Volume 26 - N.° 1
M a r ç o d e 1 9 6 8
CALCIFICATION OF THE INTRACRANIAL CAROTID ARTERY AND
ITS RELATION TO THE CLINICAL AND ANGIOGRAPHIC PICTURE
A N A N G I O G R A P H I C CLASSIFICATION OF ASTERIOSCLEROSIS CEREBRI
To our knowledge there have b e e n n o previous a t t e m p t s t o correlate t h e angiographic findings with t h e presence of intracranial carotid calci-fications in cases of arteriosclerosis cerebri. Furthermore, t h e r e is no sa-tisfactory classification of t h e angiographic findings in c a s e s of cerebral arteriosclerosis. T h e purpose of this study is t o provide information on the following q u e s t i o n s : (1) w h a t kind of angiographic c h a n g e s c a n b e s e e n m o s t often in p a t i e n t s w i t h intracranial carotid calcifications?; (2) is t h e r e a n y possibility t o classify t h e angiographic c h a n g e s observed in a r t e -riosclerosis cerebri?; (3) if this possibility exists, w h a t are the relations b e t w e e n angiographic findings, age, sex, clinical history and neurological s y m p t o m s ?
Our m a t e r i a l c o n s i s t s of 5 6 p a t i e n t s w i t h cerebral a r t e r i o s c l e r o s i s s u b m i t t e d t o c a r o t i d a n g i o g r a p h y . T h e e x i s t e n c e of cerebral a r t e r i o s c l e r o s i s h a s b e e n e s t a -blished by X - r a y s e x a m i n a t i o n s s h o w i n g c a l c i u m deposits w i t h i n t h e w a l l of t h e c a r o t i d artery. A l l p a t i e n t e s w e r e o v e r 5 0 y e a r s of a g e . A c c o r d i n g t o Wolkoff (1933) a l l h u m a n beings o v e r 4 0 s h o w a r t e r i o s c l e r o t i c c h a n g e s w i t h i n t h e l a y e r s of t h e a r t e r i a l w a l l a n d t h e o c c u r r e n c e of a r t e r i o s c l e r o t i c p a t c h e s is supposed to be t h e l a s t p h a s e of t h i s process ( F i g . 1 ) .
S u m m a r y of a d o c t o r a l d i s s e r t a t i o n p r e s e n t e d t o t h e J o h a n n e s G u t e n b e r g U n i v e r s i t y , M a i n z , G e r m a n y ( N e u r o s u r g i c a l C l i n i c : P r o f . D r . K. S c h ü r m a n n ) . P a p e r p r e s e n t e d a t t h e T h i r d E u r o p e a n C o n g r e s s of N e u r o s u r g e r y ( M a d r i d , A p r i l 23-26, 1 9 6 7 ) .
Author's note — W e w i s h t o e x p r e s s o u r t h a n k s t o P r o f . D r . K. S c h ü r m a n n f o r t h e a c c e s s t o t h e c l i n i c a l r e c o r d s of t h e N e u r o c h i r u r g i s c h e U n i v e r s i t ä s k l i n i k ( M a i n z ) , f o r t h e t e c h n i c a l a s s i s t a n c e a n d f o r h i s v e r y h e l p f u l c r i t i c i s m a n d a d v i c e .
VALTER SEIXAS
R E S U L T S
In our m a t e r i a l t h e r e w a s a p r e d o m i n a n c e of m a l e s (71 %) a g a i n s t f e m a -l e s ( 2 9 % ) .
A n a m n e s t i c d a t a s h o w a g r e a t v a r i a b i l i t y of t h e first s y m p t o m s , s o m e c a s e s p r e s e n t i n g an i n i t i a l a p o p l e c t i f o r m crisis, o t h e r s a p r o g r e s s i v e course. O n l y t h e psychic d i s t u r b a n c e s a n d t h e episodes of dizziness u s u a l l y s h o w e d a s l o w pro-g r e s s i o n upon the i n i t i a l l y m i l d s y m p t o m s ( t a b l e 2 ) .
T w o m a i n groups of s y m p t o m s led t h e p a t i e n t s to s e a r c h for m e d i c a l c a r e : ( 1 ) m o t o r deficiencies s u c h as h e m i p a r e s i s , w e a k n e s s and m o n o p a r e s i s ; (2) psychic d i s t u r b a n c e s s u c h a s f o r g e t f u l n e s s , s l o w n e s s a n d h a l l u c i n a t i o n s . Other s y m p t o m s s u c h a s h e a d a c h e , dizziness, d e f e c t i v e v i s i o n , s p e e c h disorders a n d a s y n c h r o n i s m s were g e n e r a l l y considered as secondary.
