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Agenesis or hypoplasia of the internal carotid artery (ICA) may easily be confused with dissection or occlusion. We report a case of a 24-year-old female with complaint of acute left-hand hypoesthesia and a history of occasional intermittent numbness of her right hand with myoclonic jerking. Because previous imaging studies over 2 years were interpreted as occlusion of the left ICA secondary to carotid dissection, the treating physician had prescribed anticoagulant therapy. During transcranial Doppler (TCD) examination, the spectral waveform was unexpectedly normal, prompting a repeat review of all imaging due to the TCD results. Magnetic resonance angiography (MRA) revealed the same "flame-like" appearance of the ICA origin. Late-phase digital subtraction angiography showed a small caliber cervical ICA (occluded at the skull base). Computed tomography demonstrated absence of the carotid canal, confirming an absent intracranial portion of the ICA and establishing a correct diagnosis of left internal carotid hypoplasia. Vascular ultrasound and TCD examinations are noninvasive and inexpensive tools that can improve the interpretation and understanding of the clinical significance of other "static" radiographic tests (MRA, digital subtraction angiography ). An accurate diagnosis is essential to avoid risky, aggressive treatment, such as anticoagulation for an "absent" dissection.

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INTRODUCTION: Visual loss secondary to a vascular loop or atherosclerotic carotid has been a controversial topic for many years with contemporary data supporting its existence. The role of surgery in the management of this entity is not well defined. We performed a systematic review describing the different surgical techniques and outcomes. METHOD: A search strategy was devised in accordance with the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search was performed from the databases Pubmed, Google scholar, Scopus and Web of Science databases. The search was performed from inception until the 10th of December 2023. RESULTS: A total of 2469 articles were screened with 15 articles describing 18 patients being included. Of these cases, eleven involved compression due to unilateral or bilateral dolichoectatic internal carotid artery (ICA), three for a dolichoectatic anterior cerebral artery (ACA), two for a combination of a dolichoectatic ICA with a dorsolateral ophthalmic artery and two for a combination of a dolichoectatic ICA and ACA. CONCLUSION: Two distinct compressive entities can be differentiated. Compressive optic neuropathy at the entrance of the optic canal due to pinching between an ectatic carotid and the falciform ligament. A second entity is due to compression of the cisternal optic nerve or chiasm secondary tot a vascular loop. A variety of surgical techniques have been described and include: unroofing of the optic canal with sectioning of the falciform ligament; microvascular decompression with a Teflon® pellet, a muscle patch or, rerouting of the offending vessel with a sling. Larger and prospective studies are needed to better define the role of surgery in this, probably, underreported pathology.

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BACKGROUND AND OBJECTIVES: The internal capsule is supplied by perforators originating from the internal carotid artery, middle cerebral artery, anterior choroidal artery and anterior cerebral artery. The aim of this study is to examine the vascular anatomy of the internal capsule, along with its related white matter anatomy, in order to prevent potential risks and complications during surgical interventions. METHODS: Twenty injected hemispheres prepared according to the Klingler method were dissected. Dissections were photographed at each stage. The findings obtained from the dissections were illustrated to make them more understandable. Additionally, the origins of the arteries involved in the vascularization of the internal capsule, their distances to bifurcations, and variations in supplying territories have been thoroughly examined. RESULTS: The insular cortex and the branches of the middle cerebral artery on the insula and operculum were observed. Following decortication of the insular cortex, the extreme capsule, claustrum, external capsule, putamen and globus pallidus structures were exposed. The internal capsule is shown together with the lenticulostriate arteries running on the anterior, genu and posterior limbs. Perforators supplying the internal capsule originated from the middle cerebral artery, anterior cerebral artery, internal carotid artery and anterior choroidal artery. The internal capsule's vascular supply varied, with the medial lenticulostriate arteries (MLA) and lateral lenticulostriate arteries (LLA) being the primary arteries. The anterior limb was most often supplied by the MLA, while the LLA and anterior choroidal artery dominated the genu and posterior limb. The recurrent artery of Heubner originated mostly from the A2 segment. The distance from the ICA bifurcation to the origin of the first LLA on M1 is 9.55 ± 2.32 mm, and to the first MLA on A1 is 5.35 ± 1.84 mm. MLA branching from A1 and proximal A2 ranged from 5 to 9, while LLA originating from the MCA ranged from 7 to 12. CONCLUSION: This study provides comprehensive understanding of the arterial supply to the internal capsule by combining white matter dissection. The insights gained from this study can help surgeons plan and execute procedures including oncological, psychosurgical, and vascular more accurately and safely. The illustrations derived from the dissections serve as valuable educational material for young neurosurgeons and other medical professionals.

