Imaging Studies

See the list below:

Angiography: The initial assessment for risk of stroke during internal carotid occlusion consists of 4-vessel angiography, which establishes the patency of the vessels and the potential availability of collateral flow through the circle of Willis if one carotid is occluded.
Trial balloon occlusion
- When collateral flow is present based on angiography findings, temporary preoperative occlusion provides physiologic information on the patient's ability to tolerate transient or permanent occlusion of the carotid to be resected. The original diagnostic trials of carotid occlusion were performed intraoperatively on the common carotid artery using umbilical tape under local anesthesia.^[24]Trial balloon occlusion (TBO) performed during angiography has replaced operative trial occlusion. The patient is heparinized while the balloon catheter is placed under angiographic guidance. It is inflated in the internal carotid artery for up to 15-30 minutes while the patient is monitored for development of neurologic signs and symptoms.
- For multiple reasons, even when the patient tolerates TBO, a cerebral vascular accident (CVA) may develop if simple operative ligation is ultimately performed. First, thrombus is thought to develop in the distal carotid stump, leading to subsequent delayed embolization. Second, intraoperative blood loss and decreased systemic blood pressure under general anesthesia may decrease regional cerebral blood flow (CBF) more than balloon occlusion or ligation alone. For this reason, a hypotensive challenge during TBO may improve the predictive value of the test but is not routinely performed at most centers.^[25]
Flow Scanning
- Single-photon emission computed tomography scanning
  - Because of the inadequacy of predicting cerebral ischemia with TBO alone, CBF studies during carotid occlusion have been developed. Single-photon emission computed tomography (SPECT) imaging using technetium-99m hexamethylpropyleneamine oxime (Tc-99m HMPAO) provides a semiquantitative comparison of blood flow to each hemisphere. After the patient has tolerated TBO, Tc-99m is injected intravenously, with the balloon kept inflated for an additional 15-30 minutes. Tc-99m is converted to a hydrophilic form inside the brain that is retained for hours. Because the half-life of Tc-99m is 6 hours, SPECT scanning can be delayed until after completion of angiography and TBO.
  - Tc-99m SPECT scanning does not provide an exact measurement of regional CBF. Rather, it is evaluated based on differences in tracer retention between the 2 sides, and adequate CBF is defined as less than a 10% difference between hemispheres.
- Xenon flow scanning
  - During TBO, CBF may rise or fall in either hemisphere, resulting in a significant difference in CBF between hemispheres. Thus, determination of the absolute CBF may be helpful in overcoming this ambiguity inherent in interpretation of SPECT scans. Xenon-133 scans offer a more quantitative measurement of regional CBF but are technically more difficult than SPECT when used in conjunction with TBO.^[5]Although the carotid is occluded, the patient must inhale xenon gas and, unlike with SPECT, undergo simultaneous nuclear medicine scanning because xenon is rapidly absorbed and discharged.
  - The primary difficulty with this technique lies in the need to take the patient from the angiography suite to the nuclear medicine scanner with certainty that the balloon is still in place. In order to perform this procedure optimally, the nuclear medicine scanner needs to be present in the angiography suite. With this technique, adequate CBF is defined as greater than 30 mL/100g/min, although some require a threshold of as high as 40 mL/100g/min to be considered low risk.^[26]
  - Regional CBF may also be measured using stable xenon as a CT contrast agent. This method requires transferring the patient to the CT scanning unit with a catheter in place and with the same considerations as in xenon flow scans. The quantitative results from this method have been shown to prevent frequent misinterpretation of flow asymmetries between hemispheres that may lead to a false-positive reading of a SPECT scan.^[27]

Treatment & Management

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Author

Devraj Basu, MD, PhD, FACS Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System

Devraj Basu, MD, PhD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American College of Surgeons, American Head and Neck Society

Disclosure: Nothing to disclose.

Coauthor(s)

John M Truelson, MD, FACS Chairman, Division of Head and Neck Surgery, Associate Professor, Department of Otorhinolaryngology, University of Texas Southwestern Medical Center at Dallas

John M Truelson, MD, FACS is a member of the following medical societies: American Head and Neck Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Phi Beta Kappa, Texas Medical Association

Disclosure: Nothing to disclose.

Gregory S Weinstein, MD, FACS Professor and Vice-Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Director of Division of Head and Neck Surgery, Director of Head and Oncology Fellowship, Director of Otorhinolaryngology-Head and Neck Clinic, Co-director of The Center for Head and Neck Surgery, University of Pennsylvania School of Medicine

Gregory S Weinstein, MD, FACS is a member of the following medical societies: American Head and Neck Society, American Laryngological Association, American Radium Society, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, The Triological Society, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nader Sadeghi, MD, FRCSC Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, McGill University Faculty of Medicine; Chief Otolaryngologist, MUHC; Director, McGill Head and Neck Cancer Program, Royal Victoria Hospital, Canada

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merck.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Additional Contributors

Richard V Smith, MD Director of Clinical Affairs, Associate Professor, Department of Otolaryngology, Division of Head and Neck Surgery, Einstein College of Medicine, Montefiore Medical Center

Richard V Smith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, The Triological Society, American Medical Association, American Medical Student Association/Foundation, Medical Society of the District of Columbia, New York Academy of Medicine, Vermont Medical Society

Disclosure: Nothing to disclose.

Sections Management of the Neck With Carotid Artery Involvement
Overview
Workup
Treatment
Tables
References

Study	Number of Patients	Number of Events	Temporary Ischemia	Permanent Cerebral Vascular Accident (CVA)	Deaths CNS	Total Deaths	Embolic Blindness
Maves et al^[19]	20	7	0	7	3	4	2
Konno et al^[18]	156	53	6	47	24	. . .	. . .
Razack and Sako^[20]	77	25	1	24	4	. . .	. . .

Management of the Neck With Carotid Artery Involvement Workup

Imaging Studies

References

Tables

Contributor Information and Disclosures

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