OBJECTIVE: The management of patients with ruptured cerebral aneurysms and severe vasospasm is subject to considerable controversy. We intended to describe herein an endovascular technique for the simultaneous treatment of aneurysms and vasospasm. MATERIALS AND METHODS: A series of 11 patients undergoing simultaneous endovascular treatment of ruptured aneurysms and vasospasm were reviewed. After placement of a guiding catheter within the proximal internal carotid artery for coil embolization, an infusion line of nimodipine was wired to one hub, and of a microcatheter was advanced through another hub (to select and deliver detachable coils). Nimodipine was then infused continuously during the coil embolization. RESULTS: This technique was applied to 11 ruptured aneurysms accompanied by vasospasm (anterior communicating artery, 6 patients; internal carotid artery, 2 patients; posterior communicating and middle cerebral arteries, 1 patient each). Aneurysmal occlusion by coils and nimodipine-induced angioplasty were simultaneously achieved, resulting in excellent outcomes for all patients, and there were no procedure-related complications. Eight patients required repeated nimodipine infusions. CONCLUSION: Our small series of patients suggests that the simultaneous endovascular management of ruptured cerebral aneurysms and vasospasm is a viable approach in patients presenting with subarachnoid hemorrhage and severe vasospasm.
Adult ; Aged ; Aneurysm, Ruptured/*therapy ; Carotid Artery, Internal/radiography ; Embolization, Therapeutic ; *Endovascular Procedures ; Female ; Humans ; Intracranial Aneurysm/*therapy ; Magnetic Resonance Angiography ; Male ; Middle Aged ; Nimodipine/therapeutic use ; Retrospective Studies ; Vasodilator Agents/therapeutic use ; Vasospasm, Intracranial/*therapy

Two angiographic instances of anomalous external carotid artery (ECA) and internal carotid artery (ICA) anastomosis are described, each occurring at the C2-3 level and bearing remnants of proximal ICA. The ICA remnant of one patient (identifiable immediately upon bifurcation of the common carotid artery) was hypoplastic, and that of the other patient was an occluded arterial stump. These features are not typical of non-bifurcating ICA. The occipital artery originated from an anomalous connection in one instance and from the main trunk of the ECA (just past the ECA-ICA connection) in the other.
Adult ; Arterial Occlusive Diseases/radiography ; Carotid Artery, External/*abnormalities/radiography/surgery ; Carotid Artery, Internal/*abnormalities/radiography/surgery ; Cerebral Angiography ; Humans ; Intracranial Aneurysm/*radiography/surgery ; Male ; Middle Aged

OBJECTIVE: Described herein is a microcatheter looping technique to facilitate aneurysm selection in paraclinoid aneurysms, which remains to be technically challenging due to the inherent complexity of regional anatomy. MATERIALS AND METHODS: This retrospective study was approved by our Institutional Review Board, and informed consent was waived. Microcatheter looping method was employed in 59 patients with paraclinoid aneurysms between January 2012 and December 2013. In the described technique, construction of a microcatheter loop, which is steam-shaped or pre-shaped, based on the direction of aneurysms, is mandatory. The looped tip of microcatheter was advanced into distal internal carotid artery and positioned atop the target aneurysm. By steering the loop (via inner microguidewire) into the dome of aneurysm and easing tension on the microcatheter, the aneurysm was selected. Clinical and morphologic outcomes were assessed with emphasis on technical aspects of the treatment. RESULTS: Through this looping technique, a total of 59 paraclinoid aneurysms were successfully treated. After aneurysm selection as described, single microcatheter technique (n = 25) was most commonly used to facilitate coiling, followed by balloon protection (n = 21), stent protection (n = 7), multiple microcatheters (n = 3), and stent/balloon combination (n = 3). Satisfactory aneurysmal occlusion was achieved through coil embolization in 44 lesions (74.6%). During follow-up of 53 patients (mean interval, 10.9 +/- 5.9 months), only one instance (1.9%) of major recanalization was observed. There were no complications related to microcatheter looping. CONCLUSION: This microcatheter looping method facilitates safe and effective positioning of microcatheter into domes of paraclinoid aneurysms during coil embolization when other traditional microcatheter selection methods otherwise fail.
Adult ; Carotid Artery, Internal/radiography/*surgery ; Catheterization/methods ; Cerebral Angiography/methods ; Embolization, Therapeutic/*methods ; Female ; Humans ; Intracranial Aneurysm/*therapy ; Male ; Middle Aged ; Retrospective Studies ; Stents

OBJECTIVE: To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis. MATERIALS AND METHODS: For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography. RESULTS: Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention. CONCLUSION: In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.
Adolescent ; Adult ; Aneurysm, False/radiography/*therapy ; Angiography, Digital Subtraction ; Angioplasty, Balloon ; Carotid Artery Injuries/radiography/*therapy ; Carotid Artery, Internal ; Diagnosis, Differential ; Embolization, Therapeutic ; Endovascular Procedures/*methods ; Epistaxis/radiography/*therapy ; Female ; Humans ; Male ; Maxillary Artery/*injuries ; Middle Aged ; Retrospective Studies ; Stents ; Tomography, X-Ray Computed ; Treatment Outcome

A 44-year-old woman who showed recurrent vitreous hemorrhages with vascular tortuosity received CT angiography which revealed an internal carotid artery aneurysm. A case of internal carotid aneurysm was associated with a pattern of retinal arteriolar tortuosity pathognomic for familial retinal arterial tortuosity (fRAT), suggesting possible involvement of the cerebral circulation. We present a case of internal carotid aneurysm associated with a pattern of retinal arteriolar tortuosity pathognomic for fRAT.
Adult ; Aneurysm/*complications/radiography ; Angiography ; Carotid Artery Diseases/*complications/radiography ; *Carotid Artery, Internal ; Diagnosis, Differential ; Eye Abnormalities/complications/diagnosis/*genetics ; Female ; Follow-Up Studies ; Humans ; Retinal Artery/*abnormalities ; Tomography, X-Ray Computed ; Torsion Abnormality/complications/diagnosis/*genetics ; Visual Acuity

