Case Report Australasian Radiology (2002) 46, 412–415 Bilateral common carotid occlusion without neurological deficit Serdar Karaköse,1 Aydin Karabacakoglu1 and Hasan Solak2 Departments of 1Radiology and 2Cardiothoracic Surgery, Selçuk University, Konya, Turkey SUMMARY A 40-year-old man presented with pain and numbness in his right arm. On his clinical examination, no neurological deficit was found. Bilateral common carotid artery duplex sonography scan demonstrated no flow in either lumen. No abnormality was recognized on brain CT. On cerebral digital substraction angiogram, total occlusion of the brachiocephalic trunk and left carotid artery were shown. There was a modest stenosis in the left vertebral artery. Collateral circulation feeding the intracranial carotid system mainly originated from the left vertebrobasilar system. Previous cases of bilateral carotid occlusion are reviewed and discussed. Key words: angiography; bilateral common carotid artery; occlusion. INTRODUCTION two trasient ischaemic attacks. He was a tobacco user for 15 Occlusion or severe stenosis of extracranial vessels might lead years. On his clinical examination, there were no pulses in 1 either common carotid artery or the right axillary, brachial, radial Cases of carotid occlusions have often been reported in the or ulnar arteries. No neurological deficit was found. Biochemis- literature, but most of them were related to bilateral internal try and haematological laboratory values were normal. the hypoperfusion without overt infarction of brain tissue. carotid occlusion. Bilateral common carotid artery occlusion appears to be rare. 2 The lumens of both common carotid arteries were filled with thrombus that was shown initially by ultrasonographic examina- The natural history of patients suffering from bilateral tion (Fig. 1). No flow was seen in either common carotid artery common carotid occlusion is poorly known. Cardiovascular risk on colour Doppler ultrasonography. Normal flow patterns were factors, such as smoking, are frequently found. Presenting seen in internal jugular veins (Fig. 2). No abnormality was rec- neurological episodes have been included as either transient ognized on contrast-enhanced cranial CT. In arch aortography, ischaemic attack or stroke. Collateral circulation feeding the the left subclavian artery was normal but the brachiocephalic intracranial carotid system mainly, or exclusively, originated from trunk and the left common carotid artery were occluded the vertebrobasilar system. Common carotid artery occlusions (Fig. 3a). During arch aortography in the late arterial phase, the are frequently detected by colour Doppler ultrasonography and/ right subclavian and right vertebral arteries were faintly filled or angiography.2–4 with contrast via collaterals (Fig. 3b). Selective left subclavian We present a patient with bilateral common carotid artery DSA showed 40% stenosis of the proximal part of the left verte- and right vertebral artery occlusions without neurological bral artery, just near the bifurcation. Blood flow was normal in deficit. the left subclavian artery and the distal part of the left vertebral artery (Fig. 4). In superselective DSA of the left vertebral artery, CASE REPORT the distal part of the left vertebral artery, basilar artery and pos- A 40-year-old man presented with pain and numbness in his terior cerebral arteries were normal. Bilateral anterior and right arm for the previous 3 months. In this period, he had had middle cerebral arteries and their branches were visualized S Karaköse MD; A Karabacakoglu MD; H Solak MD. Correspondence: Serdar Karaköse , Department of Radiology, Selçuk University, Konya 42080, Turkey. Email: radserkar@hotmail.com Submitted 10 December 2001; accepted 15 July 2002. BILATERAL COMMON CAROTID OCCLUSION 413 faintly during left vertebral angiography (Fig. 5). Collateral circulation feeding the intracranial carotid system mainly originated from the left vertebrobasilar system. Left common carotid embolectomy and a brachiocephalic trunk ‘Y’ graft were performed surgically. The specimens that were taken from the vessel lumens were examined histopathologically and were organized thrombi. DISCUSSION The external carotid and vertebrobasilar system are the main collaterals for supplying the brain perfusion when both internal carotid arteries are occluded.5–7 In most of these cases, neurological deficits are present. Fig. 1. Left common carotid ultrasonography. The lumen of the common carotid artery was filled with thrombus (short arrows). The lumen echogenity of common carotid artery was higher than the internal jugular vein (long arrow). De Graeve described the ocular ischaemic syndrome that is characterized by ocular symptoms and signs secondary to bilateral occlusion of the carotid artery. 8 Lambrecht reported a case of bilateral occlusion of the internal carotid arteries Fig. 2. (a) Right and (b) left common carotid artery colour Doppler ultrasonography. No flow was seen in either common carotid artery (black arrows). Normal flow patterns were seen in internal jugular veins (white arrows). Fig. 3. Arch aortography. (a) Left subclavian artery was normal but the brachiocephalic trunk (short arrow) and left common carotid artery (long arrow) were occluded (b). The right subclavian (short arrow) and right vertebral artery (long arrow) visualized faintly in the late arterial phase. 