[Current management of carotid artery stenosis. What does the evidence show us?].

Objective: Surgery of carotid artery stenosis as treatment for acute cerebral vascular accident was most used in the 1980s. This surgical procedure is one of the few to have been 'examined' to demonstrate its usefulness by means of a series of prospective multicentric trials, carried out between 1980 and 1990. This paper aims to show the results of these trials and give useful advice for current management of these patients.

Clinical presentation and management of giant anterior communicating artery region aneurysms.

Object: The authors reviewed their 20-year experience with giant anterior communicating artery aneurysms to correlate aneurysm size with clinical presentation and to analyze treatment methods.

Methods: In 18 patients, visual and cognitive impairment were quantitated and clinical outcome was categorized according to the Rankin scale. Statistical analysis was performed using Fisher's exact test.

Risk factors of moyamoya disease in Canada and the USA.

Over the past 28 years, 39 patients with Moyamoya disease or syndrome defined as spontaneous occlusion of the circle of Willis with extensive basal collateral vessels have been treated by the author in Canada and the USA. All patients presented with clinical or radiologic evidence of hemorrhage (23) or ischemia and infarction (16). A total of 12 patients had associated cerebral aneurysms and seven of these patients with aneurysms presented with subarachnoid hemorrhage.

Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992.

The paucity of information about giant fusiform intracranial aneurysms prompted this review of 120 surgically treated patients. Twenty-five aneurysms were located in the anterior and 95 in the posterior circulation. Six patients suffered from atherosclerosis and only three others had a known arteriopathy.

Pseudotumor syndrome resulting from a cerebral arteriovenous malformation: case report.

We report a case of a cerebral arteriovenous malformation presenting as a pseudotumor cerebri syndrome. The lack of mass effect, hemorrhage, or hydrocephalus, in addition to angiographic evidence of high-flow and venous outflow restriction, implicate increased cerebral blood flow and venous hypertension as the mechanism for the papilledema. This case illustrates a pathophysiological mechanism in the development of intracranial hypertension associated with vascular malformations.

Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation.

Hunterian proximal artery occlusion was used in the treatment of 160 of 335 patients harboring giant aneurysms of the anterior circulation. One hundred and thirty-three of these aneurysms arose from the internal carotid arteries, 20 from the middle cerebral arteries, and seven from the anterior cerebral arteries. Ninety percent of the patients had satisfactory outcomes.

Early surgery for ruptured vertebrobasilar aneurysms.

The authors present a series of 1767 patients with aneurysms of the vertebrobasilar circulation, most of whom were operated on 14 days or more following their last subarachnoid hemorrhage (SAH). Since 1970, 206 patients with vertebrobasilar aneurysms have been surgically treated within 7 days after their last SAH (day of SAH = Day 0). Of patients with a good preoperative grade (Botterell Grade 1 or 2), a good or excellent outcome was obtained in 80% during the first postsurgical month, irrespective of the timing of surgery.

Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients.

Deliberate occlusion of the basilar or vertebral arteries was performed in 201 patients with intracranial aneurysms, where the aneurysmal neck could not be clipped directly. The aneurysms arose from the basilar apex in 83 cases, the basilar trunk in 46, the vertebrobasilar junction in 35, and the vertebral artery in 37; 87% of the aneurysms were classified as giant lesions (> 2.5 cm).

Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.

Background: Without strong evidence of benefit, the use of carotid endarterectomy for prophylaxis against stroke rose dramatically until the mid-1980s, then declined. Our investigation sought to determine whether carotid endarterectomy reduces the risk of stroke among patients with a recent adverse cerebrovascular event and ipsilateral carotid stenosis.

Methods: We conducted a randomized trial at 50 clinical centers throughout the United States and Canada, in patients in two predetermined strata based on the severity of carotid stenosis--30 to 69 percent and 70 to 99 percent.

Magnetic resonance imaging of facial nerve neuromas.

Facial nerve neuromas are uncommon tumors often confused with other tumors of the temporal bone and cerebellopontine angle. Radiologically, it may be impossible to differentiate an intracanalicular facial nerve neuroma from an acoustic neuroma. We present three case reports of facial nerve neuromas arising within the internal auditory canal to show the important magnetic resonance imaging features of these tumors.

Surgical treatment of unruptured aneurysms of the posterior circulation.

With the ever-increasing number of intact aneurysms revealed by modern imaging, the options for their management are assuming great importance. While some knowledge has emerged as to their natural history and the results of surgical treatment of those in the anterior circulation, little information has been published concerning unruptured aneurysms arising from the posterior circulation. The authors report their experience since 1971 with 167 patients operated on for 179 unruptured vertebrobasilar aneurysms up to 25 mm in diameter.

Rupture of aneurysms following balloon embolization.

