SHIBATA Yasushi

International Journal of Critical Care and Emergency Medicine

Yasushi Shibata

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Agenesis of the Bilateral Internal Carotid Arteriesled to the Development of Vertigo

Tsukuba Repository  (Tulips-R)

International Journal ofCritical Care and Emergency MedicineShibata. Int J Crit Care Emerg Med 2017, 3:028Volume 3 | Issue 2DOI: 10.23937/2474-3674/1510028ISSN: 2474-3674Open AccessShibata. Int J Crit Care Emerg Med 2017, 3:028Citation: Shibata Y (2017) Agenesis of the Bilateral Internal Carotid Arteries Led to the Development of Vertigo. Int J Crit Care Emerg Med 3:028. doi.org/10.23937/2474-3674/1510028Received: July 28, 2017: Accepted: October 24, 2017: Published: October 26, 2017Copyright: © 2017 Shibata Y. 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.• Page 1 of 5 •Agenesis of the Bilateral Internal Carotid Arteries Led to the Development of VertigoYasushi Shibata*Department of Neurosurgery, Mito Medical Center, University of Tsukuba, Ibaraki, Japan*Corresponding author: Yasushi Shibata, MD, PhD, Department of Neurosurgery, Mito Medical Center, University of Tsukuba, Ibaraki, Japan, E-mail: yshibata@md.tsukuba.ac.jpted for hypertension and hyperlipidemia for 1 year. She developed breast pain and visited the Department of Surgery at our hospital. She was diagnosed with breast cancer, and breast surgery was scheduled. The patient suddenly became dizzy one morning after waking up and was admitted to our hospital. Her physical and neu-rological findings were almost normal. Brain Computed Tomography (CT, Figure 1) and Magnetic Resonance (MR) imaging (Figure 2) demonstrated no intracranial hemorrhage or cerebral infarction. CT angiography (Figure 3) and MR angiography (Figure 4) showed the enlargement and invagination of the basilar artery into the pons. The bilateral anterior and middle cerebral ar-teries were supplied from posterior circulation via the development of bilateral posterior communicating ar-teries. Skull CT showed the complete occlusion of the bilateral carotid canals (Figure 5). Cerebral angiography (Figure 6 and Figure 7) and carotid ultrasound confir-med agenesis of the bilateral internal carotid arteries. There was no collateral flow from extracranial arteries into the intracranial brain region. The bilateral ophthal-mic arteries were supplied from extracranial arteries. No aneurysm or major arterial stenosis was found. Te-chnetium-99m Ethyl Cysteinate Dimer (TcECD) Single Photon Emission CT (SPECT) showed mild low cerebral perfusion at the left parietal lobe (Figure 8). CT perfu-sion showed almost normal cerebral perfusion (Figure 9). Her dizziness disappeared with conservative the-rapy.DiscussionThere have been only several case reports of agene-sis of the bilateral internal carotid arteries. Most of the-AbstractAgenesis of the bilateral internal carotid arteries is a rare disease. There have been few case reports of subjects who developed cerebral infarction, intracranial hemorrhage or subarachnoid hemorrhage. We experienced a rare case of agenesis of the bilateral internal carotid arteries in which the patient developed vertigo. A 63-year-old woman sud-denly became dizzy one morning after waking up and was admitted to our hospital. Brain Computed Tomography (CT) and Magnetic Resonance (MR) imaging demonstrated no intracranial hemorrhage or cerebral infarction. CT angiogra-phy and MR angiography showed the enlargement and in-vagination of the basilar artery into the pons. Her dizziness disappeared with conservative therapy. Our case was very rare because the patient was diagnosed with agenesis of the bilateral internal carotid arteries before the development of major cerebrovascular disease. There are some possible mechanisms of vertigo in our case: One is direct pulsatile pontine compression by the elongated basilar artery; an-other is transient or chronic cerebral ischemia caused by abnormal circulation.KeywordsAgenesis of bilateral internal carotid arteries, VertigoCaSe RepoRtIntroductionAgenesis of the bilateral internal carotid arteries is a rare disease. There have been few case reports of subjects who developed cerebral infarction, intracra-nial hemorrhage or subarachnoid hemorrhage [1-4]. We experienced a rare case of agenesis of the bilateral internal carotid arteries in which the patient developed vertigo.Case ReportThe patient, a 63-year-old woman, had been trea-ISSN: 2474-3674DOI: 10.23937/2474-3674/1510028Shibata. Int J Crit Care Emerg Med 2017, 3:028 • Page 2 of 5 •         Fig. 1: Brain CTFigure 1: Brain computed tomography.         Figure 2: Magnetic Resonance (MR) imaging, T2 weighted images.         