The "incompleat" physicians: community physicians' lack of knowledge of medical socioeconomics and politics.

The suspicion that physicians in this community know little about current events in American medical socioeconomics and politics led to a survey of the local medical society membership. The results showed a discouraging lack of knowledge about information that is readily available to physicians. We concluded that current methods for educating physicians in these subjects are largely ineffective. Live, as opposed to printed, presentations at local, state, and specialty medical society meetings may be more effective in educating, and thereby involving, physicians in the critical political and economic issues presently facing them.

Extracranial surgical procedures in the management of vertebrobasilar insufficiency.

Vertebrobasilar insufficiency is an important syndrome in the spectrum of cerebrovascular disease. Its clinical importance and the frequency of its clinical manifestations are often underestimated. Our experience with a large population of patients having extensive cerebrovascular disease has led us to recognize two classes of vertebrobasilar insufficiency--simple and complex--and, also, to recognize that vertebrobasilar insufficiency is often associated with disease in multiple extracranial vessels. Until recently, direct approaches to the vertebral artery have been underutilized for these patients. In fact, there has been a tendency either to relegate patients with vertebrobasilar disease to medical follow-up or to surgical procedures upon the carotid system. We believe that the resurgence of neurosurgical interest in the vertebrobasilar system is most appropriate. Furthermore, the active interest that neurosurgeons are now taking in developing procedures for managing extracranial vertebral artery problems is in the best interest of patients with cerebrovascular disease. We believe that careful neurosurgical evaluation of patients with simple and complex vertebrobasilar insufficiency will lead to appropriate selection of candidates for vascular reconstruction of the vertebral system. Finally, we believe that vertebral artery to common carotid artery transposition, and its variations, is a procedure that has an important role in the management of cerebrovascular disease.

Intermittent appearance of a ruptured cerebral aneurysm on sequential angiograms. Case report.

The change in size of a ruptured anterior cerebral artery aneurysm was recorded in a series of angiograms. The aneurysm did not appear on the initial angiogram, but was seen on the second study. Incomplete filling was seen on the third angiogram, and the aneurysm appeared to have thrombosed on the fourth angiogram. On the fifth angiogram, done 5 weeks after the first, the aneurysm filled completely. It was subsequently clipped.

Subclavian steal syndrome. Part 1: Proximal vertebral to common carotid artery transposition in three patients, and historical review.

Three patients with central nervous system symptoms due to subclavian steal syndrome were treated with proximal vertebral to common carotid artery transposition. Neurological symptoms were relieved or improved in all three, with no decrease in blood pressure or pulse in the ipsilateral upper extremity. The colorful history of this syndrome is reviewed, and the various surgical approaches to its treatment are discussed. Although the literature suggests that the commonly used carotid to subclavian artery bypass graft and other similar extrathoracic procedures are generally safe and effective for relief of symptoms of the steal, there is also evidence that these bypasses may fail to restore antegrade flow in the vertebral artery, and, in fact, may steal from the carotid artery. Thus, the blood flow provided to the brain by these procedure may be hardly more than that provided by vertebral artery ligation, whereas the principal effect is to restore blood flow into the upper extremity. Vertebral artery ligation alone has been used in 20 patients, with neurological improvement in all cases and production of persistent intermittent brachial claudication in only one. These considerations and our patient experience suggest that a relatively simple operation, proximal vertebral to common carotid artery transposition, which emphasizes restoration of flow to the brain rather than to the upper extremity, may be preferable for most patients with neurological symptoms of subclavian steal syndrome.

Subclavian steal syndrome. Part 2: Intraoperative vertebral artery blood flow measurement.

Intraoperative vertebral artery blood flow was measured in two patients with symptomatic subclavian steal syndrome, before and after proximal end-to-side vertebral to common carotid artery transposition. This confirmed retrograde flow in the vertebral artery before transposition, and antegrade flow after transposition. The measured flow rates were compared to values in other series involving different operative procedures for correction of symptomatic subclavian steal. The greatest mean antegrade flow rates in the vertebral artery were restored by proximal end-to-side vertebral to common carotid artery transposition.

Anaplastic astrocytoma following radiation for a glomus jugular tumor.

Evaluation of radiation therapy for a given neoplasm includes consideration of possible treatment complications as well as potential benefit. A 43-year-old male with a glomus jugular tumor or the right middle ear had received 4480 rad to the right middle and inner ear and temporal bone. Eight years later, he developed an anaplastic astrocytoma of the right cerebellar hemisphere. At this time a third neoplasm, a left carotid body tumor, was demonstrated angiographically. Although radiation can be implicated in the genesis of the glial neoplasm, the presence of two neural crest derived tumors suggests that a lowered threshold for neoplastic transformation in neuroectodermal cells may have been an additional factor. Long-term follow-up of large numbers of patients with glomus jugulare tumors will be necessary to determine if multiple paragangliomas predispose to radiation-associated gliomas.

Melatonin concentration in human blood and cerebrospinal fluid: relationship to stress.

In 35 daytime paired blood and cerebrospinal fluid (CSF) samples from 15 patients, melatonin levels in CSF were undetectable or detectable but not higher than blood levels. During pneumoencephalography in 6 patients, no significant elevation of blood melatonin levels was observed, whereas cortisol concentration increased.

Aneurysms of the persistent hypoglossal artery.

The primitive hypoglossal artery is one of four embryonic anastomoses between the carotid and basilar arterial systems. The so-called persistent hypoglossal artery is most likely a complex vessel comprised proximally of a persistent hypoglossal artery and distally of components of the primitive lateral basilar-vertebral anastomotic network. This is the sixth reported case of an aneurysm of the persistent hypoglossal artery, and it is unique in its association with two supratentorial aneuryms, one of which had ruptured. All three aneurysms were treated by a direct surgical approach (two operations). Review of the other published cases demonstrates that these aneurysms arise at the junction of the persistent hypoglossal with the basilar artery. Aneurysms of this vessel require direct surgical treatment, because the parent vessel is functionally the only artery supplying the brain stem and therefore may not be ligated. The aneurysms usually lie in the subarachnoid space, indenting the brain stem, and may be approached through a suboccipital craniectomy.