A n g i o g r a p h i c a n a l y s i s of i n t r a c r a n i a l a r t e r i e s in o u r c a s e s r e v e a l e d a series of s i g n s w h i c h h a v e to be considered a s typical of a r t e r i o s c l e r o s i s b e c a u s e of their frequency and t h e i r p r e s e n c e s i m u l t a n e o u s l y to o t h e r c h a r a c t e r i s t i c signs. T h e c e r v i c a l arteries w e r e v i s u a l i z e d a n g i o g r a p h i c a l l y in 1 0 of our 56 p a t i e n t s . A l l s h o w e d t o t a l or partial block, m o r e o f t e n a f f e c t i n g t h e a r t e r i a carotis interna. T h e a r t e r i a c a r o t i s c o m m u n i s w a s t o t a l l y blocked in o n e c a s e . W e found 8 t o t a l blocks in t h e c e r v i c a l part of t h e i n t e r n a l carotid artery. N o block w a s s e e n in t h e e x t e r n a l carotid artery.
It w a s s e e n in a l l c a s e s t h a t t h e syphon w a s t h e m o s t o f t e n affected s e g m e n t , b e i n g c o m p l e t e l y o b s t r u c t e d in t w o c a s e s . T o t a l o c c l u s i o n of t h e arteria cerebri a n t e r i o r w a s observed in 5 c a s e s . A t o t a l block i n t h e a r t e r i a cerebri m e d i a w a s seen in 2 cases. S m a l l peripheral arteries w e r e o c c l u d e d in t h r e e c a s e s . A t o t a l of 2 0 o u t of 56 p a t i e n t s ( 3 6 % ) had i n t r a c r a n i a l v a s c u l a r o c c l u s i o n s of a n y kind. I r r e g u l a r i t i e s of t h e c a l i b e r a n d of t h e w a l l , p a r t i a l block and a n e u r y s m s p r e d o m i n a t e d a t t h e s y p h o n . P a r t i a l b l o c k a t t h i s s i t e w i t h l u m e n r e d u c t i o n of m o r e t h a n 50 per c e n t w a s s e e n in 7 c a s e s ; w a l l i r r e g u l a r i t i e s w i t h l u m e n r e -duction of less t h a n 5 0 per c e n t w e r e o b s e r v e d in 11 c a s e s and a n e u r i s m a l f o r m a t i o n s in 5 c a s e s .
Other partial b l o c k s w e r e f o u n d : 9 t i m e s in a n t e r i o r cerebral a r t e r y a n d o n c e in t h e arteria cerebri media. This g r o u p p r e s e n t i n g partial v e s s e l o c c l u s i o n w h i c h still s h o w s s o m e blood f l o w consisted of 21 p a t i e n t s .
COMMENTS
fre-quency and t h e localisation of the angiographic c h a n g e s in cervical and intracranial vessels in t h e s e patients w i t h calcifications of t h e carotid artery.
I t is interesting t o point out that in 15 of our p a t i e n t s (27%) t h e r e w e r e neither block nor caliber-irregularities at all despite t h e calcification of the carotid arteries. This would m e a n t h a t there m a y be arterioscle-rotic changes in t h e vessel walls w i t h o u t reduction of the arterial l u m e n .
W e have tried t o identify other angiographic signs of cerebral a r t e -riosclerosis and their frequency. Most frequently in 13 of 15 patients a w a v y course of t h e vessels could be observed; 10 c a s e s showed a very striking vessel-poverty in the periphery and in 13 c a s e s t h e presence of small knots denoted a kinking of t h e vessels.
A prolonged circulation t i m e w a s noticed in 6 cases. The course of the arteria cerebri anterior had an angular form i n s t e a d of the normal rounded one. The sign considered by Moniz as typical for arteriosclerosis — rectilinear course plus vascular dilatation — has b e e n found only in one of our cases.
This study permits t h e classification of the angiographic abnormalities due t o arteriosclerosis in 3 g r a d e s :
Grade II — P a r t i a l block ( s t e n o s i s ) ; irregularities of all and caliber as well as aneurysmal formation ( t h e s e changes still allow t h e blood t o flow into the b r a i n ) ;
Grade III — T o t a l block of s o m e vessels of t h e carotid s y s t e m causing a generalized or localized interruption of blood supply t o t h e brain.
The relations a m o n g t h e s e 3 different grades have been statistically controlled ( F i g . 3 ) . I n 7 3 % of t h e 15 patients presenting angiographic changes of grade I t h e illness had a s l o w l y progressive installation. A m o n g 21 cases in w h i c h angiographic c h a n g e s of grade I I w e r e found the disease had a n a c u t e apoplectiform course in 14 (67%) and a slowly progressive evolution in 7 (33%) cases.
T h e s a m e relation w a s s e e n in t h e 20 c a s e s w i t h angiographic changes of grade III, the onset of disease being predominantly acute, a s s u m i n g the f o r m of an ictus ( 6 5 % ) .