Three cases of complex aneurysms are presented in which balloon embolization therapy was associated with subsequent aneurysmal rupture, causing subarachnoid hemorrhage in two cases and a carotid-cavernous fistula in one. Two of these patients were treated directly by balloon embolization following surgical exploration. The third patient developed the fistula during postembolization volume expansion and heparinization.

Carotid transluminal angioplasty with evidence of distal embolization. Case report.

A 57-year-old woman presented with symptomatic triple tandem stenosis of the left carotid artery. Transluminal angioplasty of an atherosclerotic stenosis at the origin of the common carotid artery was performed retrogradely through a distal arteriotomy after endarterectomy. The postangioplasty effluent was collected and analyzed.

The effects of a prophylactic bolus of lidocaine in focal cerebral ischaemia.

In order to determine the cerebral protective effects of an intravenous bolus of 5 mg.kg-1 of lidocaine, the left middle cerebral artery (MCA) was transorbitally occluded in 19 cats. Ten animals received the lidocaine bolus and nine a similar volume of saline immediately before MCA occlusion.

Platelet aggregation within cerebral arteriovenous malformations.

Turbulence within cerebral arteriovenous malformations (AVM's) may lead to endothelial disruption, platelet aggregation, and thrombus formation. This hypothesis would account for many of the pathological features in AVM's, including intimal hyperplasia and arterial thrombosis with or without organization. In this study, a dual-isotope method employing indium-111-labeled platelets and technetium-99m-labeled red blood cells was used to evaluate in vivo platelet aggregation in 20 patients with AVM's.

Functional status changes following medical or surgical treatment for cerebral ischemia. Results of the extracranial-intracranial bypass study.

To determine the value of extracranial-intracranial arterial anastomosis (EC/IC bypass), we randomly allocated 1377 patients with symptomatic atherosclerosis of the internal carotid or middle cerebral arteries to medical care alone or to EC/IC bypass with continuing medical care. As previously reported, surgery did not reduce--or significantly increase--the risk of stroke. Functional status data collected during the trial provide new information.

Saccular aneurysms in basilar artery fenestration.

Of 59 cases of vertebrobasilar junction aneurysms diagnosed and treated from January 1977 to April 1986, 21 (35.5%) saccular aneurysms arose in a fenestration of the proximal basilar artery. Defects of the media at the junctures of the fenestrated segments, as well as the possible presence of turbulent flow at the vertebrobasilar junction, may explain the high incidence of vertebrobasilar aneurysms associated with proximal basilar artery fenestration.

Lumbar puncture and stroke. A statement for physicians by a Committee of the Stroke Council, American Heart Association.

This statement for physicians redefines the use and importance of lumbar puncture to suspected stroke mechanisms. It also identifies neurologic conditions in which newer imaging techniques are safer and more effective diagnostic tools than lumbar puncture.

Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms.

Of 68 patients with unclippable aneurysms treated by proximal artery occlusion with detachable balloons, permanent occlusion was achieved in 65; of these patients, 37 had carotid artery aneurysms below the origin of the ophthalmic artery, 21 had aneurysms arising from the supraclinoid portion of the carotid artery, six had basilar trunk aneurysms, and one had a distal vertebral aneurysm. Examination for treatment selection included assessment of the circle of Willis by compression angiography and xenon blood flow studies, with the ultimate evaluation being test occlusion under systemic heparinization with the balloon temporarily placed in the desired position. Of 67 patients who underwent a formal occlusion test, eight with carotid artery aneurysms did not initially tolerate the occlusion test, and ischemic signs disappeared instantaneously with deflation and removal of the balloon.

Correlation between somatosensory evoked potentials and neuronal ischemic changes following middle cerebral artery occlusion.

In an attempt to determine the usefulness of evoked potentials as a measure of focal cerebral ischemia, we examined somatosensory evoked potentials (SEP's) and morphological neuronal changes in cats following unilateral middle cerebral artery (MCA) occlusion. Fifteen adult cats underwent transorbital occlusion of the MCA under halothane anesthesia. In seven cats the ipsilateral SEP's were abolished after middle cerebral artery occlusion, and did not show any recovery after 6 hours.

An evaluation of the effect of lidocaine in experimental focal cerebral ischemia.

In order to determine the effect of lidocaine in focal cerebral ischemia, the left middle cerebral artery was transorbitally occluded in twenty cats. Eleven received lidocaine hydrochloride intravenously. The infusion was begun half an hour prior to clip occlusion and the rate was adjusted to maintain an isoelectric EEG.

Photodynamic therapy. A viable alternative to conventional therapy for early lesion of the upper aerodigestive tract?

Photodynamic therapy (PDT) is a treatment modality that results in selective destruction of malignant cells by combining a photosensitizing agent (hematoporphyrin derivative), which is taken up by the cells, and a laser light. This therapeutic modality has been effectively used in managing cancers of the skin, bronchi, and bladder. In the head and neck area, however, its use has been confined to the palliation of advanced lesions that have proved refractory to conventional therapy.