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A man in his 50s presented with acute left-sided weakness, facial drooping and slurred speech, suggestive of a major stroke. Imaging revealed a complete blockage in the right internal carotid artery (ICA) due to dissection. Perfusion studies showed a significant area at risk of infarction. Attempted navigation of standard carotid stents failed due to the tortuosity of the ICA. A balloon-mounted coronary stent was successfully deployed in the petrous ICA segment, restoring blood flow. A follow-up MRI confirmed stent patency, and the patient achieved complete recovery with return to baseline function. Symptomatic carotid artery dissections can be treated with stenting to prevent strokes, however, tortuous ICAs in distal dissections pose a technical challenge. Balloon-mounted coronary stents, though not approved for this use, can offer a feasible solution. This case highlights the need for further research and development of devices for managing dissections in distal locations in tortuous ICAs.

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Most anatomic features of the internal carotid artery (ICA) are described as a straight course to the skull base free of branches. In some cases, the excessive elongation of the internal carotid artery in a confined space results in a curvature showing a "C" or "S" shape, or in an abnormal vascular shape made of a single or double vessel loop. These anatomic variants are called dolichoarteriopathies of the internal carotid artery. The correlation between dolichoarteriopathy of the ICA and stroke is still questionable, however it is believed that it can be associated with cerebral ischemia with a clinical symptomatology that accompanies ischemic stroke. We report a case of a 41-year-old patient, with a history of hypertension, who was admitted for right hemiparesis with Broca's aphasia. The rest of the clinical examination was normal. Radiological investigations confirmed an acute left sylvian ischemic stroke with an abrupt occlusion of the posterior trunk of the left M2 segment on the CT angiogram, an excessive elongation of the ICA on both sides, describing a shape of coils or loops. Etiologic workup for ischemic stroke was negative.

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BACKGROUND: This report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis. CASE PRESENTATION: Left internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery. CONCLUSION: This case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

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It is important to examine the ocular hemodynamic changes after carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with internal carotid artery stenosis (ICAS). We aimed to compare the differences in retinal and optic nerve head blood flow after 2 surgical methods. The ipsilateral eyes of 34 patients who had over 50% ICAS with no ocular findings and 30 healthy controls were included in the study. Foveal avascular zone vessel density in the superficial retinal capillary plexus, deep retinal capillary plexus (DCP), and radial peripapillary capillary plexus (RPCP) were measured with an optical coherence tomography angiography device. These measurements were repeated 1 month after CAS or CEA in patients with ICAS. The preoperative and postoperative values of the patients were compared both within themselves and with the control group. When patients with ICAS were compared with the control group, lower vessel density values were found in the DCP parafovea, RPCP whole image, and peripapillary regions both before and after the procedure. There was no significant difference in terms of other parameters. Furthermore, there was no significant difference in any parameter examined between the pre- and postprocedural values of the patients who underwent CAS and CEA. DCP and RPCP are mostly affected in patients with ICAS. We observed that after application of the CAS and CEA methods, the effects on ocular blood flow were similar.

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Dynamic 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography (dFDG-PET) for human brain imaging has considerable clinical potential, yet its utilization remains limited. A key challenge in the quantitative analysis of dFDG-PET is characterizing a patient-specific blood input function, traditionally reliant on invasive arterial blood sampling. This research introduces a novel approach employing non-invasive deep learning model-based computations from the internal carotid arteries (ICA) with partial volume (PV) corrections, thereby eliminating the need for invasive arterial sampling. We present an end-to-end pipeline incorporating a 3D U-Net based ICA-net for ICA segmentation, alongside a Recurrent Neural Network (RNN) based MCIF-net for the derivation of a model-corrected blood input function (MCIF) with PV corrections. The developed 3D U-Net and RNN was trained and validated using a 5-fold cross-validation approach on 50 human brain FDG PET scans. The ICA-net achieved an average Dice score of 82.18% and an Intersection over Union of 68.54% across all tested scans. Furthermore, the MCIF-net exhibited a minimal root mean squared error of 0.0052. The application of this pipeline to ground truth data for dFDG-PET brain scans resulted in the precise localization of seizure onset regions, which contributed to a successful clinical outcome, with the patient achieving a seizure-free state after treatment. These results underscore the efficacy of the ICA-net and MCIF-net deep learning pipeline in learning the ICA structure's distribution and automating MCIF computation with PV corrections. This advancement marks a significant leap in non-invasive neuroimaging.