I t w a s not possible t o establish a correlation b e t w e e n t h e grade of psychical and neurological disturbances a t t h e course of the disease and t h e angiographic findings.
SUMMARY A N D CONCLUDING REMARKS
RESUMO E CONCLUSÕES
F o r a m e s t u d a d o s , clínica e a n g i o g r à f i c a m e n t e , 56 p a c i e n t e s c o m a r t e ¬ r i o s c l e r o s e c e r e b r a l c o m p r o v a d a m e d i a n t e visibilização r a d i o l ó g i c a de c a l ¬ cificações l o c a l i z a d a s n a p o r ç ã o i n t r a c r a n i a n a d a a r t é r i a c a r ó t i d a i n t e r n a . Calcificações d a a r t é r i a c a r ó t i d a i n t e r n a o c o r r e m c o m m a i s f r e q ü ê n c i a e m i n d i v í d u o s c o m i d a d e e n t r e 55 e 65 a n o s . O s h o m e n s s ã o m a i s a f e t a d o s d o q u e a s m u l h e r e s n a p r o p o r ç ã o d e 2 , 5 : 1 . Os s i n t o m a s i n i c i a m s e p r e f e -r e n t e m e n t e c o m d i s t ú -r b i o s m o t o -r e s . P o s t e -r i o -r m e n t e f o -r a m ve-rificados, a o m e s m o t e m p o e no m e s m o p a c i e n t e , v á r i o s d i s t ú r b i o s n e u r o l ó g i c o s e psí-quicos. N e s s e s p a c i e n t e s a s a l t e r a ç õ e s a n g i o g r á f i c a s do s i s t e m a c a r o t í d e o p o d e m s e r c l a s s i f i c a d a s e m 3 g r u p o s : a ) 1.° grau — p e r c u r s o o n d u l a d o d a s a r t é r i a s c e r e b r a i s , p o b r e z a v a s c u l a r n a p e r i f e r i a , f o r m a ç ã o de a c o t o v e l a ¬ m e n t o s d a s a r t é r i a s , a u m e n t o do t e m p o d e c i r c u l a ç ã o , a r t é r i a c e r e b r a l a n t e r i o r c o m f o r m a a n g u l a d a ; b ) 2.° grau — o c l u s õ e s p a r c i a i s , i r r e g u l a r i -d a -d e s -d a s p a r e -d e s e -do c a l i b r e -d a s a r t é r i a s e f o r m a ç õ e s a n e u r i s m á t i c a s ; c) 3.° grau — o c l u s õ e s t o t a i s de a r t é r i a s do s i s t e m a c a r o t í d e o . A s a l t e r a ç õ e s de 2.° e 3.° g r a u f o r a m o b s e r v a d a s c o m m a i o r f r e q ü ê n c i a n a s p r o x i -m i d a d e s do sifão c a r o t í d e o e j u n t o à o r i g e -m d a c a r ó t i d a i n t e r n a ( z o n a s d e p r e d i l e ç ã o ) . N a m a i o r i a dos c a s o s c u j a s i n t o m a t o l o g i a e v o l u i u l e n t a e p r o g r e s s i v a m e n t e f o r a m e n c o n t r a d a s a l t e r a ç õ e s d e 1.° g r a u . E n t r e os dois g r u p o s d e p a c i e n t e s c o m oclusões p a r c i a i s ou t o t a i s (2.° e 3.° g r a u ) n ã o foi v e r i f i c a d a q u a l q u e r d i f e r e n ç a n a e v o l u ç ã o clínica pois n a m a i o r i a dos c a s o s d e s t e s dois g r u p o s , a s i n t o m a t o l o g i a c o m e ç o u d e m a n e i r a a b r u p t a . P o d e m s e r e n c o n t r a d a s d e g e n e r a ç õ e s a r t e r i o s c l e r ó t i c a s ( a t é p l a c a s a t e r o ¬ m a t o s a s ) n a s p a r e d e s a r t e r i a i s , s e m q u e o c o r r a d i m i n u i ç ã o d a l u z do v a s o . O s d o e n t e s p o d e m p e r m a n e c e r a s s i n t o m á t i c o s a t é q u e , p o r u m a c a u s a e v e n -t u a l , a c i r c u l a ç ã o c e r e b r a l se d e s c o m p e n s e .
R E F E R E N C E S
1 . A R I N G , C. D. & M E R R I T T , H . H . — A r c h . I n t . Med. 56:435-456, 1935. 2 . B A D T , B . — N e u r o l . Zbl. 138:610-656, 1932.
3 . B E R G E R H O F F , W. — In H a n d b u c h d e r m e d i z i n i s c h e n R a d i o l o g i c S p r i n g e r V e r l a g , B e r l i n - G ö t i n g e n - H e i d e l b e r g , 1963.
4 . B O N N E T , P . & B R E T , P . — A r c h . d ' O p h t a l m . 14:775-786, 1945.
