Trigeminal artery and microemboli to the brain stem. Report of two cases

The authors report two cases of transient ischemic attacks (TIA's) involving the brain stem. The TIA's were due to microemboli that originated from a carotid bifurcation atherosclerotic plaque and travelled through a persistent trigeminal artery.     

Extracranial-intracranial arterial bypass for middle cerebral artery stenosis and occlusion. Operative results in 65 cases

Forty-seven patients with middle cerebral artery (MCA) stenosis and 18 patients with MCA occlusion underwent extracranial-intracranial arterial bypass procedures. Patients presented with a history of transient ischemic attacks (TIA's), reversible ischemic neurological deficits, TIA's after initial stroke, stroke-in-evolution, or completed stroke. Angiography revealed that the MCA stenosis ranged from 70% to over 95%. Two patients (4.3%) in the stenosis group had a perioperative stroke (within 30 days of operation). There was no perioperative mortality. In the occlusion group, no patient had a perioperative stroke, and one patient (5.5%) died from a non-neurological disease. The TIA's resolved completely in 90% of the patients with stenosis and in 91.6% of those with occlusion. No patient with MCA stenosis had a late ipsilateral stroke, although five had a contralateral or vertebrobasilar stroke. One patient with MCA occlusion had a late ipsilateral stroke. The bypass patency rate at late follow-up review was 100%. The results of intracranial-extracranial arterial bypass procedures appear to be similar for patients with either stenosis or occlusion of the MCA. Symptomatic relief of TIA's was excellent and, in two patients with progressive stroke-in-evolution, the deficit was stabilized. The incidence of postoperative ipsilateral stroke was low in patients with TIA's alone or with TIA's after an initial stroke, but among patients with completed stroke, improvement was confined to slight reduction in the neurological deficit.     

Management of extracranial carotid stenosis and intracranial aneurysms.

Twenty patients with extracranial carotid stenosis and intracranial aneurysms are reviewed. Fifteen of these patients had transient ischemic attacks (TIA's) and incidental aneurysms. The other five presented with symptoms referrable to an aneurysm, and angiography revealed significant carotid stenosis. None of the patients who presented with TIA's and underwent endarterectomy suffered subarachnoid hemorrhage. However, those patients who presented with symptoms referrable to an aneurysm and underwent endarterectomy seem to be at greater risk for subarachnoid hemorrhage.     

Transient ischemic attacks due to increased platelet aggregation and adhesiveness. Ultrastructural and functional correlation.

The authors report 22 cases of transient ischemic attacks (TIA's) manifested by amaurosis fugax or hemiparesis or paresthesia of less than 24 hours' duration. None of the patients demonstrated 1) evidence of atherosclerotic cerebral vascular disease on angiography, 2) evidence of intracranial lesion on brain scan, 3) cardiac source of emboli, 4) arteritis or collagen disease, or 5) history of migraine. The only abnormalities found to explain the TIA's were abnormally increased platelet adhesiveness and/or aggregation. All of these patients were followed from 1 to 5 years, and had repeated coagulation studies. Treatment with antiplatelet drugs showed an excellent clinical response with associated decrease in platelet adhesiveness and aggregation. Discontinuance of the antiplatelet drug resulted in a recurrence of the TIA's which coincided with an increase in aggregation and adhesiveness. In two cases the platelet morphology was studied by transmission and scanning electron microscopy. It appears that there is a specific group of patients with TIA's in whom the sole cause of the attack is an abnormality of platelet function. For these people there is a specific therapy and a method monitoring the treatment.     

Disabling cerebral transient ischemic attacks.

