==================================HSR45================================== 45. Extraintracranial artery bypass surgery in the treatment of strokes. 1 UI - 87121294 AU - Vorstrup S ; Brun B ; Lassen NA TI - Evaluation of the cerebral vasodilatory capacity by the acetazolamide test before EC-IC bypass surgery in patients with occlusion of the internal carotid artery. AB - Cerebral blood flow (CBF) was measured by xenon-133 inhalation tomography in 18 patients with cerebrovascular disease before and 4 months after extracranial-intracranial bypass surgery. Only patients who showed a reduced CBF in areas that were intact on the CT scan and relevant to the clinical and angiographical findings were operated. The majority of the patients had suffered a minor stroke with or without subsequent transient ischemic attacks. They were studied at least 6 weeks following the stroke. All patients had an occlusion of the relevant internal carotid artery. To identify preoperatively the patients with a compromised collateral circulation and hence reduced CBF due to reduced perfusion pressure, a cerebral vasodilatory stress test was performed using acetazolamide (Diamox). In normal subjects, Diamox has been shown to increase tomographic CBF without change of the flow distribution. In the present series 9 patients showed a significant redistribution of flow in favor of the non-occluded side ("positive: Diamox test). Two of these 9 patients showed even a paradoxical decrease in focal CBF preoperatively, i.e., a "steal: effect. These 2 patients were the only patients who improved in focal CBF after shunting. The remaining 9 patients all showed uniform flow responses ("negative: Diamox test), and none of these increased in focal CBF postoperatively. The finding of an unchanged flow map postoperatively confirmed that the low flow areas were not due to restricted flow via collateral pathways. However, an increase in the regional vasodilatory capacity was observed postoperatively in the majority of patients. MH - Acetazolamide/*DIAGNOSTIC USE ; Adult ; Aged ; Carotid Artery Diseases/ *DIAGNOSIS/SURGERY ; Carotid Artery, Internal/PATHOLOGY ; Case Report ; Cerebral Angiography ; *Cerebral Revascularization ; *Cerebrovascular Circulation ; Collateral Circulation ; Human ; Male ; Middle Age ; Preoperative Care ; Support, Non-U.S. Gov't ; Tomography, Emission Computed ; Xenon Radioisotopes/DIAGNOSTIC USE SO - Stroke 1986 Nov-Dec;17(6):1291-8 2 UI - 87121257 AU - Bogousslavsky J ; Wong W ; Barnett HJ ; Fox AJ TI - Bilateral occlusion of the trunk of the middle cerebral artery. Results of an international randomized trial. The EC/IC Bypass Study Group. AB - Bilateral occlusion of the middle cerebral artery (MCA) trunk theoretically should be a very severe condition, but its actual prognosis has never been studied. Nine of 1,377 patients (7 Asians, 1 Black, 1 Caucasian) from the Cooperative Study of Extracranial/Intracranial Arterial Anastomosis were found to have atherosclerotic bilateral occlusion of the middle cerebral artery (MCA) trunk before entering the trial. Three presented with a stroke followed by a contralateral stroke, two experienced a unilateral stroke, two had a unilateral stroke preceded by ipsilateral TIAs, one had a unilateral stroke preceded by TIAs on both sides and one experienced isolated unilateral TIAs. Retrograde filling to the distal MCA was universally present. During follow-up (mean: 45 months), only one (non-operated) patient had further cerebrovascular events, and ultimately a fatal stroke. One additional patient died of sepsis and one had a silent myocardial infarct. All survivors resumed their previous activities. This study shows that in bilateral MCA trunk occlusion, the long-term prognosis is reasonable in the patients who do not present with a devastating stroke. MH - Adult ; Aged ; Case Report ; Cerebral Arteries/*SURGERY ; Cerebral Arteriosclerosis/COMPLICATIONS/*SURGERY ; *Cerebral Revascularization ; Cerebrovascular Disorders/ETIOLOGY ; Clinical Trials ; Comparative Study ; Female ; Human ; Male ; Middle Age ; Prognosis ; Support, U.S. Gov't, P.H.S. SO - Stroke 1986 Nov-Dec;17(6):1107-11 3 UI - 87116228 AU - Mehdorn HM ; Nau HE ; F:orster M TI - Carotid artery occlusion and ocular ischemia: therapy control with evoked potentials. AB - We present a patient with internal carotid artery occlusion and ischemic oculopathy in whom extracranial-intracranial arterial bypass improved vision. Visual evoked potentials were studied