No description available.

No description available.

Abstract The aim of this study was to analyze angiographic findings and the presence and topography of cerebral ischemic and/or hemorrhagic lesions in cerebral CT or MRI, and to assess the long-term clinical outcome of a series of 136 consecutive cervicocephalic artery dissection (CCAD) patients. Pulsatile tinnitus was evaluated as a symptom of CCAD. Medical records and films were reviewed retrospectively. Irregular stenosis was found in angiography in 50% and occlusion in 33% of the dissected cervicocephalic arteries. Irregular stenosis normalized in 81% and occlusion recanalized in 34%. Other findings, such as pseudoaneurysms, intimal flaps, double lumens, and irregular dilatations were rare and often remained unchanged in follow-up. Pulsatile tinnitus was a presenting symptom in 12% of the CCAD patients, but the majority of patients had concomitant head or neck pain, ischemic brain symptoms, Horner's syndrome, or cranial neuropathies. Of the 131 patients who underwent brain imaging, 73 (56%) had signs of infarction in cerebral CT or MRI. Occlusion of the dissected vessel was accompanied by infarction in 76%, irregular stenosis in 40%, and other findings only rarely. Of the anterior circulation infarctions, 95% (39/41) were territorial, subcortical, or territorial infarctions with fragmentation and could thus be considered embolic. Subarachnoid hemorrhage was found in CT in 5 of the 22 patients (23%) with intracranial dissection. The patient's long-term clinical outcome was assessed using two methods: a classification into categories based on neurological symptoms and defects and the modified Rankin Scale (mRS). Of the 136 CCAD patients, 60% recovered with no or mild disability and 79% scored 0–2 on mRS. In the case of dissection of one or more cervicocephalic arteries without occlusion, the figures were 75% and 89%. In the case of occlusive dissection of one or more arteries, only about 35% of the patients recovered well, having no or mild disability, and 61% scored 0–2 on mRS. No significant differences were seen in recovery after intra- and extracranial dissections. In conclusion: irregular stenosis, which is the most common angiographic finding in CCAD, is associated with brain infarction less frequently than occlusion, and the long-term clinical outcome is good in most cases. Occlusion of the dissected vessel causes more brain infarctions, and only about 35% of the patients recover well, having no or mild disability. More than 10% of CCAD patients have pulsatile tinnitus as a presenting, and sometimes the only symptom.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23807号 / 医博第4853号 / 新制||医||1058(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 湊谷 謙司, 教授 YOUSSEFIAN Shohab, 教授 石見 拓 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Hintergrund: Das Auftreten von frühen postinterventionellen Komplikationen nach Stenting der Arteria carotis interna (ACI) wird auf die Embolisierung von Material aus dem Stentsegment zurückgeführt. Zerebrale Thrombembolien können nicht invasiv mittels transkraniellem Dopplerultraschall (TCD) als mikroembolische Signale (MES) detektiert werden. Studienziel : Die Studie wurde durchgeführt um Prädiktoren zu finden, welche eine hohe Anzahl von MES im Intervall einer Stunde nach dem Eingriff voraussagen könnten. Methodik: Bei 134 konsekutiven Patienten, die ein Stenting der ACI erhielten, wurde postinterventionell über eine Stunde eine TCD der ipsilateralen Arteria cerebri media durchgeführt. Zur Identifizierung von klinischen, morphologischen und prozedurabhängigen Parametern für vermehrte MES, wurde eine multivariate logische Regressionsanalyse durchgeführt. Ergebnisse: Bei 134 Patienten (111 männlich, 23 weiblich, mittleres Alter 69,7 Jahre) wurden in 38% MES detektiert (Mittelwert 4 MES/h; Streuung von 1-62MES/h). Zwei Variablen waren mit einer erhöhten postinterventionellen MES Rate vergesellschaftet. Diese waren: Symptomatische Läsionen (p=0,048) und erhöhtes Gesamtcholesterin (p=0,037). Die duale Thrombozytenaggregationshemmung (ASS und Clopidogrel) konnte als unabhängiger Prädiktor (p=0,0001) für eine erniedrigte MES Rate festgestellt werden. Schlussfolgerungen: Postinterventionelle MES konnten am häufigsten bei symptomatischen Läsionen und bei Patienten mit Hypercholesterinämie festgestellt werden. Deren Anzahl viel im Verlauf ab. Das Stentdesign hatte keinen Einfluss auf die Anzahl der gemessenen MES. Die Kombinationstherapie mit ASS und Clopidogrel war ein Prediktor für eine erniedrigte cerebrale Embolisationsrate. Die TCD der MES Rate könnte eine brauchbare Methode sein um mögliche Risikofaktoren für neurologische Komplikationen nach Stenting der ACI zu entdecken und somit die Sicherheit der Stentingprozedur der ACI zu verbessern.