The surgical management of an emerging clinical entity, namely disabling transient cerebral ischemic attacks, is described. A series of 19 patients treated in a 2-year period (12 with anterior circulation dysfunction and seven with posterior insufficiency) met the following criteria: 1) stereotypical recurrent episodes of transient neurological dysfunction related to the anterior or posterior circulation distribution; 2) failure of maximum medical therapy to control the transient neurological dysfunction; 3) four-vessel cerebral angiography demonstrating an isolated vascular territory corresponding to patient symptoms; 4) inhalation xenon cerebral blood flow studies with at least three of eight probe-pairs showing significant asymmetries in the initial slope index, localizing an area of relative oligemia to the symptomatic hemisphere (anterior circulation only); and 5) severe restriction of lifestyle due to transient ischemic attacks (TIA's). Seventeen patients underwent surgical bypass therapy: deep sylvian superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in nine; surface STA-MCA bypass in three; STA-superior cerebellar artery bypass in three; STA-posterior cerebral artery bypass in one; and aorta-carotid artery bypass in one. There was one perioperative death and four perioperative strokes (two ipsilateral and two contralateral to the operated side). The average follow-up period was 14 months. Of the 16 surviving surgically treated patients, 13 (81%) have had an excellent to good outcome with complete resolution of TIA's and minimal neurological deficits. Three patients had a poor outcome with either a significant persistent neurological deficit or continued TIA's. The two patients not treated surgically continue to have vertebrobasilar insufficiency episodes while receiving oral anticoagulation medication. The overall mortality rate (5.5%) and stroke morbidity rate (22.2%) of surgical therapy for disabling TIA's are high in this neurologically unstable group of patients, but are associated with an 81% excellent to good response. Although the natural history of disabling TIA's is not known, these patients present with significant to total disability due to their symptoms. It is concluded that disabling TIA's respond to surgical revascularization and may represent an indication for cerebral revascularization surgery.     

Acute cerebral revascularization

Fifteen patients evaluated for acute cerebral ischemia underwent acute cerebral revascularization between March, 1979, and May, 1983. Clinical presentation included crescendo transient ischemic attacks (TIA's) in eight cases, progressing neurological dysfunction in three cases, and completed nonfluctuating deficits in four cases. Nine patients received intravenous heparin but did not improve neurologically. The patients with crescendo TIA's were operated on within 4 hours of their last event; those with progressing deficits were operated on while the deficit was developing, and those with established deficits were operated on 4, 6, 9, and 12 hours, respectively, after the event began. The clinical picture for 10 patients had resolved within 10 hours after surgery. One patient with crescendo TIA's, two with progressing deficits, and two with established deficits had postoperative residual deficits, of which three were mild and two severe. One patient, who had a saphenous vein graft to the middle cerebral artery, developed an intracerebral hematoma. In this prospective noncontrolled nonrandomized study, acute cerebral revascularization was performed safely, had limited risks, and offered the potential to help some patients. Further controlled randomized studies are indicated.     

Results of extracranial-intracranial arterial bypass for bilateral carotid occlusion

The results of superficial temporal to middle cerebral artery bypass surgery for bilateral internal carotid artery occlusion were reviewed in 39 patients. Preoperative symptoms included recurrent transient ischemic attacks (TIA's) in 31 patients (80%) and mild or moderate stroke in 15 (29%). Deficits were unilateral in 23 cases and bilateral in 14. Dementia or personality changes were observed in 19 patients (49%). Operative morbidity occurred in six of 39 cases and was neurological in one; the surgical mortality rate was 8% (three of 39 patients), including two cases of cerebral hemorrhage. The outcome was good or excellent (relief of TIA's and reduction of neurological deficit) in 82% of patients over a follow-up period of 3 to 139 months. Five patients had a late postoperative stroke, which occurred in the unoperated hemisphere in each case; one patient had an ipsilateral TIA 6 years after the bypass procedure. These results suggest that an extracranial-intracranial arterial bypass procedure to augment collateral cerebral blood flow can be performed safely in patients with bilateral internal carotid artery occlusion and may be associated with relief of ischemic symptoms. Future studies may document a role for this procedure in the prevention of stroke.     

Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency

Eighty-three patients underwent 85 intracranial to extracranial pedicle bypass anastomosis procedures to the posterior circulation. There were 15 patients with occipital artery (OA) to posterior inferior cerebellar artery (PICA) anastomosis, 20 patients with OA to anterior inferior cerebellar artery (AICA) anastomosis, and 50 patients with superficial temporal artery (STA) to superior cerebellar artery (SCA) anastomosis. All patients had transient ischemic attacks (TIA's) suggestive of vertebrobasilar ischemia. Twenty-seven patients had crescendo TIA's or stroke in evolution and were considered to be clinically unstable. All patients had severe bilateral distal vertebral artery or basilar artery disease. Twenty-two patients had bilateral vertebral artery occlusion and three had basilar artery occlusion. In this series, 69% had complete resolution of symptoms; the mortality rate was 8.4% and the morbidity rate 13.3%. Clinically stable patients did better than unstable patients. The STA-SCA anastomosis was well tolerated and technically less demanding than the OA-PICA or OA-AICA anastomosis procedures. Patients with symptomatic severe bilateral vertebral or basilar artery disease have a grave prognosis and the option of a surgical arterial pedicle revascularization procedure should be offered to them.     

