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Concept: Common carotid artery

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Fine particulate matter (PM2.5) has been linked to cardiovascular disease, possibly via accelerated atherosclerosis. We examined associations between the progression of the intima-medial thickness (IMT) of the common carotid artery, as an indicator of atherosclerosis, and long-term PM2.5 concentrations in participants from the Multi-Ethnic Study of Atherosclerosis (MESA).

Concepts: Common carotid artery, Brachiocephalic artery, United States Environmental Protection Agency, Particulate, Smog, Air pollution, Dust, Scrubber

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BACKGROUND: Takayasu arteritis is a large vessel vasculitis occurring in young females. We report a rare presentation of Takayasu arteritis in a Sri Lankan woman. She presented with bronchiectasis and left recurrent laryngeal nerve palsy prior to the onset of vascular symptoms. This case illustrates an atypical presentation of this disease and the diagnostic dilemma that the physician may be faced with. CASE PRESENTATION: A 39-year-old woman presented with chronic cough, haemoptysis and hoarseness of voice. She had left recurrent laryngeal nerve palsy and high inflammatory markers on investigation. CT thorax revealed aortic wall thickening and traction bronchiectasis. 2 D echocardiogram revealed grade 1 aortic regurgitation compatible with aortitis. She did not have weak peripheral pulses or a blood pressure discrepancy and did not meet American College of Rheumatology (ACR) criteria for diagnosis of Takayasu arteritis at this stage. Tuberculosis, syphilis and sarcoidosis was excluded. While awaiting angiography, she developed left arm claudication and a pericardial effusion. Angiography revealed evidence of Takayasu arteritis and absence of flow in the left subclavian artery. Takayasu arteritis was diagnosed at this stage after a period of eight months from the onset of initial symptoms. She is currently on prednisolone, azathioprine and aspirin. CONCLUSION: Bronchiectasis and recurrent laryngeal nerve palsy is a rare presentation of Takayasu arteritis. Atypical presentations can occur in Takayasu arteritis prior to the onset of vascular symptoms. Elevation of inflammatory markers are an early finding. A high degree of suspicion is needed to identify these patients in the early course of the disease.

Concepts: Cardiology, Common carotid artery, Brachiocephalic artery, Subclavian vein, Vertebral artery, Subclavian artery

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The development of minimally invasive procedures such as the balloon dilation Eustachian tuboplasty (BET) is an alternative to the grommet tympanum membrane. BET is applied in the cases where, after elimination of all factors influencing the ET and middle ear functioning, no sufficient improvement is observed. The aim of this study was to present the therapeutic benefits of the BET method in the treatment of ETD caused by disorders in the middle ear ventilation. The BET procedure was offered to four patients (3 men and 1 woman) after subjective, physical, otorhinolaryngological and audiometric examinations including pure tone audiometry, tympanometry and pressure-swallow test. As the method was novel, preinterventional CT angiography of the carotid arteries was performed in all patients. Any complications were noticed during and after the procedure (bleeding or damage of regional mucosa) in any patients. Our clinical studies assessed the feasibility and safety of the BET during a short-term period-only a 6-week observation. Although patients revealed a significant improvement of ET score, longer long-term studies are necessary to determine whether this method will demonstrate lasting benefits and safety in the treatment of chronic Eustachian tube dysfunction. In other investigations, improvement was found to be time dependent.

Concepts: Scientific method, Auditory system, Common carotid artery, Middle ear, Eustachian tube, Otitis media, Ear, Patulous Eustachian tube

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We report on oxygenation changes noninvasively recorded by multichannel continuous-wave near infrared spectroscopy (CW-NIRS) during endovascular neuroradiologic interventions requiring temporary balloon occlusion of arteries supplying the cerebral circulation. Digital subtraction angiography (DSA) provides reference data on the site, timing, and effectiveness of the flow stagnation as well as on the amount and direction of collateral circulation. This setting allows us to relate CW-NIRS findings to brain specific perfusion changes. We focused our analysis on the transition from normal perfusion to vessel occlusion, i.e., before hypoxia becomes clinically apparent. The localization of the maximal response correlated either with the core (occlusion of the middle cerebral artery) or with the watershed areas (occlusion of the internal carotid artery) of the respective vascular territories. In one patient with clinically and angiographically confirmed insufficient collateral flow during carotid artery occlusion, the total hemoglobin concentration became significantly asymmetric, with decreased values in the ipsilateral watershed area and contralaterally increased values. Multichannel CW-NIRS monitoring might serve as an objective and early predictive marker of critical perfusion changes during interventions-to prevent hypoxic damage of the brain. It also might provide valuable human reference data on oxygenation changes as they typically occur during acute stroke.Journal of Cerebral Blood Flow & Metabolism advance online publication, 4 December 2013; doi:10.1038/jcbfm.2013.207.

Concepts: Spectroscopy, Blood, Middle cerebral artery, Internal carotid artery, Common carotid artery, Anterior cerebral artery, Infrared, Digital subtraction angiography

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There are considerable variations in the anatomy of the human ophthalmic artery (OphA), such as anomalous origins of the OphA and anastomoses between the OphA and the adjacent arteries. These anatomical variations seem to attribute to complex embryology of the OphA. In human embryos and fetuses, primitive dorsal and ventral ophthalmic arteries (PDOphA and PVOphA) form the ocular branches, and the supraorbital division of the stapedial artery forms the orbital branches of the OphA, and then numerous anastomoses between the internal carotid artery (ICA) and the external carotid artery (ECA) systems emerge in connection with the OphA. These developmental processes can produce anatomical variations of the OphA, and we should notice these variations for neurosurgical and neurointerventional procedures.