414 S KARAKÖSE ET AL. Sottiurai presented a patient with bilateral internal carotid occulsion and concomitant vertebral artery stenosis who had lateralized amaurosis fugax, syncope and partial visual field defect resolved by surgical and radiological interventions. 11 Catala reported a study of 19 patients with bilateral occlusion of the internal carotid arteries that were demonstrated by angiography. In these patients, smoking was particularly frequent (95%). Presenting neurological episodes included either transient ischaemic attack (8/19) or stroke (9/19). 12 Their results confirmed that the patietns suffering from atheromatous bilateral occlusion of the internal carotid arteries might survive with minimal neurological deficits. Wroblewski discussed a case of a 46-year-old man with bilateral internal carotid artery and right vertebral artery occlu- Fig. 4. Selective left subclavian angiography. Forty percent stenosis was seen at the proximal part of the left vertebral artery (arrow) just near the bifurcation. Blood flow was normal in the left subclavian artery and in the distal part of the left vertebral artery. sion in an unexpected good clinical state. The clinical diagnosis was documented by angiographical and Doppler findings and brain CT scan.13 Bilateral common carotid occlusion has been reported rarely in the literature. In recent years, most of the articles related to bilateral common carotid artery occlusion dealt with experimental studies. Rats and gerbils have been widely used to investigate the molecular mechanism of selective neuronal death following global ischaemia due to bilateral common carotid occlusion. 14 Uehara et al. described hypoxic-ischaemic brain injury and periventricular leukomalacia in neonatal rats with bilateral carotid artery occlusion. Periventricular leukomalacia is an important cause of cerebral palsy and is characterized by cysts and coagulation necrosis in the periventricular white matter. 15 Yamaguchi et al. described a 68-year-old woman who had become unconscious suddenly because of simultaneous bilateral common carotid artery occlusion that was shown by cerebral angiography and a normal CT scan. She died on the Fig. 5. Superselective left vertebral artery angiography. The distal part of the left vertebral artery, basilar artery and posterior cerebral arteries were normal. Bilateral anterior and middle cerebral arteries and their branches were visualized faintly during left vertebral angiography. eleventh day after hospitalization. From the autopsy findings, they considered that this case was one of simultaneous bilateral common carotid occlusion due to cardiogenic thrombi. 2 Maier documented a case of a patient who became deeply unconscious due to complete obstruction of both common carotid arteries caused by near-suicidal hanging. After surgical presenting with right hemiparesis and hypoesthesia, associ- repair of blunt carotid lesions, the neurological deficits ated to meningovascular syphilis in a patient with AIDS. 9 regressed and the patient had a good outcome. 3 AbuRahma described bilateral internal carotid artery occlu- Zbornikova treated three patients with modest neurological sion in 21 patients who were suffering from hemispheric deficit and bilateral occlusion of the common carotid arteries transient ischaemic attack, amaurosis fugax, stroke or non- and during follow up, none of these patients had a new stroke. 4 hemispheric transient ishcaemic attack. The diagnosis was Bilateral common carotid artery, right vertebral artery occlu- confirmed using carotid duplex ultrasound and angiography. sions and concomitant vertebral artery stenosis were identified The majority of patients had more than one risk factor for athero- in our patient who had no neurological deficit. There was no sclerosis, such as smoking, hyperlipidaemia, hypertension, history of hypertension, hyperlipidaemia, signs of systematic coronary artery disease and diabetes mellitus. In addition to arteriosclerosis or vasculitis, and an unremarkable family the usual medical treatment, 13 patients underwent surgical history for vascular abnormalities, but he was a smoker. After intervention.10 surgical intervention, our patient had a good outcome. BILATERAL COMMON CAROTID OCCLUSION Kluytmans determined that dynamic susceptibility contrast- 415 6. enhanced MRI could enable the measurement of relative haemodynamic changes in patients with internal carotid artery occlusions with the advantage that grey and white matter per- 7. fusion could be distinguished.16 Okada visualized four vessel occlusions of cerebral arteries 8. by MR angiography in two patients. The diagnosis was confirmed by conventional angiography. Additionally, conventional angiography demonstrated the extensive collateral vessels. 17 9. Angiography is the gold standard in the diagnosis of carotid artery occlusions.2,8–15 In some cases with bilateral carotid artery 10. occlusion, MR and CT images can be normal or unspecific. 2,12,13,16 Our results confirm that the patients suffering from bilateral occlusion of the common carotid arteries might survive without 11. neurological defects. 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