Long-term follow-up study after extracranial-intracranial bypass surgery for anterior circulation ischemia in childhood moyamoya disease.

Between May, 1974, and March, 1991, 104 patients with moyamoya disease, all under 16 years old at the time of first surgery, underwent superficial temporal-to-middle cerebral artery anastomosis and/or encephalomyosynangiosis. The mean follow-up period was 9.6 years (range 4.8 to 16.0 years). Hemiplegia was the most frequent symptom before the first operation. Transient ischemic attacks (TIA's) were noted in 57 patients and minor stroke with hemiplegia in 44. The most frequent type of cortical dysfunction was aphasia (21 cases). Postoperatively, the incidence of TIA's and/or completed stroke with motor weakness of the extremities was markedly decreased, but visual disturbance progressed and major or minor stroke with visual disturbance was found in two cases. In patients under the age of 3 years, a major stroke prior to surgery resulted in a poor outcome in 36% of cases. Preoperative major stroke in patients between the ages of 3 and 7 years was less frequent, and poor outcomes were seen in 17% of this group. There were no major preoperative strokes in patients with surgery after the age of 7 years, and no poor outcomes were recorded in this group. A major preoperative stroke prior to surgery had adverse impact on the ultimate patient intelligence quotient (IQ) following surgery. All patients operated on after the age of 7 years had a normal or borderline IQ at follow-up examination.     

Expression and Distribution of Beta Amyloid Precursor Protein and Beta Amyloid Peptide in Reactive Astrocytes After Transient Middle Cerebral Artery Occlusion

Summary  Background. In the brains of Alzheimer's disease patients, beta amyloid protein is the major component of senile plaque. In ischemic stress, beta amyloid precursor protein (APP) and beta amyloid peptide are reported to be upregulated.  Method. Using Male Wistar-ST rats, expression and distribution of APP and beta amyloid peptide were examined immunohistochemically after transient ischemia induced by a 2-h middle cerebral artery occlusion (MCAO). After reperfusion for 3, 7, 14, 30 and 60 days, brains were removed and immunostaining was performed.  Findings. The reactive astrocytes with APP were observed in the periphery of infarct from 3 days to 60 days post-occlusion. The immunoreactivity of beta amyloid peptide was also localized in the reactive astrocytes in the peripheral zone of infarct at 7, 14, and 30 days post-occlusion. However, beta amyloid expression was not identified at 3 days or 60 days post MCAO. Transient ischemia temporarily induced beta amyloid peptide expression in reactive astrocytes, but this expression peaked at 30 days and disappeared at 60 days.  Interpretation. These findings suggested that beta amyloid peptide was derived from the processing of APP produced in the same reactive astrocytes and the production of the peptide stopped within 60 days after the ischemic stress.     

Multiple intracerebral hemorrhages due to cerebral amyloid angiopathy after head trauma

Cerebral amyloid angiopathy (CAA) is an important cause of intracerebral hemorrhage and ischemic cerebrovascular disease in some normotensive elderly patients. The diagnosis is made by proof of amyloid deposition in the vessel wall. A case of recurrent and multiple intracerebral hemorrhages due to cerebral amyloid angiopathy after head injury is reported. A 74-year-old female was referred to our hospital because of head injury. CT scan showed traumatic subarachnoid hemorrhage and intraventricular hematoma. Her consciousness was clear but slight disorientation was recognized. Conservative therapy was performed. During the course subcortical hemorrhages occurred five times and during the second one, right frontal and right parietal hemorrhages occurred simultaneously. Her consciousness deteriorated. The second subcortical hemorrhage was especially complicated by a ventriculoperitoneal shunt operation. A biopsy of the cortex was performed and pathological examination revealed amyloid deposition in the walls of small pial and cortical vessels. Occasional duplicated wall, obliterative intimal proliferation and disappearance of elastic lamina were recognized. The patient sank into a vegetative state due to recurrent and multiple hemorrhages. CAA results in two possibilities, hemorrhage and ischemic cerebrovascular disease. When lobar or subcortical hemorrhage is encountered in a normotensive elderly patient, the possibility of a CAA-related hemorrhage should be considered. The author carefully emphasizes that there is indication for neurosurgical treatment in CAA patients and proposes that therapy for ischemic cerebrovascular disease should be given special attention.     

