Immediate and 90-Day Clinical Outcome of Patients with Acute Stroke Treated with the NeVa-Vesalio Mechanical Thrombectomy Device: A Retrospective Case Series.

OBJECTIVE: The NeVa stent retriever is a newly designed mechanical thrombectomy device for the treatment of acute ischemic stroke caused by large vessel occlusion. We investigate the procedural characteristics and patients' clinical outcomes at discharge and at 90 days of follow-up. METHODS: We retrospectively reviewed a cohort of 75 patients (median age, 74 years) treated with the NeVa device for acute large vessel occlusion stroke. Per pass modified Treatment in Cerebral Infarction (mTICI) scores, procedural complications, and clinical outcome parameters including the National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin Scale (mRS) score, and mortality were analyzed, based on patients' electronic medical records. RESULTS: Complete first pass effect was observed in 24 patients (32%). Vasospasm, repeated re-thrombosis, failure to advance the NeVa device through the microcatheter, and symptomatic intracranial hemorrhage were observed in 2, 1, 1, and 2 patient(s) respectively. The rate of complete (mTICI 2c-3) reperfusion was achieved in 61 patients (81.33%), with a median number of 2 passes (1-3). Median NIHSS score on admission, after 24 hours, and after 5-10 days or at discharge was 19 (15-23), 11 (4-19), and 3 (2-13.5), respectively. The number of patients with a functional mRS score (0-2) at 90 days follow-up was 29 (39%). CONCLUSIONS: Endovascular stroke management with use of the NeVa-Vesalio stent retriever may be associated with a 90-day functional mRS score in nearly 40% of treated patients.

Alternate Simultaneous Bilateral Carotid Angiography in Y-stent-Assisted Coil Embolization for an Anterior Communicating Artery Aneurysm with Triplicate A2 Variant.

The triplicate A2 variant is one of several common anomalies of the anterior cerebral artery. An anterior communicating artery aneurysm with triplicate A2 variant in close proximity to the aneurysm neck is challenging to treat due to potential unilateral/bilateral corpus callosum or parietal lobe infarction. Alternate simultaneous bilateral carotid angiography can differentiate triplicate A2 branches through time-difference alternate injection of contrast into the carotid arteries bilaterally, which can enhance anatomic understanding of complex anterior communicating artery aneurysms during complex endovascular treatment. In this case, a complex aneurysm with an associated triplicate A2 variant was treated successfully with Y-stent-assisted coil embolization using alternate simultaneous bilateral carotid angiography.

Giant Cell Tumor of the Carotid Body: A Rare Tumor with Malignant Potential.

Introduction: Carotid body tumors (CBTs) are certainly unusual. They are vascular lesions originating from paraganglionic cells, located at the common carotid artery (CCA) bifurcation. They represent less than 0.5% of head and neck tumors, approximately 1-3 cases per million. Malignant CBTs are extremely rare; in the literature, published rates on average are < 10%. The diagnostic criteria for malignancy should be based on the finding of distant metastasis. Due to its unpredictable nature and its malignant potential, diagnosis before metastasis and complete surgical resection are the keys to a favorable prognosis. Case Report: Given little experience in CBTs, its biology and treatment remain uncertain. We present the case of a 48-years-old patient, with a mass on the left side of the neck that was found to be a vast CBT with suspicious histopathology. Its size, rare location, pathologic findings, and management strategy applied for its treatment, illustrate an unusual case that highlights the importance of its publication. Conclusions: CBT is rare, but subject to cure lesion if resected without metastatic or residual disease. This is why surgery should be performed whenever possible and why it is so necessary to study this pathology thoroughly and to take it into account in the differential diagnosis.

Relationship of the Low-Density Lipoprotein Cholesterol/High-Density Lipoprotein Cholesterol Ratio with a Vulnerable Plaque in Patients with Severe Carotid Artery Stenosis: A Case-Control Study in the Han Chinese Population.