Objetivo: Avaliar a eficácia da ultrassonografia com contraste (US com contraste) de segunda geração no diagnóstico diferencial entre oclusão e pseudo-oclusão de artéria carótida interna cervical (ACI) comparativamente à ultrassonografia com Doppler (US Doppler) utilizando a angiotomografia computadorizada (angio-TC) como padrão-ouro. Materiais e Métodos: Estudo prospectivo realizado entre junho de 2006 e junho de 2008 com 72 pacientes sintomáticos (57; 15) e 78 com ACIs aparentemente ocluídas pela US Doppler. Esses pacientes foram submetidos inicialmente à US Doppler e, em seguida, à US com contraste. Todos os pacientes realizaram posteriormente a angio-TC, utilizada como padrão-ouro. A correlação entre os métodos foi feita através de estudo duplo cego. Resultados: A sensibilidade, a especificidade e a acurácia da US com contraste foram respectivamente de 100%; 90,5% e 97,4%. Quando comparada à angio-TC, a quantidade de falsas oclusões pela US Doppler foi de 26,9% (21/78), (p < 0,001), enquanto que pela US com contraste foi de 2,6% (2/78) (p = 0,500). A US com contraste obteve melhor resultado que a US Doppler, com diferença estatisticamente significante (p < 0,001). Conclusão: A US com contraste é tão eficaz quanto a angio-TC e superior à US Doppler no diagnóstico diferencial entre oclusão e pseudo-oclusão da ACI / Purpose: Evaluate the efficacy of second-generation contrast ultrasound (CEUS) for distinguishing the diagnosis of cervical internal carotid artery (ICA) occlusion from the one of pseudo-occlusion when compared with Doppler Ultrasound (DUS) utilizing computerized angiotomography (CTA) as the gold standard. Material and Methods: A prospective study was performed between June 2006 and June 2008 with 72 symptomatic patients (57 males; 15 females) and 78 ICAs apparently occluded by DUS. These patients were initially subjected to DUS and then to CEUS. All patients went through CTA later on, used as the gold standard. Correlation between the methods was made by means of a double-blind study. Results: The sensitivity, specificity and accuracy of CEUS were taken as 100%, 90.5% and 97.4% respectively. When compared with CTA the amount of false occlusions by DUS was 26.9% (21/78), (p < 0.001) whereas by CEUS 2.6% (2/78) (p = 0.500) was seen. Far better results were obtained with CEUS than with DUS with a significant discrepancy (p < 0.001). Conclusion: CEUS shows to be as effective as CTA but better than DUS for distinguishing the diagnosis of ICA occlusion from the one of pseudo-occlusion

Objetivo: Avaliar a eficácia da ultrassonografia com contraste (US com contraste) de segunda geração no diagnóstico diferencial entre oclusão e pseudo-oclusão de artéria carótida interna cervical (ACI) comparativamente à ultrassonografia com Doppler (US Doppler) utilizando a angiotomografia computadorizada (angio-TC) como padrão-ouro. Materiais e Métodos: Estudo prospectivo realizado entre junho de 2006 e junho de 2008 com 72 pacientes sintomáticos (57; 15) e 78 com ACIs aparentemente ocluídas pela US Doppler. Esses pacientes foram submetidos inicialmente à US Doppler e, em seguida, à US com contraste. Todos os pacientes realizaram posteriormente a angio-TC, utilizada como padrão-ouro. A correlação entre os métodos foi feita