to obtain objective criteria for indication and follow-up evaluation and confirmed that the improved vision was due to improved retinal function. MH - Carotid Artery Diseases/*SURGERY ; Case Report ; Cerebral Ischemia/ *SURGERY ; *Cerebral Revascularization ; *Evoked Potentials, Visual ; Eye/ *BLOOD SUPPLY ; Human ; Ischemia/*SURGERY ; Male ; Middle Age ; Postoperative Complications/DIAGNOSIS ; Reaction Time ; Tomography, X-Ray Computed ; Vision Disorders/SURGERY SO - Neurosurgery 1986 Dec;19(6):1031-4 4 UI - 87110984 AU - Mitchell SK ; Yates RR TI - Cerebral vasospasm: theoretical causes, medical management, and nursing implications. AB - Cerebral vasospasm is a potentially life-threatening complication following subarachnoid hemorrhage (SAH) from a ruptured cerebral artery aneurysm. Traditionally, vasospasm has been treated with a variety of medical interventions. However, surgical intervention with an extracranial to intracranial (EC/IC) bypass graft has yielded promising results in a limited group of patients. This article discusses the theoretical causes of cerebral vasospasm, its clinical presentation, diagnosis, and treatment modalities. Nursing interventions for the patient experiencing cerebral vasospasm are also presented. MH - Blood Pressure ; Blood Volume ; Cerebral Aneurysm/*SURGERY ; Cerebral Ischemia/NURSING ; Cerebral Ischemia, Transient/DIAGNOSIS/ETIOLOGY/ *NURSING ; Cerebrovascular Circulation ; Combined Modality Therapy ; Human ; Intensive Care Units ; Postoperative Complications/*NURSING ; Subarachnoid Hemorrhage/*SURGERY SO - J Neurosci Nurs 1986 Dec;18(6):315-24 5 UI - 87072805 AU - Auer LM ; Oberbauer RW ; Clarici G ; Pucher R TI - Surgical treatment of cerebrovascular occlusive disease. A follow-up study. AB - This prospective open study of 124 patients [80% with completed stroke (CS), 16% with TIAS, 4% with PRIND] consecutively admitted between 1976 and 1981 investigates the rates of reinfarction after surgical treatment (extra-intracranial arterial bypass, EIAB and/or carotid thrombendarterectomy, TEA). 34% of patients had unilateral carotid stenosis, 26% unilateral internal carotid artery occlusion, 17% had occlusion of one and stenosis of the contralateral internal carotid artery, 14% bilateral carotid stenosis. Combined surgical morbidity and mortality was 5% after 158 operations in 124 patients; 7 of the 8 complications occurred in patients with CS. Of the 120 survivors in the immediate postoperative period, after a mean follow-up period of 5.7 years ranging from 3-8 years, an infarct occurred in 5.8%, i.e., 1% per year; 3 of them occurred ipsilaterally, 2 contralaterally to the first infarct, two remained unknown. Among all 99 patients with CS, the reinfarction rate was 5% (1% per year); in CS patients with a minimal follow-up of 5 years, the annual reinfarction rate was 2%. Of fifty-three patients with completed stroke after EIAB with a mean follow-up of 4.6 years, 3.8% suffered reinfarction (0.8% per year). Among 26 patients with CS and unilateral carotid occlusion after a mean follow-up of 4.7 years, the reinfarction rate was 3.9% (0.8% per year). Among 46 patients with carotid occlusion with or without further stenotic or occlusive lesions, the reinfarction rate was 2.2%.(ABSTRACT TRUNCATED AT 250 WORDS) MH - Adult ; Aged ; Carotid Artery Diseases/SURGERY ; Carotid Artery, Internal/ SURGERY ; Cerebral Arteriosclerosis/*SURGERY ; Cerebral Infarction/ *SURGERY ; Cerebral Ischemia, Transient/*SURGERY ; Follow-Up Studies ; Human ; Middle Age ; Postoperative Complications/MORTALITY ; Recurrence SO - Acta Neurochir (Wien) 1986;82(3-4):102-9 6 UI - 87070208 AU - Robbs JV ; Human RR ; Rajaruthnam P TI - Extracranial arterial reconstruction for chronic cerebral ischaemia. An audit of experience in the Durban Teaching Hospitals. AB - Experience with 147 operations for extracranial cerebral arterial reconstruction in 122 patients over a 36-month period is presented. The commonest condition in white, black and indian patients was atherosclerosis, although 8 of the 23 black patients had nonspecific aorto-arteritis (Takayasu's disease). Operations within the mediastinum included bypass from the ascending aorta to major arterial branches (14), brachiocephalic endarterectomy (1), and replacement grafts of carotid (1) and subclavian (1) arteries. Cervical procedures included carotid endarterectomy or reconstruction (115), carotid-subclavian artery bypass (13) and axillary-to-axillary artery crossover (2). Both early and longer-term results are comparable with those reported in the surgical literature. MH - Adult ; Aged ; Blood Vessel Prosthesis ; Carotid Arteries/SURGERY ; Cerebral Ischemia/*SURGERY ; *Cerebral Revascularization ; Endarterectomy ; Female ; Human ; Male ; Mediastinum/SURGERY ; Middle Age ; Neck/SURGERY ; Subclavian Artery/SURGERY SO - S Afr Med J 1986 Nov 22;70(11):653-7 7 UI - 87065535 AU - Awad IA ; Spetzler RF TI - Extracranial-intracranial bypass surgery: a critical analysis in light of the International Cooperative Study. AB - The ability of extracranial-intracranial bypass surgery to alter favorably the natural history of ischemic cerebrovascular disease remains in question. A recently completed prospective randomized multicenter cooperative trial failed to confirm the hypothesis that the procedure prevents further cerebral ischemia in patients with atherosclerotic internal carotid artery or middle cerebral artery disease. We analyze findings of the study in detail, including possible effects on the natural history of the disease beyond the immediate perioperative period. Potential sources of bias that may have unpredictably affected the study are discussed. These include observational bias (patient and therapist not blinded), "randomization-to-treatment: bias (high morbidity after randomization but before operation), and "prerandomization: or allocation bias (patients in the study representing a selected sample of the population with cerebrovascular disease). The extensive analysis of secondary subgroups with small numbers of patients is discussed in light of the statistical methods used. Two particular classes of patients not addressed in the study who might benefit from the procedure are defined. They are patients failing the best available medical therapy and patients with clearly documented hemodynamic compromise. Possible indications for bypass surgery are suggested for the various lesions in light of the trial and of recent reports on the natural history and pathophysiology of ischemic cerebrovascular disease. Selected cases illustrating these indications are presented. MH - Adult ; Aged ; Case Report ; *Cerebral Revascularization/ADVERSE EFFECTS/ METHODS ; Cerebrovascular Disorders/ETIOLOGY/RADIOGRAPHY/*SURGERY ; Female ; Human ; Male ; Prospective Studies ; Random Allocation ; Tomography, X-Ray Computed SO - Neurosurgery 1986 Oct;19(4):655-64 8 UI - 87010830 AU - Benzel EC ; Sittig KM ; Mirfakhraee M TI - Internal carotid artery stump angioplasty for the treatment of cerebrovascular occlusive disease. AB - Nineteen patients underwent a total of 21 stump angioplasty procedures for an occluded internal carotid artery. Indications for surgery included the preparation of the donor vessel for a subsequent extracranial-intracranial bypass procedure, the occurrence of emboli to the intracranial vasculature from the external carotid artery circulation, and the association with symptomatic occlusive disease of the external carotid artery accompanying occlusion of the ipsilateral internal carotid artery. The technique utilized and the results obtained in these 19 patients are presented. In select patients, the removal of an occluded internal carotid artery stump via a stump angioplasty is beneficial in preventing the catastrophic sequela of embolic cerebrovascular disease. MH - Arterial Occlusive Diseases/PATHOLOGY/RADIOGRAPHY/*SURGERY ; Carotid Artery Diseases/PATHOLOGY/RADIOGRAPHY/*SURGERY ; Carotid Artery, External/ SURGERY ; Carotid Artery, Internal/SURGERY ; Cerebral Ischemia, Transient/ ETIOLOGY ; Constriction, Pathologic ; Human ; Postoperative Complications SO - J Neurosurg 1986 Oct;65(4):461-4 9 UI - 87010827 AU - Sundt TM Jr ; Piepgras DG ; Marsh WR ; Fode NC TI - Saphenous vein bypass grafts for giant aneurysms and intracranial occlusive disease. AB - The authors report their experience with the use of saphenous vein bypass grafts for treating advanced occlusive disease in the posterior circulation (77 patients, all of whom had failed medical management and showed severe ischemic symptoms), deteriorating patients with giant aneurysms of the posterior circulation (nine patients), progressive ischemia in the anterior circulation (26 patients, none of whom had a normal examination), and giant aneurysms in the anterior circulation (20 patients, all of whom presented with mass effect or subarachnoid hemorrhage). Graft patency in the first 65 cases treated was 74%. However, after significant