0:01

This was a 70-year-old woman who presented to the

0:04

emergency room with left hand weakness

0:08

and left foot weakness.

0:10

When looking at pathology of the carotid

0:13

sheath and looking at vascular lesions,

0:16

I would recommend that you focus on one vessel at

0:19

a time, scrolling through the entire data set,

0:22

looking at a single vessel, rather than trying

0:24

to look at multiple vessels at once.

0:27

So what we're going to do is we're going to start at

0:29

the bottom, and we'll start with the left common

0:32

carotid artery and just focus on

0:34

the left common carotid artery.

0:36

This first vessel, actually, that I just pointed

0:38

to is the left subclavian artery.

0:41

And if we just look briefly at the left subclavian artery,

0:44

we already see that there is pathology here with

0:47

approximately 40% stenosis with soft plaque

0:50

in the left subclavian artery.

0:53

But we're talking about the carotid sheath, right?

0:55

So let's look at the common carotid artery on the left

0:58

side, and let's follow that vessel all the way up.

1:01

So if we follow that vessel all the way up,

1:04

we're scrolling through it and we come

1:06

here to the carotid bifurcation.

1:09

So here's our carotid bifurcation.

1:12

And if we then follow the important one,

1:15

the posterior lateral one

1:17

which is the internal carotid artery on the left side,

1:20

we can follow that up.

1:21

And we see that there is some tortuosity of the blood

1:25

vessel through the cervical segment here.

1:30

It's a little bit irregular in its shape.

1:34

And then as we continue further superiorly,

1:38

we have an unusual configuration of

1:42

banding within the carotid artery,

1:44

the internal carotid artery on the left

1:46

side. Looking more superiorly,

1:48

we come into the petrous portion of the internal

1:51

carotid artery. And as we follow the petrous portion,

1:55

we see that there is a line here

1:58

going through the blood vessel.

2:01

So here you see that line within the distal

2:05

petrous internal carotid artery

2:08

which looks like an area of dissection.

2:10

You can see those two lumens, here and here.

2:14

There is slight expansion of the caliber

2:17

of the left petrous internal

2:20

carotid artery compared to the right.

2:22

So it is widening as well.

2:24

And then we come into the cavernous internal

2:27

carotid artery, and it doesn't look bad.

2:30

I will point out that as you scroll through

2:33

the middle cerebral artery,

2:36

we have an area of stenosis right through here where

2:39

the caliber of the blood vessel is not continuous.

2:43

And this patient did have an area of vascular stenosis

2:47

in the M1 segment of the middle cerebral artery.

2:51

And this leads to some of the lenticulostriate

2:55

collateral vessels that you're seeing here.

2:58

Let's look going

3:00

down at the right internal carotid artery.

3:03

So we're just focused on the right internal

3:05

carotid artery. And as we go down,

3:09

we see again that there is this area where there

3:12

appears to be an area of narrowing and widening.

3:15

It's in a horizontal plane, but the caliber of the

3:19

blood vessel is changing in that segment

3:24

of the internal carotid artery.

3:27

Here we get to the carotid bifurcation,

3:29

a little bit of soft plaque along

3:31

the medial aspect of it.

3:33

Let's follow the common carotid artery

3:35

down, and that looks good.

3:37

Let's just take a quick look at the vertebral

3:41

arteries. Here we see the two vertebral arteries.

3:44

We're going to follow the left first,

3:47

in the vertebral portion, the V2 portion.

3:52

And then here it comes out of the

3:57

vertebral canal.

3:59

And we have an area where we do not see the vertebral

4:03

artery. So the vertebral artery sort of stops.

4:08

We follow this vertebral artery.

4:10

That's downward. Let's go up following it.

4:16

Following it, comes around here

4:19

and intracranially.

4:22

And then we don't see a component coming

4:26

to the other vertebral artery.

4:28

It ends in a posterior inferior cerebellar artery.

4:31

Let's follow the other vertebral artery.

4:33

This vertebral artery has an area of irregularity to it

4:36

in its V3 portion.

4:38

Right through here. And again,

4:41

looks like there is a line going through the vertebral

4:45

artery distally in the V3 portion

4:48

of the right vertebral artery.

4:52

Let's follow it down through the cervical portion,

4:54

the V2 portion.

4:57

Looking good. A little bit tortuous. Comes out.

5:00

This is our V1 portion.

5:02

It's very much a dominant right vertebral artery.

5:06

I think that the reconstructions that you perform for

5:10

the carotid arteries and the vertebral arteries are

5:13

very important when you're looking at

5:14

a case of fibromuscular dysplasia.

5:17

Here is the reconstruction of that same

5:21

right internal carotid artery.

5:25

And notice how that variable caliber change in the

5:30

internal carotid artery on the right side is much

5:33

more, much better defined on the reconstruction,

5:36

the curved reconstruction.

5:38

And this gives away the diagnosis of fibromuscular

5:41

dysplasia, the area of narrowing, widening, narrowing,

5:44

widening,

5:44

which is characteristic of fibromuscular dysplasia.

5:49

Let's look at the left reconstruction.

5:51

The left, as you recall,

5:52

had the dissection. So left internal carotid artery...

5:56

Here's the cervical portion with

6:00

areas of narrowing, widening,

6:02

narrowing, the kind of corkscrew appearance of

6:04

fibromuscular dysplasia. But in addition,

6:09

if we look at the petrous portion,

6:13

we can see that area of dissection within the blood

6:15

vessel, as well as widening in the petrous

6:19

portion of the internal carotid artery.

6:23

This is the MIP reconstruction.

6:26

And I want to point out the right vertebral artery

6:30

which is quite large in size.

6:33

And as we flip it around,

6:36

I hope that I can convince you that there is that

6:39

area of focal narrowing in the right V3 portion. Here's a little widening,

6:46

a little area of narrowing.

6:48

Here's another area of what looks like FMD, narrowing

6:53

and widening of the vertebral artery

6:55

on the reconstruction.

6:57

So this was indeed a case of fibromuscular dysplasia

7:01

involving both internal carotid arteries, as well

7:05

as the right vertebral artery associated with a

7:10

dissection of the petrous internal carotid artery on

7:14

the left side with focal dilation, the so-called

7:18

pseudoaneurysm formation of the distal

7:20

left petrous internal carotid artery.