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BACKGROUND: Carotid siphon calcification (CSC) serves as a marker of atherosclerosis and therefore may influence the outcome after subarachnoid hemorrhage (aSAH). We aimed to analyze the impact of CSC on neurological outcomes, ischemia, and vasospasm. METHODS: A total of 716 patients with aSAH were treated between December 2004 and June 2016 in our central European tertiary neurovascular care center in Essen, Germany. CSC was recorded using the Woodcock scale (grades 0-3) on a computed tomography scan. Study end points included an unfavorable outcome at 6 months post-aSAH (modified Rankin Scale score ≥4), vasospasm, and early cerebral ischemia (72 hours) and delayed cerebral ischemia (delayed cerebral ischemia; >72 hours) in the follow-up computed tomography scans. The associations were adjusted for patients' baseline characteristics and secondary complications. Finally, within a subgroup analysis, patients with and without daily aspirin intake after endovascular aneurysm occlusion were compared. RESULTS: Increasing grades of CSC were associated with lower rates of vasospasm in the anterior circulation. Severe CSC (grade 3) was independently related to the risk of an unfavorable outcome (adjusted odds ratio [aOR], 4.06 [95% CI, 1.98-8.33]; P<0.001) and early cerebral ischemia (aOR, 1.58 [95% CI, 1.03-2.43]; P=0.035) but not delayed cerebral ischemia (aOR, 1.08 [95% CI, 0.67-1.73]; P=0.763). In the aspirin subgroup analysis, the negative effect of severe CSC on functional outcome remained significant only in aSAH cases without aspirin (aOR, 5.47 [95% CI, 2.38-12.54]; P<0.001). In contrast, there was no association between severe CSC and unfavorable outcomes among individuals with daily aspirin intake (aOR, 0.84 [95% CI, 0.59-4.21]; P=0.603). CONCLUSIONS: Our data suggest CSC as a cerebrovascular risk factor resulting in higher rates of early cerebral ischemia and unfavorable outcomes after aSAH. However, by increasing arterial stiffness, CSC might lower the probability of vasospasm, which could explain the missing link between CSC and delayed cerebral ischemia. Additionally, aspirin intake seems to potentially mitigate the negative impact of CSC on aSAH outcome. Further investigations are needed to confirm the observations from the present study.

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BACKGROUND AND OBJECTIVES: The cavernous internal carotid artery (cICA) and its branches can make it challenging to approach the lateral portion of the retrocarotid area of the cavernous sinus (RcACS) and surrounding areas during the endoscopic endonasal approach (EEA). This can sometimes require more invasive transcranial approaches, causing a higher risk of complications. We sought to explore the feasibility of adding a contralateral transmaxillary (CTM) corridor to improve access to the RcACS during EEA. METHODS: We performed EEA and CTM extensions on 6 cadavers (12 sides) using image guidance. The depth of the surgical corridor, the surgical exposure, the angle of attack, and the trajectory to the anterior genu of the cICA were measured. Two illustrative clinical cases are presented. RESULTS: Compared with the contralateral transnasal approach, the CTM corridor provided a 10.76 (5.32)-mm shorter distance ( P < .001), 36.23% (20.70%) larger surgical exposure ( P < .001), and a 24.6° (3.4°) more parallel trajectory to the anterior genu of the cICA ( P < .001). The mean angle of the lateral nasal wall line and the middle eye line was equal to the mean angle of the contralateral transnasal ( P = .075) and CTM ( P = .262) approaches, respectively. The CTM corridor allowed us to achieve near-total resection of the RcACS and beyond in 2 invasive adenomas with significant lateral extension. CONCLUSION: The CTM corridor is a feasible addition to standard EEA to access the RcACS and beyond, providing a more medial-to-lateral trajectory and improved access. The middle eye line can be used as a reference to help select patients for this approach.