BACKGROUND: Carotid plaque is often an important factor in ischemic stroke after it changes from stable to vulnerable, and low-density lipoprotein cholesterol (LDL-c) and high-density lipoprotein cholesterol (HDL-c) are associated with plaque vulnerability. We aimed to investigate whether the LDL-c/HDL-c ratio, an easily available and novel biomarker, is associated with vulnerable plaques and enhances the warning effect on vulnerability compared to LDL-c or HDL-c alone. METHODS: We conducted a retrospective study of 187 patients with severe CAS admitted to the Department of Vascular Surgery at the Nanjing Drum Tower Hospital from January 2019 to July 2021. They were divided into a stable plaque group and a vulnerable plaque group according to carotid ultrasonography, carotid angiography (CTA), and plaque pathology. Baseline information was collected and compared between the two groups. Correlation analysis was used to determine the degree of correlation between clinical variables. Univariate and multifactor logistic regression analyses were used to examine independent risk factors for vulnerable plaque in patients with severe CAS. Receiver operating characteristic (ROC) curves were used to assess the capacity of LDL-c/HDL-c to predict the occurrence of vulnerable plaque. RESULTS: The age of the vulnerable plaque group was 68.12 ± 8.90 years, with 85 males (89.91%); the age of the stable plaque group was 68.77 ± 8.43 years, with 70 males (89.74%). Multivariate logistic regression analysis showed that LDL-c/HDL-c, smoking and diabetes were independent risk factors for vulnerable plaque (all P <0.05). The risk of vulnerable plaque was 4.78-fold greater in the highest LDL-c/HDL-c quartile (≥ 2.63) than in the lowest quartile (≤ 1.31) (P-trend <0.001), and the area under the ROC curve for LDL-c/HDL-c (AUC=0.681, P <0.001) was higher than that for LDL-c and HDL-c. CONCLUSION: LDL-c/HDL-c, smoking and diabetes were independent risk factors for vulnerable plaque in patients with severe CAS, and LDL-c/HDL-c had a higher predictive value for the presence of vulnerable plaque compared with other lipid parameters.

Preprocedural Carotid Plaque Echolucency as a Predictor of In-Stent Intimal Restenosis after Carotid Artery Stenting.

OBJECTIVES: In-stent intimal restenosis (ISR) caused by neointimal hyperplasia can develop <24 months after carotid artery stenting (CAS). The utility of plaque imaging by carotid ultrasonography (US) or magnetic resonance imaging (MRI) has been investigated for the prediction of ipsilateral stroke. We aimed to investigate whether these imaging techniques are useful for detecting carotid plaques prone to ISR. MATERIALS AND METHODS: We examined 133 patients (mean age of 72.1 ± 8.4 years old) that received CAS at a single hospital from 2014 to 2018. A pre-CAS carotid plaque evaluation was performed by carotid angiography, duplex carotid US, and black-blood carotid artery MRI (BB-MRI). The mean stenosis rate was 71.0 ± 12.3% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methods. Follow-up carotid angiography was performed 6 months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosed based on the NASCET criteria. The selection of the stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis. RESULTS: Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than two stents were deployed. Univariate logistic regression analyses demonstrated echolucent lesion, floating plaque, complete occlusive or pseudo-occlusive lesion, and closed-cell stent use as significantly associated with ISR (>50%). Multivariate logistic regression analysis demonstrated that echolucent lesion (OR 4.667, 95% CI 1.849-11.779) and closed-cell stent use (OR .378, 95% CI .148-.968) were significantly associated with ISR. CONCLUSIONS: Preprocedural plaque characterization by carotid US appeared to be useful to predict ISR 6 months after CAS.

Are systolic velocity duplex metrics negatively affected by flow aliasing in areas of critical internal carotid artery stenosis.

