Acute neurobehavioral deterioration during carotid artery stenting (CAS) requires prompt evaluation for serious neurological complications. We report a patient in their 70s who developed profound hyperactive delirium approximately 15 minutes after receiving prophylactic intravenous atropine (0.25 mg) during CAS. The episode was characterized by severe agitation, bilateral mydriasis, and facial flushing without focal neurological deficits. Repeated angiography and subsequent neuroimaging showed no evidence of thromboembolism, intracranial hemorrhage, cerebral edema, or cerebral hyperperfusion. Contrast-induced encephalopathy and cerebral hyperperfusion syndrome were considered but were less consistent with the overall clinical, temporal, and radiographic findings. The patient returned to neurological and cognitive baseline approximately 16 hours after symptom onset without specific antidotal treatment. The close temporal relationship to atropine exposure and characteristic neurobehavioral and autonomic features favored atropine-associated central anticholinergic syndrome, which should be considered in the differential diagnosis of acute neurobehavioral deterioration during CAS.
Purpose: Estimated pulse wave velocity (ePWV) is a surrogate of arterial stiffness that may influence stroke outcomes and potentially affect collateral circulation. We examined the association of ePWV with collateral status and 3-month functional outcome after successful endovascular thrombectomy and explored the contribution of collateral status to this relationship across blood pressure (BP) management strategies.Materials and Methods: In this secondary analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control trial, 285 patients were analyzed. Collateral status was assessed using the Tan scale (poor, 0–1; good, 2–3). Poor functional outcome was defined as 3-month modified Rankin Scale score of 3–6. Multivariable logistic and mediation analyses were performed to evaluate the association between ePWV and functional outcomes and to explore direct and indirect pathways.Results: A total of 285 patients were included (mean age, 73.3±11.3 years; 40.4% women). Each 1 m/s increase in ePWV was associated with poor collaterals (adjusted odds ratio [OR] 1.276, 95% confidence interval [CI] 1.083–1.503) and poor functional outcome (adjusted OR 1.338, 95% CI 1.121–1.597). In mediation analyses, collateral status accounted for only a small proportion of the association between ePWV and poor functional outcome (indirect effect: adjusted β 0.022, 95% CI 0.001–0.053), whereas the direct effect remained significant (adjusted β 0.237, 95% CI 0.115–0.359). Neither the direct effect of ePWV on functional outcome nor the indirect effect through collateral status differed according to BP management strategy.Conclusion: Higher ePWV was associated with poor collateral status and unfavorable functional outcome after successful reperfusion. Collateral status accounted for only a small proportion of the observed association between ePWV and functional outcome.
Skull-base paragangliomas with persistent internal carotid artery (ICA) supply can be challenging to devascularize safely. We report a 17-yearold male with an Succinate Dehydrogenase Complex Iron Sulfur Subunit B (SDHB)-associated tympanojugular paraganglioma treated using a staged hybrid endovascular strategy after subtotal resection. Persistent supply from a short ICA feeder and circumferential involvement of the petrous ICA precluded safe conventional transarterial embolization. A Surpass Elite flow-diverting stent was deployed across the feeder after dual antiplatelet therapy to preserve parent-vessel patency, reduce tumour inflow, and reinforce the arterial wall. Four months later, protected direct transauricular and transcervical puncture embolization with Squid 12 was performed under intermittent ICA balloon occlusion. Marked tumor devascularization was achieved without embolic or thromboembolic complication, and definitive resection was completed without new neurological or cranial nerve deficit. This staged approach may provide a useful adjunct for selected skull-base paragangliomas with persistent ICA supply when conventional embolization carries unacceptable risk.
