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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
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Case 14.1: A case of spontaneous CCAD associated with hyperhomocysteinemia
• 42-year-old male
• Medical history of ischemic stroke 3 weeks before admittance, hyperhomocysteinemia and hyperuricemia
Ultrasonography of the cervico-cerebral vessels revealed the presence of a hypo-/isoechogenic image in the medium
1/3 of the left common carotid artery with uniform narrowing of the arterial lumen up to the bifurcation. The right
carotid artery and vertebral arteries were normal without atheroma plaques. Cerebral MRI revealed the presence of
multiple areas of ischemia in the superfi cial and deep territories of left middle cerebral artery and watershed ischemic
area between anterior and middle cerebral artery.
MRA and MRI of the neck with i.v. contrast ( panel A ) showed medial and anterior thickness of the wall of the left
common carotid artery on a length of 32.1 mm compatible with CCAD. Cervico-cerebral digital subtraction ( panel B )
depicted the narrowing of the left common carotid artery but without signifi cant hemodynamic stenosis. The patient
received treatment with double antiplatelet therapy with aspirin and clopidogrel.
Image Gallery
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b
F. Antochi and A. Mergeani
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Case 14.2: A case of spontaneous right extracranial ICD with severe stenosis
• 41-year-old female
• Medical history of hypertension but without treatment
• Suffered an ischemic stroke 6 months before admittance
Ultrasonography of the cervico-cerebral vessels revealed the presence of a subocclusive stenosis of the right inter-
nal carotid artery. Cerebral CT scan ( panel A ) showed the presence of an ischemic hypodensity in the territory of the
deep branches of the middle cerebral artery. MRA and MRI of the neck with i.v. contrast ( Panel B ) showed circumfer-
ential thickness of the wall of the right common carotid artery with a high-grade stenosis at the origin of the right
internal carotid artery having a diameter of approximately 4.5 mm on a length of 6 mm. Cervico-cerebral digital
subtraction angiography ( Panel C ) confi rmed the presence of the subocclusive stenosis at the origin of the right internal carotid artery with reduced intracerebral fi lling of the right middle cerebral artery and right anterior cerebral artery
from the left internal carotid artery. Angioplasty with stent was performed without any peri- or post- procedural com-
plications. Ultrasonography of the cervico-cerebral vessels ( panel D ) performed 7 days later revealed the patency of
the right internal carotid artery without signs of thrombosis. We started the treatment with double antiplatelet therapy
with aspirin and clopidogrel.
a
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cd
b
F. Antochi and A. Mergeani
311
Case 14.3: A case of posttraumatic bilateral cervical ICD
• 38-year-old male, former smoker, occasional alcohol consumer; no drug abuse with multiple chronic dental infl am-
matory foci
• Sudden movement of the head and neck 4 days before admittance
• 2 days before admittance: right upper limb paresthesias for a few hours
• Short episodes of impaired speech in the last 12 h prior to admittance
Cerebral and cervical region MRI and MRA with i.v. contrast showing the presence of bilateral cervical ICD and
multiple zones suggestive of subacute ischemic infarcts in the left cerebral hemisphere. Anticoagulant therapy was
initiated. The patient remained free of symptoms. The 3 months follow-up using ultrasonography and cervical MRI
showed recanalization of the arteries and the patient was switched to antiplatelet therapy due to the presence of an
ischemic stroke for the secondary prevention.
14.4 Vertebral Artery Dissection
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Case 14.4: A case of spontaneous extracranial ICD with recanalization
• 39-year-old female
• Medical history of migraines without aura, in the last several years, and an upper respiratory tract infection with
fever and cough 3 weeks before admittance
• Admitted for abrupt onset of slurred speech accompanied by left laterocervical pain which developed a week before
presentation.
