared to the nGH group (P = .01) but the distance sphenoid sinus-sella was reduced (P < .01). Finally, the sella was not deeper, nor larger in acromegalic patients. CONCLUSIONS: The sphenoid sinus of acromegalic patients resulted in being deeper, characterized by more septa and by a reduced intercarotid distance. These alterations deserve special pre- and intraoperative care, being potentially responsible for surgical difficulties.

Does bilateral transverse cerebral venous sinus stenosis exist in patients without increased intracranial pressure?

OBJECTIVE: Transverse cerebral venous sinus stenosis (TSS) is common among patients with idiopathic intracranial hypertension. TSS likely also exists among individuals with normal intracranial pressure (ICP) but the prevalence is unclear. The goal of this study was to identify patients with incidental TSS and normal ICP and describe their characteristics. METHODS: Among 240 adult patients who underwent brain magnetic resonance imaging (MRI) with magnetic resonance venography (MRV) with contrast at our institution between September 2009 and September 2011, 44 had isolated TSS without further substantial imaging abnormality. Medical records were reviewed for symptoms of increased ICP, papilledema, cerebrospinal fluid (CSF) constituents and opening pressure (OP), and reason for brain imaging. Of these, 37 were excluded for confirmed or possible idiopathic intracranial hypertension. Of the remainder, 5 had CSF-OP≤25 cmH2O without papilledema, and 2 did not have measured ICP, but had no papilledema or symptoms of increased ICP. Imaging was re-interpreted to assess for signs suggestive of elevated ICP and to characterize the TSS further. RESULTS: All patients were women (mean age: 41, mean BMI: 37.1). CSF contents were normal, but OPs were at the upper limit of normal (22-25 cmH2O). Indications for MRI/MRV included query pituitary abnormality (1), migraine (4), and anomalous-appearing optic nerves (2). All had bilateral TSS. Six had short TSS and an empty sella; 1 had long TSS and no empty sella; 1 had flattening of the posterior sclera; 2 had prominence of peri-optic nerve CSF. CONCLUSION: Asymptomatic bilateral TSS exists in patients with ICP≤25 cmH2O, but is likely uncommon. CSF-OP was at the upper limit of normal in our patients, who also had other radiologic signs suggestive (but not specific) of chronically-raised ICP. Findings of bilateral TSS on imaging should prompt funduscopic examination for papilledema.

Carotid sinus syndrome as the presenting symptom of cystadenolymphoma.

Carotid sinus syndrome is a serious manifestation of head and neck malignancy. The purpose of this study was to clarify the presence of carotid sinus syndrome in a patient with cystadenolymphoma. To our knowledge carotid sinus syndrome secondary to cystadenolymphoma has not been reported to date. A 45-year-old woman with one-week-old swelling in the left mandibular angle having disturbing symptoms of vertigo, consciousness and sinus arrest. Holter monitoring revealed several episodes of sinus arrest. Ultrasonography showed a well-defined space-occupying lesion of about 31 mm in length and 17 mm in width located in the deep lobe of the left parotid gland. Computerized tomography (CT) showed a large mass extending into the carotid space and protruding into the parapharyngeal space. Parotidectomy was performed. Surgical removal of the tumor resulted in complete amelioration of symptoms and disappearance of electrocardiogram abnormalities. Here we report on a clinical case of carotid sinus syndrome associated with cystadenolymphoma. To our knowledge carotid sinus syndrome secondary to cystadenolymphoma has not been reported to date, and is made more remarkable as a possible differential diagnosis after clarification of all possible causes. Early diagnosis and immediate management can minimize complications.

Helical flow in carotid bifurcation as surrogate marker of exposure to disturbed shear.

The main purpose of the study is to verify if helical flow might be a surrogate marker of the exposure to disturbed shear in normal carotid bifurcations. Based on hemodynamic simulations data of 50 carotid bifurcations, we defined appropriate helicity-based bulk flow descriptors and multivariate linear regression analysis was performed to assess the potential for a combination of helicity-based indicators in describing the exposure to disturbed shear. To select the optimal combination of helicity-based descriptors in the regression model, the Akaike information criterion was applied. The identified statistical model is composed of two bulk flow descriptors proposed here to quantify helicity intensity and the balance between counter-rotating helical flow patterns in the flow field. The model revealed the existence of a significant relationship with adjusted squared Pearson's correlation coefficient in the range 0.4-0.7 (P<0.0001). In detail, while a high helicity intensity is instrumental in suppressing flow disturbances, this protective effect could be moderated when one direction of rotation is dominant in the flow field. The in vivo quantification of the bulk flow features emerging in this study would offer a practical way to infer the presence of disturbed shear in large-scale in vivo studies of local risk factors in atherosclerosis.

Histological examination of the carotid bifurcation in case of violence against the neck.

The carotid body and carotid sinus are localized in the area of the carotid bifurcation and respond to pressure fluctuations in the arterial blood vessel system. In case of irritation or stimulation, nervous impulses can reflexively increase the ventilation or slow down the heart rate and blood pressure, respectively. The external stimulation of the carotid sinus by neck compression with subsequent bradycardia or asystolia, especially in pre-existing heart-disease, is discussed controversially in the literature. Histological examination of the tissue of the carotid bifurcation, particularly with regard to haemorrhage as an indication of tissue trauma, should be carried out in terms of simple and easy feasibility in routine diagnostics. In 20 cases of violence against the neck and additionally 82 cases of a control group without neck trauma and variable causes of death, the carotid bifurcations were examined histologically. Only in one case of violence against the neck haemorrhage was found, which suggested a direct trauma to the tissue of the carotid bifurcation, but evidence of lethal cardiac reflex was not found in any case.

[Permanent cardiac pacing in vasovagal syncope and carotid sinus syndrome].

Vasovagal syncope and carotid sinus syndrome are common conditions in young and elderly people, respectively, mostly with benign prognosis. Nevertheless, severe or "malignant" syncopal attacks in some patients may be associated with life-threatening injury. Unfortunately, up to now almost all drug trials have failed to demonstrate any benefit in preventing syncope and interventional approach (pacemaker) may be appropriate. This article contains literature review and discussion of indications for pacing in vasovagal syncope and carotid sinus syndrome.