Atheromatous disease of the carotid artery

Correlation of angiographic, clinical, and surgical findings

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✓Angiograms of patients who underwent carotid artery surgery were correlated with the surgical findings, cerebral blood flow measurements, and the following manifestations of cerebral ischemia: amaurosis fugax, transient cerebral ischemia,small completed infarct, generalized cerebral ischemia, and progressing stroke. The degree of carotid stenosis and presence of ulcerating plaques and soft thrombi could be predicted accurately; tiny ulcerations were not angiographically identifiable in the presence of severe stenosis. Generalized cerebral ischemia corresponded closely with severe degrees of bilateral carotid stenosis or unilateral occlusion in conjunction with contralateral stenosis. Internal carotid to middle cerebral artery slow flow was found in many patients with a progressing stroke or an unstable neurological state. Retrograde ophthalmic flow was found frequently in symptomatic patients with high-grade stenotic lesions at the origin of the internal carotid artery. Localized alterations included small vessel occlusion, retrograde collateral flow, avascular areas, focal slow flow, and reactive hyperemia and were correlated with symptoms of focal cerebral ischemia.

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Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Mayo Clinic, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Angiography of “carotid slim sign” indicating a vessel with unusually low perfusion pressure; this must be distinguished from a hypoplastic artery. Note multiple occlusions of the left middle cerebral arterial branches and opaciflcation of the meningeal and scalp arteries distally. (Fig. 7 shows right brachial angiogram from same case.)

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    Angiograms demonstrating occlusion of small cortical vessels. A. Midarterial phase of angiography. B. Late arterial phase showing occlusions (arrows) of embolic origin.

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    Angiograms demonstrating focal slow flow. A. Midarterial phase. B. Late arterial phase showing area of focal slow flow, probably due to embolic occlusion of multiple small vessels in parieto-occipital region. Note densely opacified irregular vessel, particularly in parietal region.

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    Right lateral views of same case as in Fig. 3, showing collateral or retrograde flow into multiple occluded branches of the left middle cerebral artery. A. Late arterial phase. B. Early venous phase.

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    Angiograms demonstrating reactive hyperemia. A. Midarterial phase. B. Late arterial phase showing vascular stain and early draining vein in posterior frontal area. Reactive hyperemia (“luxury perfusion”) is evidenced by the early venous drainage due to physiological shunting between arterioles and venules in the pia arachnoid surrounding an area of ischemia.

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    Angiograms showing focal mass effect in temporal lobe, manifested by displacement of normal vessels in peripheral zones of ischemia and due to focal edema. A. Anteroposterior view. B. Lateral view.

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    Angiograms showing ICA-MCA slow flow. A. Early phase. B. Late arterial phase. Note that distal branches of the external carotid artery fill simultaneously with, if not before, distal branches of middle cerebral artery.

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