Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS Investigators.

BACKGROUND AND PURPOSE: The Asymptomatic Carotid Atherosclerosis Study (ACAS) established the effectiveness of prophylactic carotid endarterectomy, for patients in good health who had stenosis >/=60%, if conducted by surgeons with a surgical morbidity and mortality of <3%. This secondary analysis was performed to determine whether the presence of contralateral cervical carotid occlusion alters the efficacy of asymptomatic ipsilateral carotid endarterectomy. METHODS: One hundred sixty-three participants who had a baseline contralateral occlusion documented by Doppler ultrasound (77 medical, 86 surgical) were compared with 1485 participants with a patent contralateral carotid artery (748 medical, 737 surgical) for the risk of a combined end point of perioperative (30-day) death or stroke or long-term (5-year) ipsilateral stroke. RESULTS: For those without contralateral occlusion, surgery was associated with a 6.7% absolute reduction in the 5-year risk (95% CI, 2.1% to 11.4%), while for those with a contralateral occlusion, surgery was associated with a 2.0% absolute increase in risk (95% CI, -9.3% to 5.2%), which was a statistically significant difference in the effect of surgery (P:=0.047). This difference is primarily attributable to low long-term risk for medically managed patients with contralateral occlusion. CONCLUSIONS: While this post hoc analysis should be interpreted with caution, the findings suggest that endarterectomy in asymptomatic subjects with contralateral occlusion provides no long-term benefit (and may be harmful) in preventing stroke and death. These findings were a result of the benign course of medically treated subjects.

The effect of radiation on carotid arteries. A review article.

The effects of irradiation on blood vessels supplying the brain are reviewed. Short-term and long-term effects on large arteries result in an atheroscleroticlike disorder. The response may have a latency up to 20 years before the onset of symptoms and signs. This delay is probably related to the diameter of the irradiated artery; the interval is longer for larger arteries. However, it is possible that the apparent injury to the large arteries is in fact due to occlusion of the vasa vasorum because the microvasculature is especially vulnerable to radiation damage.

Physician attitudes. Management of asymptomatic carotid artery murmur and transient ischemic attacks.

We polled 582 physicians to determine what their approach would be to management of an asymptomatic murmur at the carotid bifurcation and to carotid-distribution transient ischemic attack. We discovered a great disparity in attitudes attributable to location and type of practice. However, there was no difference attributable to age, and few differences were found with respect to measures of the physician's awareness of his own health. Physicians' attitudes and practices do not necessarily parallel scientific literature or recommendations of experts in the field.

1860--neurology was there.

The year 1860 was a beginning of social, political, and medical upheaval in the United States. The Civil War over states' rights, which would last for 4 years and change the political landscape of the United States forever, had its roots in that year. American neurology was conceived and gestated by the Civil War because of the collaboration between William A. Hammond (1828-1900) and Silas Weir Mitchell (1829-1914), who became the founders of American neurology. Thus, 1860 serves as a pivotal point from which to view the precursors of American neurology and the later war and postwar developments.

The global burden of disease study: implications for neurology.

Because of the epidemiological transition, the global burden of illness has changed. Several factors have contributed to this change, including improvements in maternal and child health, increasing age of populations, and newly recognized disorders of the nervous system. It is now evident that neurologic disorders have emerged as priority health problems worldwide. This is reflected in the Global Burden of Disease Study, jointly published by the World Health Organization and other groups. The proportionate share of the total global burden of disease resulting from neuropsychiatric disorders is projected to rise to 14.7% by 2020. Although neurologic and psychiatric disorders comprise only 1.4% of all deaths, they account for a remarkable 28% of all years of life lived with a disability. This study provides compelling evidence that one cannot assess the neurologic health status of a population by examining mortality statistics alone. Health ministries worldwide must prioritize neurologic disorders, and neurologists must be prepared to provide care for increased numbers of people individually and in population groups.

Asymptomatic carotid bruit and stenosis. A prospective follow-up study.