Purpose: Duplex scanning is a useful noninvasive screening tool for the detection of carotid bifurcation disease. Internal carotid artery (ICA) peak systolic velocity (PSV) and ICA/common carotid artery (CCA) PSV ratios are proven metrics determining 70%-99% ICA stenosis. A potential disadvantage of using dramatically increasing systolic velocity measurements in areas of critical arterial stenosis is flow aliasing. Diastolic velocity should be less influenced by this flow artifact. We evaluate ICA and CCA end diastolic velocity (EDV) metrics in predicting severe ICA stenosis and document the prevalence of an aliasing artifact in a population of patients with critical ICA stenosis. Methods: Consecutive patients undergoing carotid duplex assessments and contrast angiography were compared (n = 140). ICA and CCA PSV and EDV were recorded as was evidence of the flow aliasing of ICA waveforms. ICA/CCA PSV and EDV ratios were calculated. Duplex parameters were compared with angiographic ICA measurements. Receiver-operator characteristic curve (ROC) analysis was used to determine optimal criteria to identify ICA stenosis of 70% to 99%. Results: Of 256 carotid bifurcation duplex studies, critical angiographic stenosis was present in 105 arteries. Only four completed arterial duplex scans demonstrated flow aliasing. In three of these patients, systolic metrics were non-diagnostic versus ICA/CCA EDV ratios. An ICA/CCA EDV ratio of 2.3 provided the best combination of sensitivity 73.8% and specificity 75.18%. Conclusion: ICA/CCA diastolic ratios reliably determine 70% or greater ICA stenosis. Flow aliasing infrequently complicates ICA PSV.

The Ratio of Fibrinogen to Albumin as a Predictor of Contrast-Induced Nephropathy After Carotid Angiography.

Contrast-induced nephropathy (CIN) is acute kidney failure that occurs after exposure to contrast agent. There is no sensitive biomarker to predict the development of CIN. In a retrospective study, we investigated the predictive value of the fibrinogen to albumin ratio (FAR) to determine the risk of CIN in patients (N = 246) who underwent carotid angiography. Contrast-induced nephropathy was defined as a 0.5 mg/dL or 25% increase in serum creatinine levels 48 to 72 hours following exposure to a radiocontrast agent. Patients were grouped according to whether they developed CIN or not, that is, CIN(-) and CIN(+) groups, respectively. Contrast-induced nephropathy developed in 39 (15.8%) of all the patients. The fibrinogen levels, neutrophil to lymphocyte ratio (NLR), and FAR in the CIN (+) group were higher than in the CIN (-) group ( P < .001). Multivariate analysis showed that age, diabetes, NLR, platelet-lymphocyte ratio, and FAR were independent risk factors for CIN. The area under the curve (AUC) of FAR was 0.800 for the prediction of CIN, and the best cutoff value was 57.4 with sensitivity, specificity, positive predictive value, and negative predictive value of 74.4%, 60.8%, 26.4%, and 92.7%, respectively. The FAR may be useful as a predictor of CIN.

Incidental pulmonary embolism in suspected stroke patients undergoing carotid CT angiography.

PURPOSE: The purpose of this study was to investigate the prevalence of incidental pulmonary embolism (IPE) in suspected stroke patients receiving carotid computed tomography angiography (CTA) and its characteristics. MATERIALS AND METHODS: A total of 4873 cases receiving carotid CTA between January 2013 and December 2016 were retrospectively reassessed by one radiologist. Patients with previous or suspected PE were excluded. The remaining prior contrast-enhanced carotid CTA studies were regarded as a "potentially incidental" IPE when a filling defect was found in one or more pulmonary arteries and subjected to the other two thoracic radiologists independently for reviewing and assessing for characteristics of the IPE and the image quality of the PE. The differences were noted between inpatients and outpatients in prevalence of IPE. Characteristics of the patients with IPE were also studied in terms of gender, age, as well as clinical indication. RESULTS: The prevalence of IPE among these suspected stroke patients was 0.8% on carotid CT angiography, and 24 (96%) of all IPEs had not been previously diagnosed by the original reporting radiologists. Most of the IPEs were at the lobar or segmental levels, single and in right upper lobe of pulmonary arteries. In most of the cases, the reviewing radiologists judged the contrast bolus as good. The outpatient group had a lower percentage of patients with IPE when compared with the inpatient counterpart (p = 0.024). The prevalence of IPE in patients with suspected stroke was higher with the increasing of age (p = 0.013). CONCLUSIONS: IPE can occur in suspected stroke patients on carotid CT angiography, and most of them have been previously neglected in clinical practice. Radiologists should check the higher pulmonary arterial vasculature carefully on the contrast-enhanced carotid CTA scans.