Controlled hypothermia in carotid endarterectomy

Successful carotid endarterectomy under controlled hypothermia, induced by shell cooling, is described. The patient, whose ipsilateral vertebral and contralateral internal carotid arteries were obstructed, and whose contralateral external carotid artery was stenosed, had presented with recurrent TIA's and amaurosis fugax. Some observations on the indication for and technique of hypothermia are made.     

Outcome of asymptomatic cervical bruits in a veteran population

The potential risk of stroke in patients with a localized asymptomatic cervical bruit continues to be a source of debate. We identified 273 patients with 374 asymptomatic mid-cervical bruits. Using Doppler with spectral analysis, the internal carotid artery (ICA) was stratified into one of three groups; greater than or less than 75% cross section area stenosis, or occlusion. Each carotid artery was evaluated for progression of stenosis and occurrence of neurologic events (TIA's and strokes). During an average follow-up of 29.6 months, 26 neurologic events (10 strokes, 16 TIA's) occurred ipsilateral to the carotid bruits. Most asymptomatic bruits (308/374; 82%) were associated with carotid arteries having less than 75% stenosis and the risk of stroke from those arteries remaining at less than 75% stenosis (254/308) was 1.5%. However, progression to greater than 75% stenosis or occlusion as determined at the most recent noninvasive examination (54/308) was associated with a significant risk for stroke (7.4%; p less than 0.001). Progression to occlusion in the total population was highly significant for the risk of developing stroke (4 out of 19; p less than 0.001).     

Carotid endarterectomy in patients with occlusion of the contralateral carotid artery. Perioperative risk and late results

Recent reports on the outcome of carotid endarterectomy in patients with contralateral occlusion have been conflicting. Therefore, we reviewed 51 cases identified, among 675 consecutive carotid endarterectomies. A perioperative mortality of 2% and a permanent morbidity rate of 16% was observed. Compared with a complication rate of about 5% previously reported from this institution, this clearly indicates contralateral carotid occlusion as a major risk factor in carotid surgery. Though not statistically significant, patients with severely reduced cerebral perfusion pressure (CPP) had suffered more severe strokes when compared to patients with only minor reduction in CPP. In addition, the internal carotid artery blood flow following endarterectomy was significantly higher in the low pressure group (P less than 0.02). No patients were lost during follow-up, for a mean of 34 months. The cumulative five-year survival rate was 74%, not significantly different from the expected survival of an age and sex matched population. During the period of follow-up 16 patients experienced new neurologic symptoms, in six (2 strokes and 4 TIA's) referable to the hemisphere ipsilateral to operation and in 10 (2 strokes and 8 TIA's) referable to the contralateral hemisphere. The five-year stroke rate was 16%. This together with the observed survival rate indicated a better-than-expected course in this group of patients with severe cerebrovascular atherosclerosis.     

Prospective clinicopathologic study of carotid intraplague hemorrhage

A prospective study was conducted of 82 carotid endarterectomy plaques from 73 patients to determine the incidence of intraplaque hemorrhage, its relation to the production of cerebral ischemic symptoms, and the role of the antiplatelets. These included 42 with hemispheric transient ischemic attacks (TIA), nine with hemispheric stroke (Group A), and 31 with nonhemispheric TIA's or asymptomatic carotid stenosis (Group B). The plaques were evaluated for the presence of hemorrhage. Intraplaque hemorrhage was present in 63 (76.8%) of 82; 46 (90.2%) of 51 in Group A had hemorrhage, in contrast to 17 (54.8%) of 31 in Group B (P less than .001). Twenty-nine (56.86%) plaques from patients in Group A had multiple hemorrhages and 22 (43.14%) had single or no hemorrhages; in contrast to two (6.45%) that had multiple hemorrhages and 29 (93.55%) that had single or no hemorrhages in patients in Group B (P less than .0005). Forty-seven plaques were removed from patients receiving antiplatelets; 43 (91.48%) of these showed hemorrhages. Of the 35 plaques that were removed from patients not receiving antiplatelets, 26 (74.2%) showed hemorrhages (P = .071). However, when the plaques were studied for multiple hemorrhages, 28 (59.5%) of 47 had multiple hemorrhages in patients receiving antiplatelet agents in contrast to 3 (8.57%) of 35 in patients receiving antiplatelet agents (P less than .00001). The authors conclude that 1) the intraplaque hemorrhage is an important and common feature in symptomatic carotid disease, 2) antiplatelets increase the incidence of plaque hemorrhages, particularly multiple hemorrhages that carry higher incidence of symptoms. Therefore the use of antiplatelet agents in certain patients with carotid artery disease is questioned.     