We observed 70 patients with asymptomatic carotid bruits with and without stenoses for cerebral and myocardial ischemic events. Four patients developed transient ischemic attacks (TIAs) without subsequent cerebral infarctions; all of the TIAs occurred distal to vessels with greater than or equal to 50% stenoses. Three cerebral infarctions occurred, but only one was distal to a vessel with stenosis greater than or equal to 50%. Six myocardial infarctions occurred, predominantly in patients with previous myocardial infarctions, congestive heart failure, and left ventricular hypertrophy. Our results confirm previous reports that an asymptomatic carotid stenosis is more often complicated by a TIA than an unheralded cerebral infarction. Cerebral infarctions that do occur are often only marginally related to the carotid bifurcation lesion. In patients with asymptomatic carotid bruit and stenosis, myocardial infarctions occur more frequently and are more commonly the cause of death than cerebral infarctions.

Disability in US presidents report. Recommendations and commentaries by the Working Group. The Working Group on Presidential Disability.

If the president of the United States must decide within minutes how to respond to a dire emergency, its citizens expect him or her to be mentally competent and to act wisely. Because the presidency of the United States is now the world's most powerful office, should its incumbent become even temporarily unable to exercise good judgment, the consequences for the world could be unimaginably far-reaching.

Doppler ultrasound scanning of the carotid bifurcation.

The results of Doppler scanning of 146 carotid bifurcations in 86 patients were correlated with carotid arteriography. The correlations for normal carotid arteries ranged from 63% to 98%; the correlation for occlusions of carotid arteries was 100%. The Doppler scan correlated in 70% to 85% of stenoses of the internal or external carotid arteries near their origins. The technique may be performed by a well-trained technician or physician.

Monocular blindness in nasopharyngeal cancer.

The sudden onset of painless monocular blindness was the initial manifestation of a nasopharyngeal cancer in a 78-year-old woman. Computerized cranial tomography demonstrated encasement of the optic nerve by tumor. Examination of the nasopharynx and paranasal sinuses is important in patients with primary neuro-ophthalmologic complaints.

Cephalic fibromuscular dysplasia in 32 patients: clinical findings and radiologic features.

The clinical and angiographic features of 32 patients with cephalic fibromuscular dysplasia (FMD) are reported. All of our patients were women, 78% of whom were between 41 and 70 years of age. At examination, 18 (56%) patients had the sudden onset of focal ischemic neurologic deficits. Seven (22%) patients had intracranial berry aneurysms, which ruptured in five patients but were asymptomatic in two. The most common angiographic pattern was the "string of beads" deformity, which involved both extracranial internal carotid arteries at or distal to the third cervical vertebral level. The vertebral artery was affected in six cases, while three cases had intracranial involvement. Less common angiographic findings in this series consisted of segmental fusiform dilation of the artery, and lesions in the form of a septum that extended across the lumen. Twelve patients were followed up for an average of four years. Progression of FMD lesions was shown in two of the six patients who had repeated angiograms. The literature contains reports of only nine cases of cephalic FMD with repeated angiograms, three of which demonstrated progression. Our experience suggests a beneficial role for surgery in patients with specific symptoms in the distribution of the affected vessel, when coexistent disease is negligible or absent.

Nonbacterial thrombotic endocarditis. A neurologic perspective of clinicopathologic correlations of 99 patients.

Of 13,913 patients examined at autopsy between 1939 and 1980, the diagnosis of nonbacterial thrombotic endocarditis (NBTE) was made in 99 instances. There were 53 males and 46 females ranging in age from 4 to 89 years. Vegetations were found on the aortic valve in 39; the mitral in 37; the tricuspid in nine; and the mitral in 37; the tricuspid in nine; and the pulmonic in two. Two-valve involvement was present in 12 cases. Malignant neoplasms were found in 42 autopsies. Embolism to the brain was found in 33 cases and to other organs in 62. Coagulation abnormalities were documented in 22 cases, and a distinct picture of disseminated intravascular coagulation of thrombophlebitis elsewhere in the body should arouse suspicion of NBTE. The high incidence of multiple emboli and its association with malignant neoplasms and with a variety of cardiovascular, pulmonary, renal, and gastrointestinal disorders should provide clues for recognition of this serious disorder.