technical changes of vein-graft preparation and construction of the proximal anastomosis, patency in the following 67 cases was 94%. Excellent or good results (including relief of deficits existing prior to surgery) were achieved in 71% of patients with advanced occlusive disease in the posterior circulation, 44% of those with giant aneurysms of the posterior circulation, 58% of those with ischemia of the anterior circulation, and 80% of those with giant aneurysms of the anterior circulation. Mean graft blood flow at surgery in the series was 100 ml/min for posterior circulation grafts and 110 ml/min for anterior circulation grafts. Experience to date indicates that this is a useful operation, and is particularly applicable to patients who are neurologically unstable from advanced intracranial occlusive disease in the posterior circulation or with giant aneurysms in the anterior circulation. The risk of hyperfusion breakthrough with intracerebral hematoma restricts the technique in patients with progressing ischemic symptoms in the anterior circulation, and the intolerance of patients with fusiform aneurysms in the posterior circulation to the iatrogenic vertebrobasilar occlusion limits the applicability of this approach to otherwise inoperable lesions in that system. MH - Aged ; Arterial Occlusive Diseases/COMPLICATIONS/RADIOGRAPHY/SURGERY ; Cerebral Aneurysm/COMPLICATIONS/RADIOGRAPHY/*SURGERY ; Cerebral Angiography ; Cerebral Ischemia/ETIOLOGY ; Cerebrovascular Disorders/ COMPLICATIONS/RADIOGRAPHY/*SURGERY ; Follow-Up Studies ; Human ; Male ; Postoperative Complications ; Regional Blood Flow ; Saphenous Vein/ *TRANSPLANTATION ; Vascular Patency SO - J Neurosurg 1986 Oct;65(4):439-50 10 UI - 86316389 AU - Jack CR Jr ; Diaz FG ; Boulos RS ; Ausman JI ; Mehta B ; Patel SC TI - Radiologic evaluation of extracranial to Sylvian middle cerebral artery bypass. AB - At this institution a new procedure has been developed that involves anastomosing one of the branches of the superficial temporal artery to one of the major trunks of the middle cerebral artery in the Sylvian fissure. This procedure has been performed in 22 cases to date. Clinical indications for this procedure have fallen into four major categories. This new type of anastomosis produces greater bypass flow than conventional cortical middle cerebral artery anastomoses, and may be a better therapeutic alternative in certain clinical situations. The preoperative and postoperative angiographic evaluation of these patients is discussed. The radiologic results in this series of patients are reviewed. MH - Adult ; Aged ; Arteriovenous Fistula/RADIOGRAPHY/SURGERY ; Carotid Sinus ; Cavernous Sinus ; Cerebral Aneurysm/RADIOGRAPHY/SURGERY ; *Cerebral Angiography ; Cerebral Ischemia/RADIOGRAPHY/SURGERY ; *Cerebral Revascularization ; Comparative Study ; Female ; Human ; Male ; Middle Age ; Postoperative Period ; Reoperation ; Temporal Arteries/*RADIOGRAPHY/ SURGERY SO - Surg Neurol 1986 Oct;26(4):321-9 11 UI - 86311742 AU - Hanakita J ; Miyake H ; Nagayasu S ; Nishi S ; Suzuki T TI - Surgically treated cerebral arterial ectasia with so-called moyamoya vessels. AB - The case of a 43-year-old woman with multiple intracranial arterial ectasia was reported. The arterial ectasia was accompanied by stenosis of the middle cerebral artery and so-called moyamoya vessels. After extracranial to intracranial bypass surgery, the size and contour of the arterial ectasia decreased. Because the arterial ectasia decreased in size after the extracranial to intracranial bypass surgery, this operation might be useful for space-occupying lesions due to arterial ectasia. MH - Adult ; Aortography ; Arterial Occlusive Diseases/*COMPLICATIONS ; Case Report ; Cerebral Angiography ; Cerebral Arteries ; Cerebral Revascularization ; Cerebrovascular Disorders/*COMPLICATIONS/RADIOGRAPHY/ SURGERY ; Constriction, Pathologic ; Female ; Human ; Moyamoya Disease/ *COMPLICATIONS/RADIOGRAPHY/SURGERY SO - Neurosurgery 1986 Aug;19(2):271-3 12 UI - 86311734 AU - Batjer H ; Samson D TI - Use of extracranial-intracranial bypass in the management of symptomatic vasospasm. AB - Delayed ischemic deficits from vasospasm after subarachnoid hemorrhage remain a major source of death and disability to patients surviving subarachnoid hemorrhage. Ideal treatment for this condition would prevent or reverse spasm in major subarachnoid vessels. This goal remains elusive. Considerable success has been obtained with augmentation of