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Roberto C. Heros and Laligam N. Sekhar

✓ An increasing number of patients with symptomatic carotid artery occlusion are being referred for extracranial to intracranial bypass grafts. After careful clinical and angiographic assessment, a number of these patients have been treated with a direct approach to the carotid arteries in the neck or with anticoagulation rather than with a bypass graft. These patients may be categorized diagnostically under the following headings: 1) complete occlusion of the internal carotid artery (ICA) with intracranial patency; 2) spontaneous dissection of the ICA; 3) atheromatous pseudo-occlusion; 4) carotid artery occlusion with stenosis of the contralateral ICA; 5) occlusion of the ICA and stenosis of the external carotid artery; and 6) thrombus in the intracranial segment of an occluded ICA. Each of these categories is discussed briefly, and illustrative cases are presented.

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Laligam N. Sekhar, Roberto C. Heros, Preston R. Lotz, and Arthur E. Rosenbaum

✓ In the past year, three patients were referred for microvascular bypass surgery for relief of symptoms secondary to an apparently occluded internal carotid artery (ICA). Careful review of the late films of their initial arteriographic series or repeat arteriography with a specialized technique revealed a thin trickle of contrast medium flowing antegrade through a region of extreme stenosis. This thin line of contrast material ascended slowly to meet the column of contrast medium in the cavernous carotid segment that was filling by collateral circulation. Surgical exploration of the neck in these patients revealed a patent but collapsed ICA distal to a localized atheromatous plaque. These patients have been asymptomatic following carotid endarterectomy. This distinctive angiographic appearance may be described as “atheromatous pseudo-occlusion.” Once recognized, carotid endarterectomy is the logical treatment of choice.

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Laligam N. Sekhar, Roberto C. Heros, and Charles W. Kerber

✓ Carotid arterial puncture during percutaneous retrogasserian procedures is a common but usually harmless complication. Strokes, resulting presumably from carotid artery thrombosis, have been reported previously following percutaneous retrogasserian coagulation. The authors report two cases of carotid-cavernous fistula, one following percutaneous radiofrequency rhizotomy and the other after percutaneous retrogasserian block. The latter patient had an anomalous primitive foramen lacerum. Both fistulas were obliterated successfully by intracavernous injection of isobutyl-2 cyanoacrylate, using intra-arterial balloon flotation catheters. Carotid-cavernous fistula is a potentially serious complication of such procedures, and may be more common than realized since small fistulas may close spontaneously.