A 61-year-old man presented with aphasia and right hemiparesis. Severe stenosis of the left internal carotid artery (ICA) was found 2 years previously when he presented with left retinal arterial branch occlusion. Brain magnetic resonance angiography, carotid ultrasonography (US), and cerebral angiography confirmed that the stenosis had progressed to asymptomatic occlusion 1 year before admission (Figure 1A). Brain computed tomography revealed an ischemic lesion in the left basal ganglia (Figure 2A). However, the left ICA images were confusing; brain magnetic resonance angiography on day 7 indicated left ICA recanalization, whereas carotid US immediately after magnetic resonance angiography showed ICA occlusion with an intraluminal thrombuslike entity (Figure 2B). Cerebral angiography showed recanalization with severe segmental stenosis on day 13 (Figure 1B); the occlusion revealed by magnetic resonance angiography on day 18 was recanalized according to carotid US 1 hour later. Carotid US on day 20 initially detected left ICA flow in the supine position that gradually diminished with an intraluminal thrombuslike entity appearing over a period of 20 minutes. Flow was suddenly visualized again after the patient sat up (video). The left greater horn of the hyoid bone seemed to compress the narrowest segment of the ICA from behind (video), confirmed by helical computed tomography (Figure 1C). Because secondary atherosclerosis at the site of compression, suspected before surgery, was not observed, the operative procedure was changed from carotid endarterectomy to adhesiotomy from the circumferential tissues and patch formation of the left ICA. The hyoid bone removal was given up because of the technical difficulty. A pathological examination of the arterial wall tissue showed only fibrotic change. The left ICA remained patent after surgery. Antiplatelet therapy, started before surgery, was continued. The patient recovered without sequelae and was discharged on day 41.
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Imaging findings on admission. A, Brain computed tomography shows an ischemic lesion in the left basal ganglia. B, Carotid ultrasound shows a thrombuslike entity in left internal carotid artery.
Imaging findings of the left internal carotid artery and hyoid bone. Cerebral angiography showed occlusion of the internal carotid artery 1 year before admission (A), recanalized, with severe segmental stenosis on day 13 (B). C, Helical computed tomography shows the greater horn of hyoid bone compressing the narrowest segment of the left internal carotid artery from behind.
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Hyoid Bone Compression–Induced Repetitive Occlusion and Recanalization of the Internal Carotid Artery
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