Transient Cerebral Vasospasm After Carotid Artery Stenting: A Case Report and Literature Review.

BACKGROUND: Cerebral embolism after carotid artery stenting (CAS) is a well-known complication, but cerebral ischemia owing to cerebral vasospasm after CAS is rare and has seldom been reported. We describe a patient with transient ischemic complications owing to reversible cerebral vasospasm of the middle cerebral artery after CAS. CASE DESCRIPTION: A 74-year-old man presented with right hemiparesis caused by acutely scattered brain infarction in the left cerebral hemisphere. Magnetic resonance angiography showed severe stenosis of the left cervical internal carotid artery origin. CAS under a distal filter protection was performed without any intraprocedural complications, but 12 hours later, the patient had aphasia and Gerstmann syndrome. Urgent magnetic resonance imaging revealed no evidence of an intracranial hemorrhage or new cerebral infarction. However, magnetic resonance angiography showed diffuse vasospasm of the left middle cerebral artery. His symptoms and imaging findings improved gradually with conservative treatment. The patient was discharged without new neurologic deficit or recurrent attack 3 weeks after CAS. CONCLUSIONS: In a patient with delayed neurologic symptoms after CAS, the possibility of cerebral vasospasm should be kept in mind to select appropriate treatment.

Plasma thrombin-cleaved osteopontin elevation after carotid artery stenting in symptomatic ischemic stroke patients.

Atherothrombosis is the primary pathophysiology that underlies ischemic cerebral infarction. Osteopontin (OPN) is produced in atherosclerotic lesions and is cleaved by activated thrombin. We hypothesized that the rupture or damage of an unstable atherosclerotic plaque increases plasma levels of thrombin-cleaved OPN (trOPN). This study included 90 patients who received carotid angioplasty with stenting (CAS), 23 patients with essential hypertension (EHT) and 10 patients who were treated with carotid endarterectomy (CEA). The CAS patient group included 36 patients that had pre- and post-operative blood tests, diffusion-weighted imaging (DWI) using cerebral MRIs and estimated thrombus debris within the protection device. Immunohistochemistry of CEA specimens revealed that trOPN was detected around intra-plaque vessels. The highest tertile of plasma trOPN levels in CAS patients was higher than trOPN levels in EHT patients. Post-operative trOPN levels were significantly higher in symptomatic compared with asymptomatic patients (P=0.003). New ipsilateral DWI-positive patients revealed higher post-operative trOPN levels (P=0.003) and a higher grade of thrombi (P<0.001) than DWI-negative patients. TrOPN may be a novel biomarker that reflects the atherothrombotic status in ischemic stroke.

Cerebrospinal fluid enhancement on fluid attenuated inversion recovery images after carotid artery stenting with neuroprotective balloon occlusions: hemodynamic instability and blood-brain barrier disruption.

PURPOSE: A rare complication of carotid artery stenting (CAS), prolonged reversible neurological symptoms with delayed cerebrospinal fluid (CSF) space enhancement on fluid attenuated inversion recovery (FLAIR) images, is associated with blood-brain barrier (BBB) disruption. We prospectively identified patients who showed CSF space enhancement on FLAIR images. METHODS: Nineteen patients-5 acute-phase and 14 scheduled-underwent 21 CAS procedures. Balloon catheters were navigated across stenoses, angioplasty was performed using a neuroprotective balloon, and stents were placed with after dilation under distal balloon protection. CSF space hyperintensity or obscuration on FLAIR after versus before CAS indicated CSF space enhancement. Correlations with clinical factors were examined. RESULTS: CSF space was enhanced on FLAIR in 12 (57.1%) cases. Postprocedural CSF space enhancement was significantly related to age, stenosis rate, acute-stage procedure, and total occlusion time. All acute-stage CAS patients showed delayed enhancement. Only age was associated with delayed CSF space enhancement in scheduled CAS patients. CONCLUSIONS: Ischemic intolerance for severe carotid artery stenosis and temporary neuroprotective balloon occlusion, causing reperfusion injury, seem to be the main factors that underlie BBB disruption with delayed CSF space enhancement shortly after CAS, rather than sudden poststenting hemodynamic change. Our results suggest that factors related to hemodynamic instability or ischemic intolerance seem to be associated with post-CAS BBB vulnerability. Patients at risk for hemodynamic instability or with ischemic intolerance, which decrease BBB integrity, require careful management to prevent intracranial hemorrhagic and other post-CAS complications.

Probable blood-brain barrier disruption after carotid artery stenting.