Cerebral CT scan demonstrated early signs of cerebral ischemia in the left middle cerebral artery territory. Doppler
ultrasonography examination of the cervico-cerebral arteries (A) exhibited the presence of a thin fl apping fold of the
vessel wall, distal to which a thrombus occluded the origin of the left internal carotid artery. CT angiography (B) illus-
trated gradually narrowing of the left internal carotid artery, with the absence of blood fl ow at the level of the second
cervical vertebrae and a circumferential parietal hematoma. Cerebral angiography (C) confi rmed the occlusion of the
left internal carotid artery at the origin and the presence of collateral fl ow through the circle of Willis. The patient
underwent a favorable course on receiving dual antiplatelet therapy with aspirin and clopidogrel. At the 3 months
follow-up visit, the ultrasonography of the cervico-cerebral arteries revealed almost complete spontaneous recanalization of the left internal carotid artery, also confi rmed by cerebral angiography, which demonstrated recanalization, with
irregularity of the artery wall and a good intracerebral perfusion.
a
b
c
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Case 14.5: A case of spontaneous ICD with fusiform aneurysm and Villaret syndrome
• 37-year-old male
• No known history of any disease, also no family history suggestive of any disease
• Presented to the hospital 2 weeks after sudden onset of left laterocervical pain associated with diffi culty in swallow-
ing and pupillary abnormalities after lifting heavy weights; the symptoms attenuated over time and upon arrival they
were minimal.
• Clinical examination revealed a right Horner syndrome, involvement of the cranial nerves IX, X, XI, and XII on the
right side.
Cerebral MRI of the brain was normal . MRA revealed a dilatation of the internal carotid artery in the cervical seg-
ment, while the native MRI of the neck showed a small hematoma in the wall of the right internal carotid artery.
Cervico-cerebral digital subtraction angiography ( B ) depicted a small fusiform dilatation of the right internal carotid
artery. CTA with 3D reconstruction ( C ) revealed the shape, caliber, and orientation of the fusiform aneurism.
Ultrasonography of the cervico-cerebral vessels revealed no thrombus or atheroma plaques on carotid and vertebral
arteries.
• We started the treatment with oral anticoagulants with warfarin for 6 months and then switch on antiplatelet therapy
with clopidogrel.
• The outcome was good; the patient did not have any new symptoms.
• The control MRI 6 months later showed the same aspect.
This is a rare case of Villaret syndrome caused by a fusiform aneurism of the right internal carotid artery secondary
to a dissection of the right internal carotid artery.
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a
c
b
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Case 14.6: A case of posttraumatic bilateral ICD in intracranial part
• 18-year-old female without any medical history
• Cervical and cerebral traumatism due to a car accident
• Tetraparesis predominantly affecting the upper limbs, arefl exia, and urinary disturbances
Cerebral and cervical region MRI and MRA with i.v. contrast (A) showing the presence of bilateral intracranial ICD
with multiple areas of ischemia in ICA territory . DSA confi rmed the presence of bilateral intracranial ICD ( B ) .
Percutaneous angioplasty with carotid stenting was performed ( C ) for the intracranial part of left ICA in the distal
segment from carotid canal with good intracerebral fi lling (left images) and for the intracranial right ICA (right images).
Both ICDs determined hemodynamic signifi cant stenoses. The patient received double antiplatelet treatment with
aspirin and clopidogrel with improvement of the neurologic defi cits. Control DSA performed 7 days later confi rmed
the patency of both ICA in the intracranial part with good intracerebral fi lling.
a
b
c
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Case 14.7: A case of spontaneous intracranial ICD
• 64-year-old Caucasian female
• No medical history
• Admitted for abrupt onset of language disorder and muscle weakness on her right side
Cerebral and cervical region MRI and MRA with i.v. contrast (A) showing the presence left intracranial IAD.
• Intramural hematoma with thickness of 2–3 mm in the intracranial part of internal carotid artery.
• Capsular–lenticular hyperintensity on T2-weighted MRI in the territory of deep branches of the left middle cerebral
artery.
• Normal fl ow in all major cervical arteries including left internal carotid artery but with poor fl ow of the left internal
carotid artery in the intracranial part (reduced with approximately 50 %) from the entrance in the skull till the supra-
clinoidian segment.
• Poor fl ow of the left sylvian artery visible only in the fi rst part of the M1 segment (B). The patient received double
antiplatelet therapy with aspirin and clopidogrel with a good outcome. Digital subtraction angiography was not
performed due to the fact that the diagnosis was confi rmed by MRI/MRA, and there were no recurrent ischemic
events that would lead to the indication of endovascular treatment.
F. Antochi and A. Mergeani