através de estudo duplo cego. Resultados: A sensibilidade, a especificidade e a acurácia da US com contraste foram respectivamente de 100%; 90,5% e 97,4%. Quando comparada à angio-TC, a quantidade de falsas oclusões pela US Doppler foi de 26,9% (21/78), (p < 0,001), enquanto que pela US com contraste foi de 2,6% (2/78) (p = 0,500). A US com contraste obteve melhor resultado que a US Doppler, com diferença estatisticamente significante (p < 0,001). Conclusão: A US com contraste é tão eficaz quanto a angio-TC e superior à US Doppler no diagnóstico diferencial entre oclusão e pseudo-oclusão da ACI / Purpose: Evaluate the efficacy of second-generation contrast ultrasound (CEUS) for distinguishing the diagnosis of cervical internal carotid artery (ICA) occlusion from the one of pseudo-occlusion when compared with Doppler Ultrasound (DUS) utilizing computerized angiotomography (CTA) as the gold standard. Material and Methods: A prospective study was performed between June 2006 and June 2008 with 72 symptomatic patients (57 males; 15 females) and 78 ICAs apparently occluded by DUS. These patients were initially subjected to DUS and then to CEUS. All patients went through CTA later on, used as the gold standard. Correlation between the methods was made by means of a double-blind study. Results: The sensitivity, specificity and accuracy of CEUS were taken as 100%, 90.5% and 97.4% respectively. When compared with CTA the amount of false occlusions by DUS was 26.9% (21/78), (p < 0.001) whereas by CEUS 2.6% (2/78) (p = 0.500) was seen. Far better results were obtained with CEUS than with DUS with a significant discrepancy (p < 0.001). Conclusion: CEUS shows to be as effective as CTA but better than DUS for distinguishing the diagnosis of ICA occlusion from the one of pseudo-occlusion

Předložená diplomová práce se zabývá interakcí mezi proudící krví a krční tepnou, obsahující aterosklerotický plat, za pomoci konečnoprvkové fluid-structure interaction analýzy. První část práce obsahuje souhrn teoretických poznatků, sestávající z kardiovaskulárního systému, cév, souvisejících konstitutivních modelů, reologie krve a úvodu do teorie proudění. Dále je v práci obsažen stručný souhrn současného poznání výpočtového modelování v této oblasti, s důrazem na strukturní a fluid-structure interaction analýzy v oblasti krční tepny, a na použité konstitutivní modely. Experimentální část se soustředí na tvorbu zjednodušeného modelu krční tepny, obsahující aterosklerotický plat, a na tvorbu odpovídajícího modelu krve. Oba modely poté společně vstupují do fluid-structure interaction analýzy, která si klade za cíl pochopit důsledky pulzujícího toku krve na stěnu tepny a na růst aterosklerotického plátu; primárními zkoumanými veličinami jsou první hlavní napětí na stěně tepny, celková deformace stěny tepny, časově zprůměrovaná hodnota smykového napětí na stěně tepny a oscilační smykový index. Všechny výsledky jsou porovnány napříč několika typy analýz, tak aby bylo možné zhodnotit rozdíly a důsledky zvoleného přístupu. Součástí práce je také zjednodušená parametrická studie, která porovnává vliv rostoucího procenta stenózy na vyhodnocované veličiny. V poslední částí práce jsou zhodnoceny výsledky, její limitace a další možnosti výzkumu v této oblasti.