Asymptomatic carotid bruit: long term outcome of patients having endarterectomy compared with unoperated controls

During 20 years (1957-1977), 1286 carotid endarterectomies were performed on 1022 private patients with cerebrovascular insufficiency. Included were 132 patients undergoing 167 endarterectomies for asymptomatic cervical carotid bruits. Ages ranged from 42 to 82 years (mean: 64.7). Operative mortality was zero. There were two transient and two permanent operation-related neurologic deficits. Complete follow-up was achieved, extending to 184 months. During postoperative follow-up, six patients (4.5%) developed TIA's appropriate to the unoperated artery, three patients had strokes (2.3%), and three patients died of strokes (2.3%). To characterize the natural history of asymptomatic bruit and determine proper indications for prophylactic endarterectomy, a control series of 138 additional patients with asymptomatic bruit not operated upon when the bruit was discovered was studied. Ages ranged from 39 to 86 years (mean: 65.7). During follow-up extending to 180 months, 77 patients (55.8%) remained neurologically asymptomatic, 37 patients (26.8%) developed TIA's one month to 99 months after detection of bruit, and 24 patients (17.4%) sustained mild to profound frank strokes one week to 124 months postdetection. Three of these 24 (2.2%) died of stroke. Asymptomatic carotid bruits may be potential stroke hazards, the risk of which can be significantly reduced by appropriately applied endarterectomy. A protocol for managment is presented.     

Surgical treatment of patients with a carotid artery occlusion and a contralateral stenosis

Patients with a carotid artery occlusion and a haemodynamically significant contralateral stenosis have an increased risk of incurring a stroke. Based on the results of a series of 33 patients our conclusion is that the surgical therapy of choice should be endarterectomy of the stenotic artery irrespective of which side the symptoms are located on. Only those patients who continue to have TIA's on the side of the occlusion after endarterectomy of the stenotic side should be considered for an ECIC bypass.     

The cerebrovascular Doppler examination in patients with non-hemispheric symptoms.

The cerebrovascular Doppler examination indicated a significant stenosis in only 19 of 53 patients with non-hemispheric TIA'S. There were no false negative or false positive examinations. Fourteen of 19 patients with an abnormal examination and 23 of 31 patients with a normal examination became asymptomatic after a carotid endarterectomy. Eleven patients were improved and two were unchanged. Therefore the cerebrovascular Doppler examination can not be used to predict therapeutic success or failure of carotid endarterectomy for non-hemispheric TIA's.     

Isolated obstructive lesions of the cervical common carotid: clinical and surgical aspects

Isolated lesions of the extra-thoracic common carotid arteries are unusual in clinical practice. Contrarily to the well known lesions of carotid bifurcation, its natural history is poorly understood and indications for surgical management are not well defined. In this paper, seven patients with isolated lesions of the common carotid arteries are reported, being two symptomatic (TIA's). Patients underwent successful surgical management. The main features of clinical presentation, diagnosis and surgical management are presented and discussed     

Risk factors in asymptomatic patients with a carotid bruit

A consecutive series of 369 asymptomatic patients with a carotid bruit was prospectively followed with Ocular Pneumoplethysmography (OPG). The aim of the study was to identify those patients most prone to cerebrovascular ischemia and/or progression of obstructive carotid disease. During follow-up 13 patients developed a stroke of which six were fatal (two thrombo-embolic and four haemorrhagic strokes). TIA's occurred in 15 patients, including eight patients with amaurosis fugax. TIA's occurred more frequently on the side of a haemodynamically significant stenosis (9% = 9/95) than on the side of a normal, OPG (2% = 6/274). There was no difference in the strokelocated side. The occurrence of symptoms and/or signs of cerebrovascular disease was 4% at two years and 10% at five years. The left hemisphere was affected twice as often as the right. The development of a haemodynamically significant carotid stenosis, according to OPG, was equal for the right and the left carotid arteries, being 18% at two years and 56% after 5 years of follow-up. The major risk factors for progression of obstructive disease were systolic blood pressure above 160 mmHg independent of age, diabetes mellitus and the presence of ischaemic heart and peripheral arterial obstructive disease. This study supports the contention that in a group of patients with an asymptomatic carotid bruit, a group of patients at risk from cerebrovascular accidents can be filtered out by a simple non-invasive test in combination with a complete physical examination.