Usefulness of contralateral carotid angiography in revascularization therapy of acute internal carotid artery occlusion.

OBJECTIVE The vascular lumen of an acutely occluded internal carotid artery (ICA) generally contains numerous thrombi. Therefore, carotid angiography on the affected side during revascularization therapy of acute ICA occlusion has a potential risk of causing distal embolization. In this study the authors propose the use of contralateral carotid angiography. METHODS Six patients with acute ICA occlusion underwent revascularization therapy using a stent retriever or Penumbra system. Revascularization therapy was performed with placement of a 9-Fr balloon-guiding catheter (BGC) in the affected ICA and a 4-Fr diagnostic catheter in the contralateral ICA. During the procedure, the 9-Fr BGC was kept inflated, and all control angiography was performed from the 4-Fr diagnostic catheter. After thrombectomy, contralateral carotid angiography combined with manual aspiration from the 9-Fr BGC was performed to assess the presence or absence of residual thrombi in the affected ICA. The 9-Fr BGC was deflated only after the complete absence of residual thrombi in the affected ICA was confirmed. RESULTS The time required for introducing the 4-Fr diagnostic catheter into the contralateral ICA was within a few minutes in all patients. Residual thrombi in the affected ICA were found in 3 of 6 patients. The residual thrombi in these 3 patients were completely removed; thus, distal embolization was prevented. CONCLUSIONS Contralateral carotid angiography is useful for avoiding distal embolization during revascularization therapy of acute ICA occlusion. Further studies involving a larger number of patients are warranted to verify the clinical efficacy of this contralateral carotid angiography.

Effectiveness of a handmade "New Carotid Catheter" in transradial carotid angiography: A comparison with conventional multipurpose catheters.

OBJECTIVE: The incidence and severity of carotid atherosclerosis increases in proportion with coronary artery disease and its severity. A special catheter specifically used for transradial carotid angiography has not yet been marketed. In this study, we investigate the feasibility and safety of our carotid catheter, which was made by reshaping currently available catheters. METHODS: Between 2010 and 2017, a total of 921 patients with indications for carotid angiography were identified after angiographic examinations and included in the study. Carotid angiography was performed in 403 patients (female, n = 161) using the 3.5 JL catheter, while in 518 (female, n = 207) patients, new catheters were employed. The new catheter was shaped like a hook in the laboratory with a heat gun. Demographic information and angiographic data from the patients in both groups were retrospectively analyzed. RESULTS: The baseline characteristics of both groups were comparable. When compared with the use of a 3.5 JL catheter, right transradial carotid angiographies performed with our new handmade catheter resulted in lesser amounts of opaque material used (55 mL vs 66 mL, P < 0.001) and shorter total fluoroscopy time, (3.60 ± 1.85 min vs 3.14 ± 1.55 min, P < 0.001). The handmade catheter also resulted in a higher success rate of selective visualization (97% vs 40%, P < 0.001). Rates of minor complication were comparable between the two catheters (6.5% vs 6.6% P = 234). Neither permanent damage nor morbidity or mortality was observed in either arm. DISCUSSION: Currently available catheters and methods are inadequate for routine transradial carotid angiography. For routine transradial carotid angiography, innovatively designed catheters are required. The catheter we developed for transradial carotid angiography was more successful than the conventional catheter in obtaining satisfactory images. High quality images can be obtained with the newly designed catheters. CONCLUSION: Transradial carotid angiography can be performed using our newly developed carotid catheter. The carotid arteries of patients with widespread coronary artery disease can be visualized, while asymptomatic patients carrying a high risk of stroke can be treated, preventing potential stroke occurrence. In a larger-scale comparative study, the favorable contributions of routine use of the new method and a decreased frequency of stroke may be demonstrated.

Automatic detection of carotid arteries in computed tomography angiography: a proof of concept protocol.

