Carotid body tumors (CBTs) are rare neoplasms of the neuroectoderm accounting for 0.6% of head and neck tumors, with a 2%-12.5% risk of malignancy. While surgical resection has been associated with a high rate of neurologic and vascular complications, it remains the mainstay of treatment for malignant CBTs. We present the case of a 40-year-old female with a 5-year history of progressively enlarging right-sided neck mass, with MRI and MRA showing a Shamblin grade III CBT encasement of the internal carotid artery (ICA). Blood flow was absent in the petrous segment of ICA, with great collateralization of brain blood supply, enabling en bloc resection of the tumor with a carotid bulb and ligation of the common carotid artery (CCA) without vascular reconstruction. Further, we describe the characteristics and current management for malignant CBTs, including surgical management, pre-surgical embolization, and adjuvant radiation therapy.

UNASSIGNED: Carotid body tumors (CBTs) are certainly unusual. They are vascular lesions originating from paraganglionic cells, located at the common carotid artery (CCA) bifurcation. They represent less than 0.5% of head and neck tumors, approximately 1-3 cases per million. Malignant CBTs are extremely rare; in the literature, published rates on average are < 10%. The diagnostic criteria for malignancy should be based on the finding of distant metastasis. Due to its unpredictable nature and its malignant potential, diagnosis before metastasis and complete surgical resection are the keys to a favorable prognosis.
UNASSIGNED: Given little experience in CBTs, its biology and treatment remain uncertain. We present the case of a 48-years-old patient, with a mass on the left side of the neck that was found to be a vast CBT with suspicious histopathology. Its size, rare location, pathologic findings, and management strategy applied for its treatment, illustrate an unusual case that highlights the importance of its publication.
UNASSIGNED: CBT is rare, but subject to cure lesion if resected without metastatic or residual disease. This is why surgery should be performed whenever possible and why it is so necessary to study this pathology thoroughly and to take it into account in the differential diagnosis.

There are over 100,000 strokes each year in the UK. A very small proportion of these can be attributed to gunshot wounds and subsequent surgical intervention. We present a rare case of a 24-year-old male patient admitted to the Emergency Department having sustained a gunshot wound to the left side of his neck. Initial imaging and surgical exploration revealed significant left-sided vertebral artery damage and a complete transection of the internal carotid artery. Following damage control surgery (DCS), the patient was admitted to ITU but had an acute neurological deterioration and was found to have suffered malignant middle cerebral artery (MCA) syndrome, requiring an urgent decompressive craniectomy. The patient\'s National Institutes of Health Stroke Scale (NIHSS) at this stage was 26. After a prolonged ITU stay and repatriation to a local stroke unit for intensive therapies input, the patient walked out of the hospital independently on day 106, with an improved NIHSS of 3. This case report aims to highlight the rarity of an ischaemic stroke, secondary to the DCS required for a near fatal gunshot wound, along with the importance of timely recognition of an acute deterioration following artery ligation. Additionally, it aims to examine the lifesaving surgical management of malignant MCA syndrome and in turn the significance of the shared decision-making process between clinicians, the patient, and family members, due to the high rate of poor functional outcomes following this major surgery.

Supergiant cerebral aneurysm (size > 6 cm) is a rare and challenging cerebrovascular disease with few documented cases in literature. We describe a simple, safe, and effective treatment option for supergiant cavernous carotid aneurysm and discuss the proposed mechanisms for a favorable outcome.

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9 mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

We are reporting a 51-year-old female patient having a history of direct carotid cavernous fistula (CCF) which was treated by internal carotid artery (ICA) ligation 17 year ago. She presented to Ho Chi Minh City University Medical Center with symptoms of recurrent CCF. The recurred CCF was supplied by multiple feeders coming from anterior, posterior communicating artery and the recanalized left ICA. Her CCF was not plausible for another surgical ligation and was referred for endovascular treatment. The fistula was eventually occluded by percutaneous embolization via the right ICA approach. Through this case, we would like to discuss about the treatment strategies of those having recurrent CCF with preexisted ICA ligation. In Vietnam, previously carotico-cavernous fistula was mainly treated with muscle occlusion, carotid artery ligation or combinations of these methods. There were reported good outcomes for treatment of CCF surgically. However, surgical repairs had carried, not only complication, but a risk of recurrence due to recanalization of the previously ligated ICA. Since the emergence of endovascular intervention, the treatment of direct CCF has evolved from surgical ligation to angiographic embolization using balloon or coils via artery route or venous access. This endovascular method currently is the treatment of choice for traumatic CCF due to its ability to preserve the carotid artery and flexibility in treatment strategy with various approaches to the fistula.

We report our experience in treatment of traumatic direct carotid cavernous fistula (CCF) via endovascular intervention. We hereof recommend an additional classification system for type A CCF and suggest respective treatment strategies. Only type A CCF patients (Barrow\'s classification) would be recruited for the study. Based on the angiographic characteristics of the CCF, we classified type A CCF into three subtypes including small size, medium size and large size fistula depending on whether there was presence of the anterior carotid artery (ACA) and/or middle carotid artery (MCA). Angiograms with opacification of both ACA and MCA were categorized as small size fistula. Angiograms with opacification of either ACA or MCA were categorized as medium size fistula and those without opacification of neither ACA nor MCA were classified as large size fiatula. After the confirm angiogram, endovascular embolization would be performed impromptu using detachable balloon, coils or both. All cases were followed up for complication and effect after the embolization. A total of 172 direct traumatic CCF patients were enrolled. The small size fistula was accountant for 12.8% (22 cases), medium size 35.5% (61 cases) and large size fistula accountant for 51.7% (89 cases). The successful rate of fistula occlusion under endovascular embolization was 94% with preservation of the carotid artery in 70%. For the treatment of each subtype, a total of 21/22 cases of the small size fistulas were successfully treated using coils alone. The other single case of small fistula was defaulted. Most of the medium and large size fistulas were cured using detachable balloons. When the fistula sealing could not be obtained using detachable balloon, coils were added to affirm the embolization of the cavernous sinus via venous access. There were about 2.9% of patient experienced direct carotid artery puncture and 0.6% puncture after carotid artery cut-down exposure. About 30% of cases experienced sacrifice of the parent vessels and it was associated with sizes of the fistula. Total severe complication was about 2.4% which included 1 death (0.6%) due to vagal shock; 1 transient hemiparesis post-sacrifice occlusion of the carotid artery but the patient had recovered after 3 months; 1 acute thrombus embolism and the patient was completely saved with recombinant tissue plaminogen activator (rTPA); 1 balloon dislodgement then got stuck at the anterior communicating artery but the patient was asymptomatic. Endovascular intervention as the treatment of direct traumatic CCF had high cure rate and low complication with its ability to preserve the carotid artery. It also can supply flexible accesses to the fistulous site with various alternative embolic materials. The new classification of type A CCF based on angiographic features was helpful for planning for the embolization. Coil should be considered as the first embolic material for small size fistula meanwhile detachable balloons was suggested as the first-choice embolic agent for the medium and large size fistula.