- Department of Neurosurgery, Moriyama Memorial Hospital (M.M.H.), 7-12-7 Nishikasai, Edogawa-ku, Tokyo 134-0088, Japan
- Department of Cardiology, Moriyama Memorial Hospital (M.M.H.), 7-12-7 Nishikasai, Edogawa-ku, Tokyo 134-0088, Japan
Correspondence Address:
Haruko Yoshimoto
Department of Neurosurgery, Moriyama Memorial Hospital (M.M.H.), 7-12-7 Nishikasai, Edogawa-ku, Tokyo 134-0088, Japan
DOI:10.4103/2152-7806.143721
Copyright: © 2014 Yoshimoto H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Yoshimoto H, Asakuno K, Matsuo S, Ishida A, Shiramizu H, Niimura K, Yuzawa M, Yamagishi Y, Munakata T, Moriyama T, Hori T. Idiopathic carotid and coronary vasospasm: A case treated by carotid artery stenting. Surg Neurol Int 30-Oct-2014;5:
How to cite this URL: Yoshimoto H, Asakuno K, Matsuo S, Ishida A, Shiramizu H, Niimura K, Yuzawa M, Yamagishi Y, Munakata T, Moriyama T, Hori T. Idiopathic carotid and coronary vasospasm: A case treated by carotid artery stenting. Surg Neurol Int 30-Oct-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/idiopathic-carotid-coronary-vasospasm-case-treated-carotid-artery-stenting/
Abstract
Background:We previously reported a case of cerebral infarction complicated by myocardial infarction. The pathogenesis of both infarctions was thought to be vasospasm; thus, we named this condition ‘idiopathic carotid and coronary vasospasm’. Various medical treatments for the prevention of carotid vasospasm have been unsuccessfully tried. Thus, other effective treatments should be established for patients who frequently suffer cerebral ischemic attacks.
Case Description:We treated the present case of ‘idiopathic carotid and coronary vasospasm’ by carotid artery stenting (CAS). The first stenting, of the carotid bifurcation, failed to prevent internal carotid artery (ICA) vasospasm. However, after an additional stent placement to the prepetrous portion, ischemic attacks were dramatically reduced.
Conclusion:The effect of CAS for extracranial ICA vasospasm was dramatic and control of the spasm at the prepetrous portion seems to be essential. Further validation of the effectiveness and safety of CAS for ICA vasospasm will be necessary.
Keywords: Carotid vasospasm, cerebral infarction, carotid stent placement, vasospastic angina, young patient
INTRODUCTION
To date, several studies have reported transient and recurring stenosis of the extracranial internal carotid artery (ICA) [
In 2011, we reported a case of a cerebral infarction complicated by myocardial infarction, both of which were caused by vasospasm. We named this condition ‘idiopathic carotid and coronary vasospasm (ICCV)’.[
Shortly after that case, we encountered another example of this syndrome.
CASE REPORT
History and examination
A 40-year-old female without known cardiovascular risk factors or migraine episodes visited the Moriyama Memorial Hospital (M.M.H.) outpatient clinic in February 2011 after suddenly developing global aphasia and right hemiparesis. Emergent diffusion-weighted magnetic resonance imaging (DW-MRI) revealed fresh cerebral infarctions [
Figure 1
At onset of cerebral infarction, diffusion weighted magnetic resonance imaging (DW-MRI) revealed fresh infarctions in the left cerebral hemisphere (1-A, arrows). MRA revealed a stenotic lesion in the cervical segment of the left ICA (1-B, arrow). DSA (1-C, arrow), and MRA (1-D, arrows) on the second day after the onset revealed no evidence of stenosis
Figure 2
Myocardial scintigraphy identified the area without myocardial viability. Thereafter, an old myocardial infarction of the inferolateral wall was confirmed (
Treatment and posttreatment course
The patient gave informed consent and CAS procedures were performed in accordance with our institutional guidelines in September 2011. Because the safety of stent deployment near to the first cervical vertebra, where the torsional stress might be larger than lower cervical levels, had not been established, CAS covering only the bifurcation in the same fashion as for atherosclerotic stenosis was performed, using a Carotid Wallstent® [
Figure 3
The first carotid stent was placed covering the bifurcation in the same fashion as for atherosclerotic stenosis from the level of the upper C2 superior endplate to the body of the C5 [
DISCUSSION
This is the second case we have reported for this rare condition ‘ICCV’ and its treatment with CAS.