PURPOSE: This study aimed to investigate the luminal stenosis of the internal carotid artery with calcification detected on panoramic radiographs. MATERIALS AND METHODS: This study used fifty carotid arteries of 36 dental patients whose panoramic radiograph and computed tomography angiography (CTA) revealed the presence of carotid artery calcification. A neuroradiologist interpreted CTA to determine the degree of stenosis of the internal carotid arteries. The degree of stenosis was stratified in four stages; normal (no stenosis), mild stenosis (1-49%), moderate stenosis (50-69%) and severe stenosis (70-99%). RESULTS: Among the fifty carotid arteries with calcification detected on both panoramic radiography and CTA, 20carotid arteries (40%) were normal, 29 carotid arteries (18%) had mild stenosis, 1 carotid artery (2%) had moderate stenosis, and there was none with severe stenosis. CONCLUSION: Sixty percent of the carotid arteries with calcification detected on both panoramic radiography and CTA had internal luminal stenosis, and two percent had moderate stenosis. When carotid atheroma is detected on panoramic radiograph, it is possible that the dental patient has luminal stenosis of the internal carotid artery.
Angiography ; Arteries ; Carotid Arteries ; Carotid Artery, Internal ; Constriction, Pathologic ; Humans ; Phenobarbital ; Plaque, Atherosclerotic ; Radiography, Panoramic

Rapid arterial rethrombosis is associated with high-grade residual stenosis and usually occurs at the site of the initial occlusion, resulting in reocclusion of the recanalized artery. Platelets may play an active role in such rethrombosis after thrombolytic-induced clot lysis. Given that glycoprotein IIb/IIIa receptor blockers, like tirofiban, prevent thrombus formation by inhibiting the final common pathway of platelet aggregation, they may be helpful for treating rethrombosis after thrombolysis. A 64-year-old man presented with an acute ischemic stroke due to internal carotid artery (ICA) occlusion. The ICA was recanalized by intravenous thrombolysis but reoccluded shortly after recanalization. The reoccluded ICA was successfully recanalized using intra-arterial tirofiban. A carotid stent was subsequently inserted to relieve severe stenosis and to prevent recurrent stroke. Here, we report a case of rescue treatment of a successfully recanalized ICA by intra- arterial tirofiban. We suggest that rescue use of intra-arterial tirofiban may be effective and safe, especially in hemorrhage prone situations, due to the relatively lower dose of tirofiban compared with intravenous doses.
*Carotid Artery, Internal ; Carotid Stenosis/*drug therapy/radiography/surgery ; Emergency Treatment ; Humans ; Infusions, Intra-Arterial ; Male ; Middle Aged ; Stents ; Tyrosine/administration & dosage/*analogs & derivatives/therapeutic use

PURPOSE: The goal of this study was to directly measure the association between the internal carotid artery (ICA) morphometry and the presence of ICA-posterior communicating artery (PCOM) aneurysm. MATERIALS AND METHODS: The authors intraoperatively measured the length of the supraclinoid ICA because it is impossible to radiologically determine the exact location of the anterior clinoid process. We used an image analyzer with a CT angiogram to measure the angle between the skull midline and the terminal segment of the ICA (ICA angle), as well as the diameter of the ICA. The lengths and diameters of the supraclinoid ICA and the ICA angle were compared among PCOM aneurysms, anterior communicating artery (ACOM) aneurysms, and middle cerebral artery (MCA) bifurcation aneurysms (n=27 each). Additionally, the lengths and the diameters of M1 and A1 were compared for each aneurysm. RESULTS: The lengths of the supraclinoid ICA were 11.9+/-2.3mm. The lengths of the supraclinoid ICA in patients with ICA-PCOM aneurysms (9.7+/-2.8mm) were shorter than those of patients with ACOM aneurysms (13.8+/-2.2mm, Student's t-test, p<0.001) and with MCA bifurcation aneurysms (12.2+/-1.9 mm, Student's t-test, p<0.001). The diameters of the supraclinoid ICA and A1 in patients with ACOM aneurysms were larger than those in patients with MCA bifurcation aneurysms (Student's t-test, p<0.05). There were no significant differences in the lengths of M1 and A1, ICA angle, or diameter of M1 for each aneurysm. CONCLUSION: These results suggest that the relatively shorter length of the supraclinoid ICA may be a novel risk factor for the development of ICA-PCOM aneurysm with higher hemodynamic stress.
Carotid Artery Diseases/congenital/*radiography ; Carotid Artery, Internal/abnormalities/*radiography ; Humans ; Intracranial Aneurysm/*radiography ; Risk Factors

Abnormalities, Multiple ; diagnostic imaging ; Basilar Artery ; abnormalities ; diagnostic imaging ; Carotid Artery, Internal ; diagnostic imaging ; Humans ; Intracranial Aneurysm ; complications ; diagnostic imaging ; Male ; Middle Aged ; Radiography ; Vertebral Artery ; diagnostic imaging

*Abnormalities, Multiple/radiography ; Basilar Artery/*abnormalities ; Basilar Artery/radiography ; Carotid Artery, Internal/radiography ; Intracranial Aneurysm/*complications ; Intracranial Aneurysm/radiography ; Vertebral Artery/radiography