Atherosclerosis is one of the leading causes of mortality in the western world. Computed tomography angiography (CTA) is the conventional imaging method used for pre-surgery assessment of the blood flow within the carotid vessel. In this paper, we present a proof of concept of a novel, fast and operator independent protocol for the automatic detection (seeding) of the carotid arteries in CTA in the thorax and upper neck region. The dataset is composed of 14 patients' CTA images of the neck region. The performance of this method is compared with manual seeding by four trained operators. Inter-operator variation is also assessed based on the dataset. The minimum, average and maximum coefficient of variation among the operators was (0, 2, 5 %), respectively. The performance of our method is comparable with the state of the art alternative, presenting a detection rate of 75 and 71 % for the lowest and uppermost image levels, respectively. The mean processing time is 167 s per patient versus 386 s for manual seeding. There are no significant differences between the manual and automatic seed positions in the volumes (p = 0.29). A fast, operator independent protocol was developed for the automatic detection of carotid arteries in CTA. The results are encouraging and provide the basis for the creation of automatic detection and analysis tools for carotid arteries.

Retinal Arterial Obstruction-still Remains an Enigma.

Retinal artery obstruction is an ocular emergency which usually carries a poor visual prognosis. Restoration of fruitful vision depends on the underlying cause and the immediate start of treatment. However, none of the known treatment modalities, have so far, assured positive results consistently. Retinal artery obstructions are forewarners of possible systemic emboli/infarcts. Thus, it is imperative for ophthalmologists to identify the disease and get a thorough systemic examination done, preferably by a cardiologist, so as to prevent serious systemic morbidity. It is to be noted that in our case report, in spite of having delayed presentations, both the patients were subjected to thorough cardiovascular examinations. In clinical practice, patients are not further investigated, once the chances of visual recovery are bleak. Our case report highlights the importance of subjecting these patients to complete cardiovascular work ups, even though a poor visual recovery is expected, which can lead to detection of various cerebrovascular infarcts.

Flow-diversion headaches in a patient with high-grade internal carotid artery stenosis.

BACKGROUND: High-grade stenosis of the internal carotid artery (ICA) may result in flow diversion to the external carotid artery (ECA) and its branches. Head and facial pain secondary to flow-diversion to ECA and increase in regional blood flow are under-recognized and unreported. DESIGN/METHODS: We report a patient with high-grade ICA stenosis and recurrent ipsilateral headaches that resolved after revascularization. RESULTS: A 69-year-old woman presenting with right-arm weakness had neuroimaging evidence of ipsilateral high-grade ICA stenosis and left hemispheric ischemic stroke. Her history was significant for unilateral recurrent headaches that clinically resolved after left ICA angioplasty and stenting. With prior evidence supporting extracranial vasodilatation as the source of pain in migraine, and current clinical observation, we propose flow-diversion phenomenon as the connection between high-grade ICA stenosis and ipsilateral headache. CONCLUSION: Recognition of flow-diversion into the ECA as a possible mechanism for headaches may help in further understanding of ICA disease, its progression, and the effects of carotid revascularization on quality of life. Headache as a likely surrogate marker of carotid stenosis with flow-diversion warrants more research, and may be critical in the early identification of significant ICA stenosis and prevention of TIA or stroke.

Skin to Skin: Transradial Carotid Angiography and Stenting.

Carotid artery stenting (CAS) is a proven alternative to carotid endarterectomy in patients with significant carotid disease. The femoral artery is the conventional access site for CAS procedures. However, this approach may be problematic because of peripheral vascular disease and anatomic variations. Access site complications are the most common adverse event after CAS from the transfemoral approach (TFA) and most technical failures are related to a complex aortic arch. The transradial approach has been evaluated to address the shortcomings of TFA. In cases involving a complex arch, transradial access may be a viable alternative strategy.

Skin to Skin: Transfemoral Carotid Angiography and Stenting.

Carotid artery stenting (CAS) has emerged as an attractive alternative to carotid endarterectomy (CEA) for the treatment of carotid artery disease. Several recent trials demonstrate excellent and improving results, even at high risk in CEA patients. Randomized North American trials suggest equivalence of CAS to CEA in high-risk and standard-risk patients. However, these improved CAS results apply only to CAS procedures performed by experienced operators at experienced centers. Furthermore, these improved results are due largely to operators' lessons learned, helping with appropriate case selection.