Among 12 past patients, only 1 case almost identical to ours has been reported, by Kuzumoto et al.[
In the literature, the focus has been on whether ICA vasospasm is related to migraine, like reversible cerebral vasoconstriction syndrome[
Alternatively, it has been pointed out that the prevalence of migraine was significantly higher in the patients with vasospastic angina than in the control groups. On the basis of the result, Miller et al. proposed the concept ‘generalized vasospastic disorder’.[
If this concept was extended to include extracranial ICA vasospasm, it could consistently elucidate the combination of carotid vasospasm, migraine, and vasospastic angina in the past nine cases. However, it should be validated further.
Until now, few specific recommendations for the prophylaxis of extracranial ICA vasospasm could be made. Some papers report calcium antagonists[
CAS showed a curative effect for our previous patient.[
Our previous case experienced amaurosis fugax of the contralateral side proceeding to the initial side. Including this patient, in 9 (69%) of the past 13 patients, the affected side advanced from unilateral to bilateral, or both carotid arteries were initially affected. Patients presenting with ICCV may have a wide distribution of potentially sensitive arteries. Thus, they should be carefully followed and optimal medical strategies should remain sought.
Extracranial ICA stenosis is always relieved for hours to days. For this reason, diagnosis of extracranial ICA vasospasm is potentially difficult. Extracranial ICA vasospasm or ICCV should be included in the differential diagnoses for younger patients who suffered from cerebral infarctions of unknown etiology.
References
1. Arning C, Schrattenholzer A, Lachenmayer L. Cervical carotid artery vasospasms causing cerebral ischemia: Detection by immediate vascular ultrasonographic investigation. Stroke. 1998. 29: 1063-6
2. Calabrese LH, Dodick DW, Schwedt TJ, Singhal AB. Narrative review: Reversible cerebral vasoconstriction syndromes. Ann Intern Med. 2007. 146: 34-44
3. Dembo T, Tanahashi N. Recurring extracranial internal carotid artery vasospasm detected by intravascular ultrasound. Intern Med. 2012. 51: 1249-53
4. Fujimoto M, Itokawa H, Morita M, Okamoto N, Tomita Y, Kikuchi N. Treatment of idiopathic cervical internal artery vasospasms with carotid artery stenting: A report of 2 cases. Journal of Neuroendovascular Therapy. 2013. 7: 24-31
5. Janzarik WG, Ringleb PA, Reinhard M, Rauer S. Recurrent extracranial carotid artery vasospasms: Report of 2 cases. Stroke. 2006. 37: 2170-3
6. Kuzumoto Y, Mitsui Y, Ueda H, Kusunoki S. Vasospastic cerebral infarction induced by smoking: A case report. No To Shinkei. 2005. 57: 33-6
7. Lieberman AN, Jonas S, Hass WK, Pinto R, Lin J, Leibowitz M. Bilateral cervical carotid and intracranial vasospasm causing cerebral ischemia in a migrainous patient: A case of ‘diplegic migraine’. Headache. 1984. 24: 245-8
8. Miller D, Waters DD, Warnica W, Szlachcic J, Kreeft J, Theroux P. Is variant angina the coronary manifestation of a generalized vasospastic disorder?. N Engl J Med. 1981. 304: 763-6
9. Moeller S, Hilz MJ, Blinzler C, Koehn J, Doerfler A, Schwab S. Extracranial internal carotid artery vasospasm due to sympathetic dysfunction. Neurology. 2012. 78: 1892-4
10. Mosso M, Jung HH, Baumgartner RW. Recurrent spontaneous vasospasm of cervical carotid, ophthalmic and retinal arteries causing repeated retinal infarcts: A case report. Cerebrovasc Dis. 2007. 24: 381-4
11. Rothrock JF, Walicke P, Swenson MR, Lyden PD, Logan WR. Migraneous stroke. Arch Neurol. 1988. 45: 63-7
12. Wissgott C, Schmidt W, Behrens P, Brandt C, Schmitz KP, Andresen R. Experimental investigation of modern and established carotid stents. Rofo. 2014. 186: 157-65
13. Yokoyama H, Yoneda M, Abe M, Sakai T, Sagoh T, Adachi Y. Internal carotid artery vasospasm syndrome: Demonstration by neuroimaging. J Neurol Neurosurg Psychiatry. 2006. 77: 888-92
14. Yoshimoto H, Matsuo S, Umemoto T, Kawakami N, Moriyama T. Idiopathic carotid and coronary vasospasm: A new syndrome?. J Neuroimaging. 2011. 21: 273-6