The delay in reporting symptoms of carotid artery stenosis in an at-risk population. The Asymptomatic Carotid Atherosclerosis Study experience: a statement of concern regarding watchful waiting.

OBJECTIVE: To examine whether patients in the Asymptomatic Carotid Atherosclerosis Study reported symptoms of cerebral and retinal ischemia promptly to the investigating team. DESIGN: Cohort study within the Asymptomatic Carotid Atherosclerosis Study, a prospective, randomized, multicenter clinical trial, with a median follow-up time of 2.7 years. SETTING: Thirty-nine clinical sites across the United States and Canada. PATIENTS: Patients with asymptomatic carotid artery stenosis (> or = 60% reduction in diameter) who experienced either a transient ischemic attack (TIA) (n = 115) or stroke (n = 127) during the follow-up period, as verified by an external committee. MAIN OUTCOME MEASURE: Proportion of patients who reported cerebrovascular symptoms to a study nurse or physician within 3 days of occurrence. RESULTS: Thirty-seven patients (32.2%) experiencing TIA and 57 (44.9%) experiencing stroke reported symptoms to the study staff within 3 days of onset. For TIA, there was a statistically significant inverse association between prompt reporting and the amount of time a patient was enrolled in the study before the event occurred (48% with TIA occurring within 6 months vs 9% with TIA after year 3; P = .04). For stroke, there was a statistically significant association between prompt reporting and treatment arm (56% for the surgical vs 38% for the medical group; P = .05). For either TIA or stroke, none of the other factors examined were significantly associated with prompt reporting. CONCLUSIONS: Despite extensive education and reinforcement, fewer than 40% of all first events were reported within 3 days and fewer than 25% were reported in less than 24 hours. Frequent outpatient evaluation of high-risk patients and careful review of symptoms is necessary to determine when asymptomatic carotid artery stenosis has become symptomatic to offer appropriate forms of therapy.

Transient ischemic attacks due to atherosclerosis. A prospective study of 160 patients.

Patients with transient ischemic attacks (TIAs) due to atherosclerosis were studied by aortocranial arteriography. Onset of TIAs was before age 55 in 24% and between 55 and 64 in 47%. Men exceeded women by two to one. Of 160 patients, 77 were treated medically and 82 surgically. Five died in the immediate postoperative period. In the survivors, mortality has been the same in the medically and surgically managed groups. For patients with multiple lesions, surgical reconstruction of the carotid arteries was associated with very high surgical risk. In the medically treated group, anticoagulant therapy reduced the frequency of TIAs, but did not appear to protect patients from stroke. Mortality was 23% at four years, 57% of deaths being attributable to myocardial infarction and 38% to stroke.

Extracranial carotid artery arteriosclerosis. Diagnosis with continuous-wave Doppler and real-time ultrasound studies.

To determine the predictive accuracy of Doppler and real-time ultrasound studies, continuous-wave Doppler (CWD) and B-mode real-time ultrasound (RTU) studies of the carotid bifurcation were compared in 50 consecutive patients before cervicocranial arteriography. Four categories of CWD results were formed according to the severity of stenosis. Except for mild to moderate stenosis, there was a high degree of agreement (87.5% to 98.1%) between CWD results and arteriographic diagnosis. Of the arteries classified as normal on RTU study, 95.5% were arteriographically normal; of those classified as abnormal, 94.9% were abnormal on arteriography. In 94.7% of the cases in which RTU demonstrated a possible ulcer, the diagnosis was confirmed by arteriography.

Clinical and computerized tomographic study of hypertensive intracerebral hemorrhage.