5 . B R A I N , R. — D i s e a s e s of t h e N e r v o u s S y s t e m . O x f o r d U n i v e r s i t y P r e s s , L o n d o n , 1962.
6 . B R E D T , H . — T h e r a p i e w o c h e 7:1-4, 1956.
7 . B R U N E T T I , L. — R i v . R a d i o l , e F i s . m e d . 3:567-602, 3 9 3 1 .
8 . D I E T Z , H . & S C H Ü R M A N N ,K. — M a t e r i a M e d i c a 1 3 : 7 - 1 9 e 73-86, 1961. 9 . F I S C H G O L D , H.; B R E G E A T , P . & D A V I D , M. — L a T o m o g r a p h i e de l a B a s e
1 0 . H E I N R I C H , A. — Z s c h r . A l t e r s f o r s c h . 2 : 2 4 0 , 1940.
1 1 . J U L I A O , O. F . & M E L A R A G N O F I L H O , R. — A r q . N e u r o - P s i q u i a t . ( S ã o P a u l o ) 20:255-274, 1944.
1 2 . L E H O C Z K Y , T. & H A L A S Y , M. — A c t a m e d . ( B u d a p e s t ) 5:215-230, 1955. 1 3 . L I M A , P . A. — C e r e b r a l A n g i o g r a p h y . O x f o r d U n i v e r s i t y P r e s s , L o n d o n , 1950. 1 4 . L I N D G R E N , E . — In H a n d b u c h d e r N e u r o c h i r u r g i e , Bd. I I . S p r i n g e r V e r l a g ,
B e r l i n , 1954.
1 5 . L O H R , W. & J A K O B I , W. — A r c h . k l i n . C h i r . 177:510-527, 1933.
1 6 . M E L A R A G N O F I L H O , R. — A f e c ç õ e s v a s c u l a r e s c e r e b r a i s . L i v r a r i a L u s o - ¬ E s p a n h o l a e B r a s i l e i r a , S ã o P a u l o , 1959.
1 7 . M O N I Z , E . — D i e c e r e b r a l e A r t e r i o g r a p h i e u n d P h l e b o g r a p h i e . Bd. I I . S p r i n -g e r V e r l a -g , B e r l i n , 1940.
1 8 . N E W T O N , R. H . ; A D A M S , J . E . & W Y L E , E . J . — N e w E n g l a n d J . Med. 2 7 0 : 14-18, 1964.
1 9 . R A U S C H , F . ; S C H I E F E R , W. & S T R U C K , G. — F o r t s c h r . N e u r o l . 24:512-520, 1956.
2 0 . S C H E I D , W. — In H a n d b u c h d e r I n n e r e n M e d i z i n , 5 Bd., T e i l 3 . S p r i n g e r V e r l a g , B e r l i n , 1953.
2 1 . S C H M I T Z , E. & S A L M - S A L M , E . — A l b r e c h t v. G r a e f e s A r c h . O p h t a l m . 1 5 6 : 303-312, 1955.
2 2 . S C H Ü L E R , A. — W i e n . K l i n . W s c h r . 2 6 : 6 4 2 , 1913. 2 3 . S C H Ü R M A N N , K. — Zbl. N e u r o c h i r . 1 9 : 3 4 6 - 3 6 3 , 1959.
2 4 . S C H Ü R M A N N , K. — A c t a N e u r o c h i r . S u p p l . V I I :556-558, 1 9 6 1 . 2 5 . S C H Ü R M A N N , K. & D I E T Z , H . — Zbl. N e u r o c h i r . 21:107-126, 1961. 2 6 . S C H Ü R M A N N , K . — A r z t l . F o r t b i l d u n g 13:126-132, 1963.
2 7 . T A R T A R I N I ; E . & C A N D E L E R O , G. — Sist. n e r v . 5:313-320, 1954.
2 8 . T Ö N N I S , W. & S C H I E F E R , W. — Z i n k u l a t i o n s t ö r u n g e n d e s G e h i r n s i m S e r i e n ¬ a n g i o g r a m m . S p r i n g e r V e r l a g , B e r l i n , 1959.
2 9 . W E C S L E R , I. S. — C l i n i c a l N e u r o l o g y . W. B . S a u n d e r s Co., P h i l a d e l p h i a - ¬ L o n d o n , 1963.
3 0 . W O L K O F F , K. — B e i t r . p a t h . A n a t . 9 1 : 5 1 5 - 5 5 3 , 1953.
3 1 . Z A C L I S , J . — A r q . N e u r o - P s i q u i a t . ( S ã o P a u l o ) 1 7 : 1 - 2 2 , 1959.
3 2 . Z A C L I S , J. & CRUZ, O. R. — A r q . N e u r o - P s i q u i a t . ( S ã o P a u l o ) 19:295-306, 1961.
