Kenneth E. Livingston

Development and distribution of gross atherosclerotic lesions at cervical carotid bifurcation.

THE RECENT UTILIZATION of vascular surgical procedures for the relief of segmental obstruction in the cervical portion of the carotid art e ~ y l ~ has increased the importance of information regarding the development and distribution of the underlying atherosclerotic lesions. Because of its relative inaccessibility in routine autopsy examinations, the cervical carotid artery has, until recently, been considerably neglected in the analysis of pathologic alterations underlying “stroke” disabilities.10-13 Anatomic studies demonstrate that the atherosclerotic lesion in the carotid is commonly maximal at the level of the cervical bifurcation,l”* and clinical data from arteriographic study reveal a surprising frequency of partial or complete obstruction at this site.le-26 Because of the technical feasibility of surgical procedures in these vessels, obstructing lesions acquire particular interest and importance. The present study was undertaken to obtain information regarding the localization and progression of the atherosclerotic process in this region; 123 carotid bifurcation specimens were studied from individuals ranging in age from 17 to 90 years, with a median age of 48. Specimens were divided into 3 groups according to age (Table 1). Both carotids were available for study in all but 15 individuals. Specimens were removed, cleaned of excess connective tissue, and fixed in 10% formalin. Before the tissues hardened, the “normal” lumen contour was established by filling the segment with warm p a r a h . Standard photographs of each specimen were made to permit measurements and comparisons. The gross external characteristics were recorded (Fig. 1). The approximate center of the bifurcation was established, and the proximal and distal arteries were transected 1 cm. from this point (Fig. 2) . A thin cross section of each artery was taken at this level to permit measurements of lumen area (Fig. 3) . The bifurcation segment was then split longitudinally to show internal detail and changes within the arterial wall (Fig. 4). Gross evidence of atherosclerosis from minimal to severe was found in all specimens. The intensity of the lesion increased with age. Although surprising differences in the extent of

Delayed focal convulsive seizures after head injury in infants and children: A syndrome that may mimic extradural hematoma

THE CLASSIC CLINICAL HISTORY of extradural hematoma after head injury-transient unconsciousness followed by a lucid interval and then coma-has received great emphasis in medical teaching literature. I t is widely assumed that this sequence invariably means that the patient has a massive hematoma requiring immediate surgical treatment. However, in infants and children, a similar syndrome which is not due to hematoma is seen after head injury. The clinical sequence is head injury with or without transient unconsciousness, a lucid interval, and then a convulsive seizure leading to coma. The initial seizure is frequently not seen, and the patient is found in postictal coma. Subsequent seizures may not be recognized or, if recognized, may not be treated because the patient is then en route to a neurosurgeon or because the seizure is assumed to be due to intracranial hematoma and the attending physician is reluctant to give depressant anticonvulsant medication. Unless the true nature of the disturbance is recognized and controlled, serious or even fatal complications may result. If the syndrome is recognized and treated, the patient should recover without residual disability. During a period of one month, 4 children with this syndrome were admitted to the Head Injury Service of the Nemazee and Saadi Hospitals, together with 1 child with classic extradural hematoma treated surgically. This group of cases illustrates the problem of differential diagnosis and management of the 2 lesions.