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PURPOSE: To describe a case of multiple extremely rare cervical arterial variations. METHODS: A 55-year-old man with a tentative diagnosis of right internal carotid artery (ICA) stenosis was examined using computed tomography (CT) angiography for the evaluation of vascular lesions in the neck and head region. A 64-slice CT machine was used. RESULTS: On CT angiography, there was laterally located and narrowed petrous segment of the right ICA, indicative of aberrant course of the petrous ICA. Right vertebral artery (VA) was small in caliber and a relatively large anomalous artery arose from the proximal right ICA. This anomalous artery entered the posterior fossa via the foramen magnum, indicative of a type 1 proatlantal artery. Right occipital artery (OA) arose from the proximal ICA. The left OA also arose from the proximal ICA. CONCLUSION: An aberrant course of the petrous ICA is an extremely rare arterial variation which is formed by segmental agenesis of the cervical ICA, and the collateral channel passes through the middle ear cavity. It can be dangerous during middle ear surgery. The type 1 proatlantal artery is also an extremely rare arterial variation formed by the persistence of the proatlantal intersegmental artery. It is clinically significant because of its unique blood flow from the carotid system to the vertebrobasilar system. The OA rarely arises from the proximal ICA. Identification of these cervical arterial variations before surgery and vascular intervention are important to avoid complications during the procedure.

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OBJECTIVE: To investigate the effect of embolic protection device (EPD) use on periprocedural complications in patients with carotid artery stenosis with anatomical variations. METHOD: The study retrospectively evaluated 185 patients who consecutively underwent carotid artery stenting between November 2020 and December 2023. Forty-four patients with difficult anatomical structures, anatomical variations in the common carotid artery (CCA) and internal carotid artery (ICA) (tortuosity, kinking, or coiling), and a CCA-ICA angle of >60 degrees were included in the sample. The patients were divided into two groups according to the use of EPD filters during the procedure and compared in terms of periprocedural events. RESULTS: Of the 44 patients included in the study, 24 (54.5 %) were male, and the mean age of all patients was 68.7 ± 8.7 years. Comorbidities were present in 93.2 % (n = 41) of the patients. The most common comorbidity was hypertension (n = 32, 72.8 %). The CCA-ICA angle was ≥60 degrees in 45.4 % (n = 20) of all patients. ICA tortuosity was detected in 27.2 % (n = 12) of the patients, ICA kinking in 13.6 % (n = 6), ICA coiling in 6.8 % (n = 3), and CCA tortuosity in 6.8 % (n = 3). Procedure-related periprocedural events developed in 38.6 % (n = 17) of the patients. Postprocedural mortality occurred in two patients, secondary to myocardial infarction in one and COVID-19 pneumonia in the other. There was no significant difference between the filter and non-filter groups in relation to periprocedural events (p = 0.638). Major stroke did not occur in either group. Minor neurological events occurred in 15 % (n = 3/20) of the patients in the filter group and 16.7 % (n = 4/24) of those in the non-filter group. The incidence of vasospasm was statistically higher in patients using filters compared to those without filters (30 % vs. 0 %; P = 0.005, respectively). CONCLUSION: Evaluation of vascular anatomy before carotid artery stenting is important to decide on the technical procedure to be applied in the procedure. The use of EPD in unfavorable anatomy does not reduce periprocedural neurological events. Instead, it results in technical difficulties, prolongs the duration of procedure, and leads to arterial vasospasm. Considering the high periprocedural events in this study, carotid endarterectomy may be a better alternative to endovascular treatment in patients with unfavorable carotid artery anatomy.

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BACKGROUND: Proximal carotid tandem lesions are defined as multilevel lesions with significant (> 50%) atherosclerotic disease involving the internal carotid artery (ICA) in combination with the proximal ipsilateral common carotid artery (CCA) or innominate artery (IA). It is a relatively rare disease with an incidence of less than 5% in all patients with carotid stenosis at the level of the bifurcation. METHODS: These patients are at high surgical risk and were, therefore, excluded from current randomized controlled trials. Although the effectiveness of carotid endarterectomy (CEA) and carotid stenting (CAS) in stroke prevention for patients is established, the optimal treatment approach for the subgroup of patients with a proximal tandem lesion is still controversial. Treatment of this condition is not well understood because it is difficult to determine the risk of each individual lesion becoming symptomatic. Therefore, concurrent treatment of severe (> 70% stenosis) proximal lesions is recommended when treating severe stenosis at the carotid bifurcation. CONCLUSION: This disease can lead to embolic ischemic strokes or hemodynamic compromise. It is not possible to determine diagnostically which lesion led to the clinical symptoms, which is why both lesions should be corrected.

