Burton A. Sandok

Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits

Emergency revascularization procedures for patients with acute stroke are controversial. Thirty-four patients with acute internal carotid artery occlusion documented at the time of emergency endarterectomy were analyzed. Before operation, all these patients had profound neurological deficits including hemiplegia and aphasia. There was a 94% success rate in restoring patency. In follow-up, nine patients (26.5%) had a normal neurological exam, four (11.8%) had a minimal deficit, 10 (29.4%) had a moderate hemiparesis, which was improved over their preoperative deficit, 4 (11.8%) remained hemiplegic, and seven (20.6%) died. The natural history of patients with acute carotid occlusion and profound neurological deficits is dismal. In comparison, 13 patients (38%) made a dramatic recovery. The surgical mortality rate compares favorably with the natural history. Good collateral flow was a good prognostic factor, while a simultaneous middle cerebral artery embolus was associated with a poorer prognosis. An emergency carotid endarterectomy may be indicated in selected patients with acute internal carotid artery occlusion with profound neurological deficits. Full preoperative angiography may identify those patients who would benefit from surgical intervention and reduce the operative mortality rate.

Rehabilitation for stroke: a review.

Survivors of stroke are often left with severe mental and physical disabilities, which create a major social and economic burden. Many investigators have attempted to assess the role of rehabilitation in reducing such disability. Few controlled studies provide accurate assessment and documentation of benefit. Because of the presence of multiple variables and inadequate measures of outcome, it is difficult to design studies evaluating the effectiveness of rehabilitation for stroke. It is unclear how early rehabilitation should begin and what aspects of rehabilitation are important. Intensive rehabilitation is an expensive and limited resource; thus, the ability to identify the subgroup of patients with stroke who are likely to benefit is a critical issue. Although preliminary guidelines for the selection of patients who are appropriate for rehabilitation are given, no uniform criteria reliably differentiate patients who need rehabilitation from those who will recover spontaneously or do poorly. Controlled studies in the practice of rehabilitation for stroke will provide much useful information for patient management.

Prospective comparison of a cohort with asymptomatic carotid bruit and a population-based cohort without carotid bruit.

This study is a prospective analysis of the predictive value of diffuse and localized carotid bruit. Patients with asymptomatic carotid bruits are compared with a population-based age- and sex-matched control group known not to have carotid bruit, in regard to subsequent transient ischemic attack, stroke, and death. Each person was followed until death or for 5 years. Among the 566 patients with asymptomatic carotid bruit, the annual stroke rate given survival was 1.5%/yr or 7.5% at 5 years by actuarial analysis. The annual stroke rate given survival for the 428 patients in the population-based cohort was 0.5%/yr or 2.4% at 5 years. Patients with localized carotid bruit were not significantly different from those with diffuse carotid bruits in regard to subsequent cerebral ischemic events (p = 0.11). These data indicate that patients with asymptomatic diffuse or localized carotid bruit are approximately three times more likely to have ischemic stroke than an age- and sex-matched population sample known not to have carotid bruit.

Cerebral ischemic events in patients with mitral valve prolapse.

All patients 20 years old or older referred for echocardiographic examination and found to have mitral valve prolapse during the period January 1975 through December 1979 were included in the study. Of the 1,138 patients, two-thirds were women and one-third were men. Their average age was 48.4 years. Forty patients (3.5%) had histories of prior focal cerebrovascular ischemic events. In 26 of the 40 patients, no responsible mechanism other than mitra valve prolapse was identified, and in 4, the ischemic event occurred during an episode of bacterial endocarditis, a known complication of mitral valve prolapse. In 10 of the 26 patients, there was clinical information to suggest an embolic mechanism for the ischemic. A conservative estimate of the prevalence rate for cerebral infarction in this group of patients is four times greater than the rate expected in a normal population. This difference is likely due to the contribution of mitral valve prolapse in the pathogenesis of cerebral infarction.

Clinical Indicators of Extracranial Carotid Artery Disease in Patients With Transient Symptoms

The clinical findings in 64 patients with transient symptoms of unilateral carotid system ischemic disease (amaurosis fugax or transient focal cerebral ischemic attacks or both) were reviewed in an effort to determine the value of the neurovascular examination in predicting the presence and extent of roentgenographically demonstrated ipsilateral extracranial internal carotid artery disease. Amaurosis fugax seems to be a highly specific indicator of disease, being associated with 4% of normal vessels as compared to 27% for patients with transient focal cerebral ischemic attacks alone. In patients with transient symptoms, the incidence of a normal, ipsilateral carotid artery was 36% in the absence of any positive neurovascular findings, 15% in the presence of an ipsilateral carotid bruit, 6% in the presence of ipsilateral retinal embolic events, 5% in the presence of ipsilateral reduction in superficial temporal or carotid (or both) pulse, 4% in the presence of an ipsilateral reduction in retinal artery pressure, and 3% when more than one of these findings were noted. The neurovascular examination appears to be a useful adjunct in detecting the presence or absence of ipsilateral carotid disease. However, no combination of symptoms or signs would, in all cases, allow one to accurately determine whether a vessel was abnormal, stenotic, or occluded.

Focal Encephalitis in a Young Woman 6 Years After the Onset of Lyme Disease: Tertiary Lyme Disease?

A 19-year-old woman had severe focal inflammatory encephalitis. Six years previously, she had had classic untreated Lyme disease characterized by erythema chronicum migrans, bilateral facial palsies, and lymphocytic meningitis. During her recent encephalitic illness, Lyme disease serologic tests were positive by indirect immunofluorescence microscopy, enzyme-linked immunosorbent assay, and western blot (immunoblot technique) testing. We hypothesize that the patients focal inflammatory encephalitis was a result of a persistent spirochetal infection of the central nervous system.

A-Mode Echoencephalography in the Evaluation of Cerebrovascular Disease

The value of A-mode echoencephalography was studied in a series of patients with Cerebrovascular disease of various types. The procedure proved to be restricted value limited to those situations in which (1) a midline shift was obtained, and (2) the midline shift was observed within 36 hours after the onset of symptoms. Whereas after 36 hours some patients with cerebral infarction showed a midline shift (presumably due to edema), such a shift was not noted in patients with cerebral infarct who were examined within 36 hours after its occurrence. Those patients showing a midline shift before this interval should be suspected of having an intracerebral hemorrhage or other intracranial space-occupying process.