Hintergrund: Das Auftreten von frühen postinterventionellen Komplikationen nach Stenting der Arteria carotis interna (ACI) wird auf die Embolisierung von Material aus dem Stentsegment zurückgeführt. Zerebrale Thrombembolien können nicht invasiv mittels transkraniellem Dopplerultraschall (TCD) als mikroembolische Signale (MES) detektiert werden. Studienziel : Die Studie wurde durchgeführt um Prädiktoren zu finden, welche eine hohe Anzahl von MES im Intervall einer Stunde nach dem Eingriff voraussagen könnten. Methodik: Bei 134 konsekutiven Patienten, die ein Stenting der ACI erhielten, wurde postinterventionell über eine Stunde eine TCD der ipsilateralen Arteria cerebri media durchgeführt. Zur Identifizierung von klinischen, morphologischen und prozedurabhängigen Parametern für vermehrte MES, wurde eine multivariate logische Regressionsanalyse durchgeführt. Ergebnisse: Bei 134 Patienten (111 männlich, 23 weiblich, mittleres Alter 69,7 Jahre) wurden in 38% MES detektiert (Mittelwert 4 MES/h; Streuung von 1-62MES/h). Zwei Variablen waren mit einer erhöhten postinterventionellen MES Rate vergesellschaftet. Diese waren: Symptomatische Läsionen (p=0,048) und erhöhtes Gesamtcholesterin (p=0,037). Die duale Thrombozytenaggregationshemmung (ASS und Clopidogrel) konnte als unabhängiger Prädiktor (p=0,0001) für eine erniedrigte MES Rate festgestellt werden. Schlussfolgerungen: Postinterventionelle MES konnten am häufigsten bei symptomatischen Läsionen und bei Patienten mit Hypercholesterinämie festgestellt werden. Deren Anzahl viel im Verlauf ab. Das Stentdesign hatte keinen Einfluss auf die Anzahl der gemessenen MES. Die Kombinationstherapie mit ASS und Clopidogrel war ein Prediktor für eine erniedrigte cerebrale Embolisationsrate. Die TCD der MES Rate könnte eine brauchbare Methode sein um mögliche Risikofaktoren für neurologische Komplikationen nach Stenting der ACI zu entdecken und somit die Sicherheit der Stentingprozedur der ACI zu verbessern.

INTRODUÇÃO. Durante a última década, os avanços tecnológicos, o maior domínio da anatomia e das técnicas operatórias e de reconstrução da base do crânio por via endonasal propiciaram a expansão da cirurgia endoscópica para além dos limites da sela túrcica. O acesso transpterigóideo é uma etapa comum ao acesso as fossas cranianas média e posterior, e o conhecimento da anatomia endoscópica da artéria carótida interna (ACI) é um ponto fundamental e comum a estes acessos. OBJETIVO. Descrever a anatomia endoscópica relacionada ao acesso transpterigóideo e da ACI utilizando um modelo anatômico em cabeças cadavéricas frescas procurando definir os parâmetros seguintes: reparos anatômicos do acesso endoscópico a região supra e infrapetrosa, os limites para exposição endoscópica da ACI, os reparos anatômicos para localização dos seus segmentos lacerum, petroso e parafaríngeo. MÉTODOS. Foi realizado estudo anatômico em 20 espécimes (10 cabeças) de cadáveres frescos. As cabeças foram previamente preparadas com a injeção intravascular de silicone corado para enaltecer as estruturas vasculares (ACI, artéria maxilar e seus ramos e seio cavernoso). Em todos os casos foi realizado o acesso transpterigóideo às regiões supra e infrapetrosa, assim como a fossa infratemporal, e a dissecção endoscópica da ACI. RESULTADOS. A injeção de silicone corado no sistema arterial e venoso proporcionou modelo anatômico adequado para dissecção e documentação do acesso transpterigóideo assim como dos diferentes segmentos da ACI. A dissecção por etapas proporcionou exposição adequada da ACI do seu segmento cavernoso ao parafaríngeo distal. O acesso transpterigóideo forneceu exposição adequada do segmento lacerum da ACI e região suprapetrosa e seus principais reparos anatômicos foram o nervo vidiano, nervos maxilar e mandibular (V2, V3) e gânglio de Gasser. A exposição caudal da ACI (segmentos petroso e parafaríngeo) e região infrapetrosa requer maxilectomia medial para exposição e remoção de todo o processo pterigóideo, seguida pela ressecção da tuba auditiva e do tecido fibrocartilaginoso do forame lacerum. Os principais reparos anatômicos desta etapa foram a tuba auditiva e V3. CONCLUSÃO. Durante o acesso endoscópico à região suprapetrosa, o nervo vidiano, os ramos maxilar e mandibular do nervo trigêmeo (V2 e V3) e o gânglio