Concordancia diagnóstica de la angiorresonancia y la angiografía carotídea en los aneurismas cerebrales / Diagnostic agreement of the angiographic resonance and the carotid angiography in the cerebral aneurysms

Se describen 3 casos clínicos de pacientes ingresados en el Hospital General Docente Dr Juan Bruno Zayas Alfonso de Santiago de Cuba por sospecharse la presencia de aneurismas cerebrales, teniendo en cuenta las manifestaciones neurológicas que presentaban. Mediante los estudios de resonancia magnética y angiorresonancia realizados, se observaron las imágenes de la lesión vascular, las cuales fueron confirmadas por angiografía carotídea

Three clinical cases of patients admitted in Dr Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba due to the suspicious presence of cerebral aneurysms are described, keeping in mind the neurological manifestations they presented. By means of the studies of magnetic resonance and angiographic resonance carried out, the images of the vascular lesion were observed, which were confirmed by carotid angiography

The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms.

OBJECTIVE: Successful coil embolization of anterior communicating (A-com) artery aneurysms requires good visualization and understanding of the entire H complex. Bilateral carotid angiography may optimize anatomical understanding and visualization of the H complex. We therefore assessed the efficacy of simultaneous bilateral internal carotid angiography during coil embolization for A-com artery aneurysms. METHODS: Of the 153 patients with intracranial saccular aneurysms who underwent embolization between July 2008 and December 2009, 12 had A-com artery aneurysms and were embolized under bilateral carotid angiography. Patients were evaluated angiographically, immediately and 6 months (n=11) after embolization, using a 3-point scale (complete, residual neck, residual aneurysm). The safety, performance and efficacy of this approach were retrospectively evaluated. RESULTS: In all patients, bilateral internal carotid artery angiography provided more detailed anatomical information and understanding around the A-com artery, and, in complex situations, it allowed for more effective coil embolization through bilateral routes to the A-com artery. Angiography immediately after embolization showed occlusion of 11 of the 12 (92%) aneurysms, with none of these 11 showing evidence of recanalization at 6 months. CONCLUSION: These findings indicate that simultaneous bilateral carotid angiography during coil embolization of selected complex A-com artery aneurysms provided improved anatomical understanding, and resulted in more effective and safer procedures than typical unilateral angiography.

The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms

OBJECTIVE: Successful coil embolization of anterior communicating (A-com) artery aneurysms requires good visualization and understanding of the entire H complex. Bilateral carotid angiography may optimize anatomical understanding and visualization of the H complex. We therefore assessed the efficacy of simultaneous bilateral internal carotid angiography during coil embolization for A-com artery aneurysms. METHODS: Of the 153 patients with intracranial saccular aneurysms who underwent embolization between July 2008 and December 2009, 12 had A-com artery aneurysms and were embolized under bilateral carotid angiography. Patients were evaluated angiographically, immediately and 6 months (n=11) after embolization, using a 3-point scale (complete, residual neck, residual aneurysm). The safety, performance and efficacy of this approach were retrospectively evaluated. RESULTS: In all patients, bilateral internal carotid artery angiography provided more detailed anatomical information and understanding around the A-com artery, and, in complex situations, it allowed for more effective coil embolization through bilateral routes to the A-com artery. Angiography immediately after embolization showed occlusion of 11 of the 12 (92%) aneurysms, with none of these 11 showing evidence of recanalization at 6 months. CONCLUSION: These findings indicate that simultaneous bilateral carotid angiography during coil embolization of selected complex A-com artery aneurysms provided improved anatomical understanding, and resulted in more effective and safer procedures than typical unilateral angiography.

A Bilateral Internal Carotid Angiography-Based Neck Remodelling Technique for Anterior Communicating Artery Aneurysms: Technical Notes / 대한뇌혈관외과학회지

We report three cases of a novel balloon remodelling technique across the anterior communicating artery (ACoA) through simultaneous bilateral internal carotid angiography. In all three cases, simultaneous bilateral carotid angiography for balloon-assisted coil embolisation of anterior communicating artery aneurysms (ACoAA) provided improved anatomical detail and resulted in effective and safe procedures compared to typical unilateral angiography.