Percutaneous transluminal angioplasty for memory disturbance caused by stenosis of the innominate artery
Hiroaki NekiShoichiro IshiharaHideaki IshiharaRyuzaburou KanazawaShinya KohyamaFumitaka YamaneAiko OosawaShinichiro Maeshima
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It is well known that significant narrowing of the subclavian or innominate artery may cause cerebrovascular ischemic symptoms. We report a case of a 62-year-old man who was suffering from progressive cognitive impairment and was treated by perctaneous transluminal angioplasty (PTA). The patient had undergone aorto-bifemoral bypass, left femoropopliteal bypass, and right femoral artery endoarterectomy. On admission, he was alert, but had memory impairment, especially delayed recall. He complained of dizziness and dysesthesia on his right upper extremity which got worse on exertion. The right radial pulse was diminished and the right brachial blood pressure was lower about 40 mmHg than the left. Angiography demonstrated severe stenosis of the innominate artery near its origin, hypoplasty of the left horizontal anterior cerebral artery segment (Al), and dilation of the left external carotid artery. Left vertebral arteriography revealed retrograde flow of the right vertebral artery in the late arterial phase. Single photon emission computed tomography (SPECT) revealed marked reduction in cerebral blood flow to the left frontal lobe. The patient underwent PTA of the innominate artery with satisfactory results. Cognitive impairment improved remarkably after the angioplasty. The right radial pulse was quite palpable, and the bilateral brachial blood pressures were the same. The cerebral blood flow was increased in SPECT. Memory disturbance can be generated by stenosis of the innominate artery. PTA is one of the effective methods to reverse such cognitive impairment.Cite
We report the case of a man presenting with a brain-stem stroke from which he recovered fully, who developed right-sided weakness and numbness on walking despite no demonstrable postural fall in arterial blood pressure. Angiography revealed an occluded left vertebral artery, a tight stenosis at the origin of the right vertebral artery and non-patent left posterior communicating artery. Percutaneous transluminal angioplasty to the right vertebral stenosis results in a good angiographic result, and remission of symptoms which has persisted for 1 year. Identification of such patients with vertebrobasilar positional haemodynamic symptoms due to a focal stenosis is important as angioplasty offers an effective therapeutic option.
Vertebrobasilar insufficiency
Stroke
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A 72-year-old man suffered blindness due to right central retinal artery occlusion. Cerebral angiography revealed tandem stenosis in the cervical, petrosal and cavernous portions of the right internal carotid artery (ICA). Blood flow from the vertebrobasilar artery via the right posterior communicating artery mainly perfused the right cerebral hemisphere. In addition, significant stenosis was observed in the left cervical carotid artery and the origin of the left vertebral artety. First, the patient underwent left carotid endarterectomy and vertebral artery to subclavian artery transposition. Two months later, ligation of the right ICA at its origin was performed. Postoperative course was uneventful and the patient has not experienced further ischemic events. We suggest that proximal ligation of the parent artery is a useful procedure for medically-refractory extradural ICA stenosis when surgical direct revascularization and percutaneous transluminal angioplasty cannot be performed.
Vertebrobasilar insufficiency
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症例は80歳の女性.1ヶ月前に大動脈弁置換術を受け,発作性心房細動がありワルファリン内服中であった.某日,意識障害,左片麻痺を発症し,来院時,右橈骨動脈の触知減弱を認めた.頭部MRI拡散強調画像では右中大脳動脈領域に高信号域があり,MRAでは右M1遠位閉塞,右内頸動脈の信号低下を認めた.胸部造影CTでは腕頭動脈閉塞があり,心原性塞栓子による腕頭動脈塞栓および右M1遠位塞栓と診断した.ヘパリンとワルファリンによる抗凝固療法を行い,症状は徐々に改善し,右中大脳動脈,腕頭動脈は再開通した.右橈骨動脈触知減弱の際には,胸部大動脈解離のみならず心原性塞栓子による腕頭動脈塞栓症も念頭に置く必要がある.
Cerebral embolism
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Pseudoocclusion of a superficial temporal-middle cerebral artery bypassAB Dublin and DC RicheyAudio Available | Share
Superficial temporal artery
Temporal artery
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Eighteen of twenty patients with subclavian or innominate artery obstruction experienced episodes of transient cerebral arterial insufficiency; one patient suffered acute stroke and coma; all patients had angiographic evidence of subclavian or innominate artery obstruction; and most were shown to have retrograde flow in a vertebral artery. Two clinical patterns were apparent by arteriographic studies. Six patients had single lesions of a subclavian artery resulting in centrifugal cerebral ischemia. A second group of 14 patients had other significant lesions of either the carotid or vertebral-basilar arterial systems. Carotid-subclavian bypass or aorto-subclavian bypass are the preferred methods of reconstruction of subclavian obstructions. Of these two approaches, the extrathoracic procedure is preferable.