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PURPOSE: To highlight the clinical and diagnostic importance of correctly identifying cervical internal carotid artery fenestration (fcICA), an extremely rare vascular anomaly, and to present a case where fcICA was initially misdiagnosed as a dissection in a patient with fibromuscular dysplasia (FMD). METHODS: A 47-year-old woman with pulsatile tinnitus underwent computed tomography angiography (CTA) and digital subtraction angiography (DSA) to differentiate between fenestration and dissection of the internal carotid artery. RESULTS: CTA revealed a fusiform dilatation of the distal C1 segment of the right internal carotid artery (ICA) with a linear filling defect, suggesting either fenestration or dissection. DSA confirmed the presence of a fenestrated right ICA segment composed of two symmetrical, smooth-walled limbs without a dissection flap, along with signs of FMD in the proximal vessel. The patient's symptoms were attributed to local flow perturbations induced by fcICA and FMD. CONCLUSION: This case illustrates that fcICA can be a true anatomical variant rather than a result of dissection, emphasizing the need for accurate imaging and diagnosis to avoid unnecessary treatments. The coexistence of fcICA with FMD increases the risk of dissection, necessitating careful monitoring. The distinction between fenestration and pseudofenestration remains challenging, requiring comprehensive imaging and close collaboration between radiologists and vascular neurologists.

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Objective:To summarize the application of internal carotid artery stent in glomus jugular paraganglioma surgery, and to provide an effective strategy for reducing the risk of internal carotid artery injury. Methods:This article reviewed the surgical cases of internal carotid artery stent implanting from 2018.06 to 2022.12, and discussed the stent placement method, treatment protocols, and perioperative management strategies. Results:A total of 5 patients underwent a comprehensive evaluation of the degree of internal carotid artery invasion using imaging techniques such as MRI, carotid CT angiography （CTA）, and digital silhouette angiography （DSA）. All patients were found to have varying degrees of internal carotid artery involvement. Stenting of the internal carotid artery was performed in all patients before surgery, and the stenting process went smoothly without any internal carotid artery injury. Three months after stenting, tumor resection or subtotal resection surgery was performed to avoid internal carotid artery injury during the surgery, and the surgical process was successfully completed. Postoperative follow-up from 4 months to 2 years showed that the internal carotid artery was patent after stent placement, with great endothelialization process and no stent-related complications. Conclusion:In patients with glomus jugular paraganglioma, when preoperative imaging shows internal carotid artery involvement, preoperative stenting is a safe and effective therapeutic strategy to reinforce the arterial wall structure, protect and maintain the integrity of the artery, and reduce the risk of vascular injury during the surgery. This article summarizes the experience of internal carotid artery stent in glomus jugular paraganglioma surgery, which provides an important reference for clinical practice.

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Objective:This study aims to discuss the necessity，surgical method and effect of reconstruction of internal carotid artery （ICA） in the resection of paraganglioma of head and neck. Methods:We retrospectively analyzed the data of the patients who underwent head and neck paraganglioma resection and ICA reconstruction in Peking Union Medical College Hospital from May 2015 to August 2023. The demographic characteristics, preoperative examinations, diagnoses, surgical techniques, and follow-up information were collected. Results:Six patients were enrolled, including four females and two males, with an average age of（39.8±13.0） years. All the patients presented mainly complaining local masses with or without pain. Four cases underwent surgery through Fisch infratemporal fossa approach type A+B, and one through approach type A and one through transcervical approach. Five patients had vascular reconstruction using the great saphenous vein while one patient used an artificial vessel. The average follow-up period was（43.8±31.6） months. One patient had tumor recurrence after 3 years and underwent second surgery to remove the residual tumor, and the other 5 patients had no tumor recurrence. One patient had acute bridging vessel embolism, and the other was found to have occlusion of the bridging vessel at follow-up. Conclusion:Carotid revascularization during resection of paraganglioma of head and neck is an important technique to completely remove the tumor, cure the disease, ensure intracranial blood supply, and reduce cerebrovascular complications. The "pre-reconstruction technique " is an effective method to minimize the duration of brain blood flow interruption, compared to traditional carotid revascularization. Close observation is necessary, along with regular radiological examinations to assess the patency of transplanted vessels, and the residual or recurrent tumors.