A 74-year-old man presented with prolonged reversible neurological deficits caused by internal carotid artery stenosis. He underwent carotid artery stenting (CAS) and developed persistent neurological deficits shortly following the intervention. Delayed gadolinium enhancement of the cerebrospinal fluid space on fluid-attenuated inversion recovery images indicated probable blood-brain barrier (BBB) disruption. Post-procedural perfusion-weighted magnetic resonance images could not demonstrate distinct areas of hyperperfusion or hypoperfusion. The neurological deficits probably resulted from BBB disruption secondary to sudden hemodynamic change occurring during CAS.

[Experience of cerebral angiography using gadolinium for renal insufficiency].

Angiography by means of iodinated contrast material, before endovascular or surgical treatment, may result in serious complications in patients with renal insufficiency or previous anaphylactoid reaction to iodine. Alternative techniques, such as magnetic resonance angiography or carbon dioxide angiography, have their own limitations. We report effectiveness and safety of cerebral angiography using gadolinium for a patient with right vertebral artery and basilar artery occlusion and renal insufficiency. A 66-year-old woman with diabetes under medical treatment suffered loss of consciousness and left hemiparesis following dehydration for 24 hours. She was transferred to our hospital. Emergent MRI suggested brain stem and cerebellar infarction due to vertebral artery occlusion with diffusion-perfusion mismatch. Because of renal insufficiency, the digital subtraction cerebral angiography using gadolinium was performed. Appropriate diagnosis was achieved by angiography using gadolinium of 0.4 mmol/kg. There was no any complication including deterioration of renal function. Gadolinium appears to be a safe and useful intraarterial contrast agent in patients with renal insufficiency.

Severe ocular and orbital toxicity after intracarotid injection of carboplatin for recurrent glioblastomas.

BACKGROUND: Glioblastoma is a malignant tumor that occurs in the cerebrum during adulthood. With current treatment regimens including combined surgery, radiation and chemotherapy, the average life expectancy of the patients is limited to approximately 1 year. Therefore, patients with glioblastoma sometimes have intracarotid injection of carcinostatics added to the treatment regimen. Generally, carboplatin is said to have milder side effects than cisplatin, whose ocular and orbital toxicity are well known. However, we experienced a case of severe ocular and orbital toxicity after intracarotid injection of carboplatin, which is infrequently reported. CASE: A 58-year-old man received an intracarotid injection of carboplatin for recurrent glioblastomas in his left temporal lobe. He complained of pain and visual disturbance in the ipsilateral eye 30 h after the injection. Various ocular symptoms and findings caused by carboplatin toxicity were seen. RESULTS: He was treated with intravenous administration of corticosteroids and glycerin for 6 days after the injection. Although the intraocular pressure elevation caused by secondary acute angle-closure glaucoma decreased and ocular pain diminished, inexorable papilledema and exudative retinal detachment continued for 3 weeks. Finally, 6 weeks later, diffuse chorioretinal atrophy with optic atrophy occurred and the vision in his left eye was lost. CONCLUSION: When performing intracarotid injection of carboplatin, we must be aware of its potentially blinding ocular toxicity. It is recommended that further studies and investigations are undertaken in the effort to minimize such severe side effects.

Intracranial meningeal melanocytoma.

A 59-year-old man presented with a rare intracranial meningeal melanocytoma in the left cerebellopontine angle. The patient underwent partial surgical excision and radiosurgery for successful control of the tumor. Meningeal melanocytoma is an essentially benign melanotic tumor, derived from the melanocytes of the leptomeninges, and may occur anywhere in the cranial and spinal meninges. Preoperative differential diagnosis of intracranial meningeal melanocytoma from malignant melanoma is difficult based on magnetic resonance imaging. Ultrastructural findings are essential to establish the diagnosis. The prognosis of this tumor is not always favorable with occasional local recurrence. Total resection is the best treatment, but gamma knife radiosurgery is effective for the residual tumor following partial resection.

Stent-assisted angioplasty for intracranial atherosclerosis.

We report on two patients with intracranial atherosclerosis of the carotid artery or vertebral artery treated with stent-assisted angioplasty. Both patients have severe intracranial atherosclerosis (>70%) with refractory symptoms despite optimal medical treatment. In both patients, a coronary balloon-expandable stent was successfully placed using a protective balloon technique without procedural complications. The patients were asymptomatic and neurologically intact at a mean clinical follow-up of 13 months. Follow-up angiograms did not show restenosis 3 or 4 months after procedure, respectively. Stent-assisted angioplasty for intracranial atherosclerosis in the elective patient has proven effective, with an acceptable low rate of morbidity and mortality.