Figure 3: 3D CT angiography (Lt: volume rendering, Rt: MIP image).ISSN: 2474-3674DOI: 10.23937/2474-3674/1510028Shibata. Int J Crit Care Emerg Med 2017, 3:028 • Page 3 of 5 •se cases presented as subarachnoid hemorrhage caused by the rupture of a cerebral aneurysm rupture in the posterior circulation [3]. One young boy presented with two episodes of severe headache [1]. Although no intra-cranial aneurysm was observed, subarachnoid hemor-rhage was suggested. In one patient, bilateral internal carotid artery agenesis manifested as intracerebellar hemorrhage [4].There is one reported case of a patient who presen-ted with dizziness due to cerebellar infarction [2]. Some patients demonstrated incidental headache without ce-rebrovascular accident [5].Some cases were diagnosed as occlusion of the bila-teral internal carotid arteries [6]. Agenesis and occlusion should be differentiated by bone window CT. In cases involving congenital agenesis of the bilateral internal carotid arteries, both of the carotid canals in the skull base are absent and occluded. For patients with acqui-         Figure 4: MR angiography, MIP image.         Figure 5: Skull CT (absence of carotid canal at arrows).         Rt CAG Lt CAGFigure 6: Cerebral angiography-1 (Lt: Rt carotid angiography, Rt: Lt carotid angiography, lateral view).ISSN: 2474-3674DOI: 10.23937/2474-3674/1510028Shibata. Int J Crit Care Emerg Med 2017, 3:028 • Page 4 of 5 •         Fig.7: Cerebral angiography-2Lt VAG Lat APFigure 7: Cerebral angiography-2 (Lt vertebral angiography, Lt: lateral view, Rt: AP view).         Fig. 8:  ECD SPECT (Rest, Diamox)Figure 8: Tc ECD single photon emission CT (Lt: at rest, Rt: Diamox image).Our case was very rare because the patient was dia-gnosed with agenesis of the bilateral internal carotid ar-teries before the development of major cerebrovascu-lar disease. Only one patient has demonstrated occa-sional vertigo in association with bilateral carotid artery red occlusion of the bilateral internal carotid arteries, both the carotid canals in the skull base are present and patent. Most reported cases of agenesis of the bilateral internal carotid arteries demonstrated occluded bilate-ral carotid canals in the skull base on skull CT [1,3-5].ISSN: 2474-3674DOI: 10.23937/2474-3674/1510028Shibata. Int J Crit Care Emerg Med 2017, 3:028 • Page 5 of 5 •References1. Steer AC, Rowe PW (2008) Bilateral agenesis of the inter-nal carotid artery: Case report and approach to manage-ment. J Paediatr Child Health 44: 511-513.2. Luk YS, Man EM, Sy AN (2010) Bilateral hypoplasia of the internal carotid arteries. Singapore Med J 51: e163-e165.3. Cruz e Silva V, Brito M (2017) Bilateral absence of the in-ternal carotid artery and basilar aneurysm. Br J Neurosurg 31: 487-488.4. Sunada I, Inoue T (1996) Bilateral internal carotid artery agenesis. J Neurol Neurosurg Psychiatry 61: 206-207.5. Alexandre AM, Visconti E, Schiarelli C, Frassanito P, Pe-dicelli A (2016) Bilateral Internal Carotid Artery Segmental Agenesis: Embryology, Common Collateral Pathways, Cli-nical Presentation, and Clinical Importance of a Rare Con-dition. World Neurosurgery 95: 620.e9-620.e15.6. Owada Y, Sakuta Y (1995) [Bilateral carotid artery agene-sis with corpus callosum hypogenesis--a case report]. No To Shinkei 47: 589-594.agenesis without cerebrovascular accident; however, the patient had mental retardation and corpus callosum hypogenesis [6].There are some possible mechanisms of vertigo in our case: one is direct pulsatile pontine compression by the elongated basilar artery; another is transient or chronic ce-rebral ischemia caused by abnormal circulation. No cere-bral infarction was revealed; however, SPECT demonstra-ted low perfusion at the left parietal cortex. Appropriate management of patients with agenesis of the bilateral in-ternal carotid arteries should be discussed after the study of the natural course and a randomized therapeutic inter-ventional trial. However, because these pathological con-ditions are very rare, a large study is difficult. Thus, this kind of case report may be valuable for clinical decision-making. We will closely follow up the patient and discuss thera-peutic intervention to prevent the future development of major cerebrovascular disease.         CBV CBF MTT TTPFigure 9: CT perfusion, Cerebral Blood Volume (CBV), Cerebral Blood Flow (CBF), Mean Transient Time (MTT), Time to Peak (TTP) images.

Agenesis of the Bilateral Internal Carotid Arteries Led to the Development of Vertigo

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Agenesis of the Bilateral Internal Carotid Arteries Led to the Development of Vertigo

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