de Gasser são reparos anatômicos para localização da artéria carótida interna e fossa craniana média. Durante o acesso endoscópico à região infrapetrosa, o tecido fibrocartilaginoso do forame lacerum, a tuba auditiva e o nervo mandibular (V3) são reparos anatômicos para identificação da artéria carótida interna. O acesso endoscópico endonasal por etapas permite acesso à artéria carótida interna extracraniana desde o segmento cavernoso até seu segmento parafaríngeo inferiormente ao nível do assoalho da cavidade nasal. O reparo anatômico para localização do segmento lacerum e porção horizontal do segmento petroso da ACI é o nervo vidiano; para as porções petrosa horizontal junto ao joelho posterior e canal carotídeo os reparos anatômicos são o nervo mandibular (V3), forame oval, tecido fibrocartilaginoso do forame lacerum e a tuba auditiva; para o segmento parafaríngeo os reparos anatômicos são o tronco posterior do nervo mandibular (V3) e a tuba auditiva / INTRODUCTION. During the last decade, the technological advances, the mastery of the anatomy and operative techniques and skull base reconstruction using endonasal approaches have propelled endoscopic surgery for beyond the limits of sella turcica. The transpterygoid approach is a common step of the endoscopic approach to the middle and posterior cranial fossa and knowledge of the endoscopic anatomy of the internal carotid artery (ICA) is a common and paramount point to these approaches. OBJECTIVE. Describe the endoscopic anatomy related to the transpterygoid approach and ICA using an anatomical model with fresh human cadaveric heads to define: anatomical landmarks related to the endoscopic supra and infrapetrous areas approach, limits for endoscopic exposure of the ICA, anatomical endoscopic landmarks to lacerum, petrous and parapharyngeal ICA segments. METHODS. An anatomical study was performed using 20 specimens (10 heads) of fresh cadaveric heads. The heads were previously prepared with the injection of colored silicone to enhance the vascular structures (ICA, maxillary artery and its branches and cavernous sinus). In all cases we performed the transpterygoid approach to the supra and infrapetrous areas, as well as the infratemporal fossa, and the endoscopic dissection of the ICA. RESULTS. The injection of colored silicone in the arterial and venous system provided an adequate anatomical model for dissection and documentation of the transpterygoid approach as well as the different segments of the ICA. A stepwise dissection provided adequate exposure of the ICA from its cavernous to the distal parapharyngeal segment. The transpterygoid approach provided adequate exposure of the lacerum segment of the ICA and suprapetrous area and the landmarks were the vidian nerve, maxillary and mandibular nerves (V2, V3) and the Gasserian ganglion. Exposure of the caudal ICA (petrous and parapharyngeal) and the infrapetrous area required a medial maxillectomy for exposure and resection of the entire pterygoid process, followed by the Eustachian tube and the fibrocartilaginous tissue of the foramen lacerum. The main anatomical landmarks to this step were V3 and the Eustachian tube. CONCLUSION. During the endoscopic approach to the suprapetrous area, the vidian nerve, the maxillary and mandibular divisions of the trigeminal nerve (V2, V3) and the Gasserian ganglion are the anatomical landmarks to the internal carotid artery and middle cranial fossa. During the endoscopic approach to the infrapetrous area, the fibrocartilaginous tissue of the foramen lacerum, the Eustachian tube and V3 are the landmarks to the internal carotid artery. A stepwise endoscopic endonasal approach provided access to the extracranial internal carotid artery from its cavernous to the parapharyngeal segment down to the level of the nasal fossa floor. The anatomical landmark to the lacerum and horizontal petrous segments of the internal carotid artery is the vidian nerve; to the horizontal petrous segment before the posterior bend and carotid canal, the anatomical landmarks are the mandibular nerve (V3), foramen ovale, fibrocartilaginous tissue of the foramen lacerum and the Eustachian tube; to the parapharyngeal segment, the anatomical landmarks are the posterior trunk of the mandibular nerve (V3) and the Eustachian tube