Concepts: Embryo, Developmental biology, Internal carotid artery, Common carotid artery, External carotid artery, Embryology, Arteries of the head and neck, Ophthalmic artery

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Embozene® is a new neuroembolizing microsphere used to reduce intraoperative bleeding for head and neck tumours. We report a case of iatrogenic ophthalmic artery occlusion after Embozene® embolization of the external carotid artery (ECA).

Concepts: Head and neck anatomy, Head and neck, Internal carotid artery, Common carotid artery, External carotid artery, Arteries of the head and neck, Ophthalmic artery

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Background Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. Methods We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. Results The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P=0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. Conclusions In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725 , and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965 .).

Concepts: Better, Blood, Stroke, Modified Rankin Scale, Middle cerebral artery, Internal carotid artery, Common carotid artery, Anterior cerebral artery

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The objective of this study was to evaluate outcomes of endoscopic transsphenoidal surgery using a single-surgeon technique as an alternative to the more commonly employed two-surgeon, three-hand method. Three hundred consecutive endoscopic transsphenoidal procedures performed over a 5 year period from 2006 to 2011 were reviewed. All procedures were performed via a binasal approach utilizing a single surgeon two handed technique with a pneumatic endoscope holder. Expanded enodnansal cases were excluded. Surgical technique, biochemical and surgical outcomes, and complications were analyzed. 276 patients underwent 300 consecutive surgeries with a mean follow-up period of 37 ± 22 months. Non-functioning pituitary adenoma (NFPA) was the most common pathology (n = 152), followed by growth hormone secreting tumors (n = 41) and Rathke’s cleft cysts (n = 30). Initial gross total cyst drainage based on radiologic criteria was obtained in 28 cases of Rathke’s cleft cyst, with 5 recurrences. For NFPA and other pathologies (n = 173) gross total resection was obtained in 137 cases, with a 92 % concordance rate between observed and expected extent of resection. For functional adenoma, remission rates were 30/41 (73 %) for GH-secreting, 12/12 (100 %) for ACTH-secreting, and 8/17 (47 %) for prolactin-secreting tumors. Post-operative complications included transient (11 %) and permanent (1.4 %) diabetes insipidus, hyponatremia (13 %), and new anterior pituitary hormonal deficits (1.4 %). CSF leak occurred in 42 cases (15 %), and four patients required surgical repair. Two carotid artery injuries occurred, both early in the series. Epistaxis and other rhinological complications were noted in 10 % of patients, most of which were minor and diminished as surgical experience increased. Fully endoscopic single surgeon transsphenoidal surgery utilizing a binasal approach and a pneumatic endoscope holder yields outcomes comparable to those reported with a two-surgeon method. Endoscopic outcomes appear to be better than those reported in microscope-based series, regardless of a one or two surgeon technique.

Concepts: Pituitary adenoma, Hospital, Surgery, Physician, Growth hormone, Common carotid artery, Anterior pituitary, Rathke's pouch

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The assessment of both geometry and hemodynamics of the intracranial arteries has important diagnostic value in internal carotid occlusion, sickle cell disease, and aneurysm development. Provided that signal to noise ratio (SNR) and resolution are high, these factors can be measured with time-resolved three-dimensional phase contrast MRI. However, within a given scan time duration, an increase in resolution causes a decrease in SNR and vice versa, hampering flow quantification and visualization. To study the benefits of higher SNR at 7 T, three-dimensional phase contrast MRI in the Circle of Willis was performed at 3 T and 7 T in five volunteers. Results showed that the SNR at 7 T was roughly 2.6 times higher than at 3 T. Therefore, segmentation of small vessels such as the anterior and posterior communicating arteries succeeded more frequently at 7 T. Direction of flow and smoothness of streamlines in the anterior and posterior communicating arteries were more pronounced at 7 T. Mean velocity magnitude values in the vessels of the Circle of Willis were higher at 3 T due to noise compared to 7 T. Likewise, areas of the vessels were lower at 3 T. In conclusion, the gain in SNR at 7 T compared to 3 T allows for improved flow visualization and quantification in intracranial arteries. Magn Reson Med, 2013. © 2012 Wiley Periodicals, Inc.

Concepts: Internal carotid artery, Common carotid artery, Anterior cerebral artery, Posterior communicating artery, Sickle-cell disease, Arteries of the head and neck, Circle of Willis, Signal-to-noise ratio

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To study the role of surgery for symptom palliation in patients with advanced head and neck malignancy. Between 2000 and 2011, patients with locoregionally advanced cancer in the head and neck region, who chose surgical palliation for symptom control, were studied retrospectively. During the study period, 52 patients were included. The index tumour included carcinoma of the maxilla (23.1 %), tongue (19.2 %), larynx/hypopharynx (15.4 %), post-radiation sarcoma (11.5 %), primary sarcoma (11.5 %), carcinoma of the lower alveolus (11.5 %), nasal mucosal melanoma (3.9 %) and metastatic tumour in the head and neck region (3.9 %). The major symptoms included bleeding (53.9 %), tumour pain (19.2 %), dysphagia (11.5 %), non-healing ulcerations (7.7 %), airway obstruction (5.8 %) and pathological fracture of the mandible (1.9 %). Ligation of the carotid artery was performed in 10 patients, complete resection of tumour in 35, and surgical debulking of the tumour in 7 patients. Mean survival of the patients was 5.6 months. The majority of the patients achieved satisfactory and persistent control of symptoms. One patient died from pneumonia during the hospital stay, and the rest were discharged after a mean duration of 16.4 days. In selected patients, surgery is effective in palliating symptoms which are otherwise difficult to manage. Detailed planning and good communication is the key to success in improving the quality of dying.

Concepts: Cancer, Disease, Oncology, Hospital, Chemotherapy, Melanoma, Common carotid artery, Head and neck cancer