Historical, neurological, and computerized tomographic findings were correlated in 32 patients with hypertensive intracerebral hemorrhage. The mortality figures given in standard texts appear to be too high; the more acceptable figure would seem to be approximately 40%. Special attention was given to intraventricular rupture, which complicated 62% of the cases. Sudden onset of coma appears to correlate with the presence of intraventricular rupture. The "ring sign," if looked for, will be seen in most cases of resolving intracerebral hematoma.

The transient global amnesia-migraine connection.

Twelve patients with transient global amnesia (TGA) were studied. Seven (58%) of the 12 had a headache during their attack; five (42%) of the 12 were migraineurs. Measurement of regional cerebral blood flow (rCBF) by the xenon Xe 133 inhalation method showed similar patterns of flow in five of the seven patients tested. The rCBF abnormalities were impaired vasomotor response in the watershed area between the middle cerebral artery and posterior cerebral artery territories, and/or focal ischemia in the inferior part of the temporal lobe. These rCBF abnormalities differed from those seen in patients with carotid transient ischemic attacks (TIAs) and vertebrobasilar TIAs. We speculate that the vasomotor phenomena in migraine may play a major role in the cause of TGA.

Clinical technique for identification of external carotid bruits.

A 66-year-old woman had an asymptomatic bruit over the right carotid bifurcation. Carotid Doppler and real-time ultrasound studies demonstrated an isolated 50 to 75% stenosis of the right external carotid artery. We devised a simple maneuver to determine which artery, internal or external carotid, caused the bruit.

Carotid and vertebrobasilar transient ischemic attacks: clinical and angiographic correlation.

Carotid and vertebrobasilar transient ischemic attacks (TIAs) were clinically and angiographically correlated in 85 patients who had four-vessel angiography within 2 weeks after a TIA. The patients were divided into carotid and vertebrobasilar groups by clinical criteria. In the correlations of symptoms with arteriography, lesions of the contralateral internal carotid artery were observed in 54 percent of the patients. Of 39 patients with vertebrobasilar symptoms, 34 percent also had one carotid lesion and six patients had combinations of symptoms of both carotid and vertebrobasilar disease. In correlation with carotid bruits of the 85 patients, bruits were heard over one carotid artery in 42 percent. Subclavian bruits were heard in 47 percent of the patients with vertebrobasilar symptomatology. TIAs owing to arteriosclerosis of the cervical arteries occurred in 85 percent of the patients, but there was no significant difference in the incidence of atherosclerosis-induced TIA in the carotid and vertebrobasilar systems. For accurate population surveys of the prevalence of TIAs, and for clinical decisions, proper categorization of patients is necessary.

Transient global amnesia due to glioma in the dominant hemisphere.

A patient with transient global amnesia (TGA) had a glioma in the dominant hippocampus. Neuroradiologic studies showed local mass effect on the posterior choroidal artery on that side. This finding suggests that unilateral involvement is sufficient to cause the syndrome despite the widely held view that bilateral lesions are essential.

Low mini-mental status predicts mortality in asymptomatic carotid arterial stenosis. Asymptomatic Carotid Atherosclerosis Study investigators.

OBJECTIVE: To determine whether carotid endarterectomy is superior to best medical therapy in preserving cognition, and whether low Mini-Mental State Examination (MMSE) scores predict TIA, stroke, myocardial infarction, or death. METHODS: Subjects participating in the Asymptomatic Carotid Atherosclerosis Study were administered the MMSE at periodic intervals. Group means were calculated at randomization, 1 and 3 months later, and every 6 months thereafter. The group means were compared by treatment and over time. A proportional hazard regression model incorporating postrandomization MMSE score as a predictor variable was used to estimate risk of death, stroke, or other outcome events. RESULTS: There was no intergroup difference in mean MMSE score during 5 years of observation. For individual patients, the relationship between a low postrandomization score on the MMSE and increased risk of death was significant (p