Subclavian steal syndrome
Coma (optics)
Vertebrobasilar insufficiency
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Objective To explore the collateral compensation and clinical characteristics of severe subclavian steal syndrome(SSS).Methods The clinical data of 12 patients with severe SSS conformed by cerebral digital subtraction angiography(DSA) were analyzed retrospectively.Results The main clinical manifestations of the 12 SSS patients were repeated dizzy,feeling rotation,falling down and so on,and which became aggravate after activities with ipsilateral unper limb.DSA showed that the left subclavian artery severe stenosis or occlusion in 10 cases and bilateral subclavian artery severe stenosis in 2 cases.The ways of collateral compensation were vertebral artery-vertebral artery-subclavian artery in 10 cases,internal carotid artery-posterior communicating artery-posterior cerebral artery/basilar artery in 8 cases,external carotid artery-occipital artery inferior branches-ramimusculares arteriae vertebralis-vertebral artery-subclavian artery in 9 cases.The 8 cases recived subclavian artery stent angioplasty and the clinical symptoms were completely disappeared.The 2 cases recived contralateral vertebral artery stent angioplasty because who had with subclavian artery occlusion and contralateral vertebral artery moderate stenosis.After operation the symptoms were relieved,and also no recurrenced after following up 3 months-2.5 years.Conclusions Repeated dizzy is the main clinical symptom of severe SSS.The main way of collateral compensation is vertebral artery-vertebral artery-subclavian artery.The stent angioplasty can correct the hemodynamics disorder and relieve the clinical symptoms.
Vertebrobasilar insufficiency
Subclavian steal syndrome
Occipital artery
SSS*
Digital subtraction angiography
External carotid artery
Collateral circulation
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A 67-year-old man was admitted for status epilepticus, right hemiparesis, repeating vertigo and vomiting. Computed tomography showed no abnormality except for slight brain atrophy. Angiogram demonstrated bilateral vertebral artery stenosis at the origin, especially on the left side, and bilateral cervical internal carotid artery stenosis associated with ulceration. Intracranially, bilateral anterior cerebral artery was filled only by right internal carotid artery. Internal carotid artery on both sides did not fill the posterior cerebral artery. From these findings, we thought that both bilateral internal carotid artery and left vertebral artery should be surgically reconstructed. On June 4, 1986, left vertebral transposition to the common carotid artery and left carotid endarterectomy using double-balloon shunt were performed. Waiting for recovery of the general condition, right carotid endarterectomy was carried out on June 27, 1986. Postoperative angiogram demonstrated disappearance of bilateral internal carotid artery stenosis, and good filling of left vertebral artery through left common carotid artery. Postoperative course was uneventful and right hemiparesis gradually improved. Vertigo and vomiting completely subsided. The method and indication of combined reconstruction for extracranial vertebral and carotid artery were discussed.
Endarterectomy
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Foramen
Vertebrobasilar insufficiency
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A 49-year-old man suddenly suffered left hemiplegia, and was brought to our hospital by ambulance at the beginning of August, 2006. He had a history of hypertension, and had received replacement of a synthetic graft in the ascending aorta and aortic arch with innominate artery for dissecting aneurysm in the aorta 2 years before. On diffusion-weighted magnetic resonance images obtained after admission, cerebral infarction was detected at the right corona radiata, and MR angiography (MRA) showed obstruction of the right middle cerebral artery. He was given intravenous tissue-plasminogen activator (t-PA) a few hours after arrival, and his hemiplegia was improved on the following day. At 11 days after onset, recanalization of the right middle cerebral artery was seen by MRA. On Doppler ultrasonographic examination, obstruction and thrombus in the innominate artery were observed. Retrograde flow of the right vertebral artery was demonstrated by both pulse-Doppler ultrasonography and velocity-coded color MRA. This patient is a rare example of innominate artery steal and ischemic cerebrovascular disease with obstruction of the innominate artery. Cerebral infarction in this patient might have developed via artery-to-artery embolism, with the thrombus in the innominate artery, rather than through a hemodynamic mechanism with innominate artery steal.
Brachiocephalic artery
Anterior cerebral artery
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Superficial temporal artery
External carotid artery
Anterior cerebral artery
Posterior cerebral artery
Stroke
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