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Objective:To introduce the surgical experience of carotid body tumor（CBT） resection with preservation of internal carotid artery. Methods:The clinical data of 109 patients with CBT were retrospectively analyzed. The key points of surgical techniques were summarized, the imaging and pathological results were comprehensively analyzed, and the postoperative complications were observed. Results:Of the 109 patients, 28 were Shamblin Ⅰ, 46 were Shamblin Ⅱ, and 35 were Shamblin Ⅲ. Synaptophysin（SYN） and soluble protein-100（S-100） were positive in all cases. There was a positive correlation between the average expression area percentage of S-100 and SYN in pathological tissue of 17 patients（r=0.48）, and the difference was statistically significant（P<0.05）. The average operation time was（148.4±46.2） minutes, the average intraoperative blood loss was（64.7±22.8） mL, and the average hospital stay was（15.2±2.6） days. Three patients underwent tumor resection combined with external carotid artery ligation, 1 patient underwent tumor resection combined with internal carotid artery ligation, and the remaining patients underwent tumor resection alone. The overall rate of intraoperative vascular ligation was 3.7% and the rate of nerve injury was 6.4%. According to preoperative CTA, intraoperative situation and postoperative pathological results, a new classification of CBT was proposed, which could intuitively reflect the gap between the tumor and the carotid artery and the nature of the tumor. Conclusion:Surgical resection of CBT is recommended after diagnosis. The potential gap between the tumor and the blood vessels was found under the microscope. Low energy bipolar electrocoagulation was used to coagulate and cut off the fibrous connective tissue between the tumor and gradually separated along the adventitia of the artery. The carotid artery could be preserved in most cases while the tumor was completely removed, and the amount of intraoperative bleeding and the incidence of complications were reduced. It is particularly important to identify the difficult cases before operation.

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BACKGROUND: Calcification is common in advanced atheromatous plaque, but its clinical significance remains unclear. This study aimed to assess the prevalence of plaque calcification in the moderate-to-severe internal carotid artery stenosis and investigate its relationship with ipsilateral ischemia. METHODS: The retrospective study included 178 patients detected with proximal internal carotid artery (pICA) stenosis of ≥ 50% on multidetector computed tomography at Zhejiang Hospital from January 2019 to March 2023. Association between plaque calcification characteristics (calcification thickness, position, type, circumferential extent, calcium volume and calcium score) and ipsilateral cerebrovascular events was analyzed. RESULTS: The 178 patients (mean age 71.24 ± 10.02 years, 79.78% males) had 224 stenosed pICAs overall. Plaque calcification was noted in 200/224 (89.29%) arteries. Calcification rates were higher in older age-groups. Calcification volume (r = 0.219, p < 0.001) and calcification score (r = 0.230, p < 0.001) were correlated with age. Ipsilateral ischemic events were significantly more common in the noncalcification group than in the calcification group (χ2 = 4.160, p = 0.041). The most common calcification type was positive rim sign calcification (87/200, 43.50%), followed by bulky calcification (66/200, 33.00%); both were significantly associated with ischemic events (χ2 = 10.448, p = 0.001 and χ2 = 4.552, p = 0.033, respectively). Calcification position, thickness, and circumferential extent, and calcification volume and score, were not associated with ischemic events. In multivariate analysis, positive rim signs (OR = 2.795, 95%CI 1.182-6.608, p = 0.019) was an independent predictor of ischemic events. CONCLUSIONS: Plaque calcification in proximal internal carotid artery is common, and prevalence increases with age. Calcification characteristics could be predictive of ipsilateral ischemic events. The positive rim sign within plaque is a high-risk factor for a future ischemic event.

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BACKGROUND:  As indications for surgical Eustachian tube (ET) procedures have been expanded, it is essential to understand the anatomy of ET surroundings for safe ET interventions. METHODS:  We evaluated the peritubal region using oblique planes of temporal computed tomography (CT) with the Valsalva maneuver and classified the peritubal region between the osseous ET and the internal carotid artery (ICA) into 5 types: 1. bony prominence; 2. air cell; 3. absence of peritubal structures (3a. thick canal [>0.5 mm], 3b. thin canal [<0.5 mm], 3c. dehiscence). RESULTS:  Bony prominence and air cell types were observed in 41.0% (50/122 ears) and 13.1% (16/122 ears), respectively. The ICA was located directly medial to the osseous ET in 39.4% (48/114 ears), of which thick and thin canal types were found in 23.8% and 15.6%, respectively. Internal carotid artery canal wall dehiscence was observed in 8 ears (6.6%). The shortest perpendicular distance between the osseous ET and ICA was 1.6 (range: 0.4-4.9) mm and 2.7 (range: 1.3-5.8) mm in the bony prominence and air cell types, respectively. Osseous ET-ICA distances were 1.2 (range: 0.6-3.6) mm and 0.4 (range: 0.1-0.5) mm in thick and thin canal types, respectively. CONCLUSION:  Distinct peritubal structure types were observed on oblique CT planes with Vasalva maneuver. Bony prominence and air cell types provide a protective layer between the osseous ET and ICA. Imaging information on peritubal structures may help to better understand the anatomy of the ET pathway, leading to safe and accurate surgical approaches to the osseous ET.

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