flow in ischemic regions by induced hypertension and hypervolemia. Some patients are not good candidates for this therapy because of underlying cardiovascular disease or the presence of unsecured aneurysms. A total of 11 patients have recently undergone extracranial-intracranial bypass for the treatment of symptomatic vasospasm. Bypass was performed in 4 patients due to failure of medical management and in 7 patients due to our reluctance to induce hypertension in the setting of unsecured aneurysms. Eight of the 11 patients responded neurologically to the bypass procedure within 24 hours. In 6 cases, neurological deficits either improved or resolved. After operation, all 8 patients maintained their preoperative neurological status with lower mean arterial blood pressures than before bypass. Noncomatose patients with focal middle cerebral ischemic deficits and secured aneurysms in whom medical management has failed or in whom these measures are contraindicated may indeed benefit from extracranial-intracranial bypass. Patients with unsecured aneurysms remote from an ischemic middle cerebral territory should probably be revascularized if cautious hypertension fails to improve their conditions. MH - Adult ; Case Report ; Cerebral Angiography ; Cerebral Ischemia/ *COMPLICATIONS ; Cerebral Ischemia, Transient/COMPLICATIONS/ETIOLOGY/ RADIOGRAPHY/*SURGERY ; *Cerebral Revascularization ; Female ; Follow-Up Studies ; Human ; Male ; Middle Age ; Subarachnoid Hemorrhage/ COMPLICATIONS SO - Neurosurgery 1986 Aug;19(2):235-46 13 UI - 86311714 AU - Yokoh A ; Ausman JI ; Dujovny M ; Diaz FG ; Berman SK ; Sanders J ; Mirchandani HG TI - Anterior cerebral artery reconstruction. AB - Anterior cerebral artery end-to-end, end-to-side, and side-to-side anastomoses and grafting procedures including bypass and interposition using segments of the posterior cerebral artery harvested from the same specimen were performed. The reconstruction procedures were accomplished experimentally with the A1 and A2 segments of the anterior cerebral artery, the recurrent artery of Heubner (RAH), and the orbitofrontal and frontopolar arteries in end-to-end or end-to-side anastomosis to the A1 segment. Side-to-side anastomoses between both A2 or A3 segments were completed without difficulty. We utilized the anatomical and experimental reconstruction data in the performance of three surgical procedures for aneurysms in this area. An A1 to A2 end-to-end anastomosis, an A2 to A2 end-to-side anastomosis, and an end-to-end anastomosis of the RAh were performed with no technical difficulties or complications. This study shows the feasibility of these microvascular reconstruction procedures in the anterobasal part of the interhemisphere, where cerebral aneurysms frequently develop. MH - Adult ; Aged ; Case Report ; Cerebral Aneurysm/*SURGERY ; Cerebral Arteries/*SURGERY ; Female ; Human ; Male ; Microsurgery/*METHODS ; Middle Age ; Support, Non-U.S. Gov't SO - Neurosurgery 1986 Jul;19(1):26-35 14 UI - 86306166 AU - Hopkins M ; Valberg BM ; Robinson LM TI - A report on the EC/IC bypass study. AB - In 1967 the first extracranial to intracranial (EC/IC) arterial anastomosis was performed. Since that time, EC/IC bypass surgery has become a widely accepted surgical treatment for patients with intracranial stenotic or occlusive atherosclerotic lesions. In 1977 an international multicenter randomized trial was established to determine whether EC/IC bypass surgery reduced the rate of stroke and stroke-related death in patients with recent hemispheric and/or retinal ischemic symptoms. Completed and analyzed in 1985, the International Cooperative Study of Extracranial/Intracranial Arterial Anastomosis of 1,377 patients provides an evaluation of the surgical procedure for stroke prevention. This paper will discuss the study's objectives and organization, the methods employed, the trial results, and implications. MH - Cerebral Arteries/*SURGERY ; Cerebral Arteriosclerosis/*SURGERY ; Cerebrovascular Disorders/*PREVENTION & CONTROL ; Clinical Trials ; Female ; Follow-Up Studies ; Human ; Male ; Middle Age ; Random Allocation ; Temporal Arteries/*SURGERY SO - J Neurosci Nurs 1986 Aug;18(4):211-3 15 UI - 86289875 AU - Ausman JI ; Diaz FG TI - Critique of the extracranial-intracranial bypass study. AB - The potential benefit of extracranial-intracranial anastomosis was evaluated by a multicenter international cooperative study headed by the group in London, Ontario, Canada. The final conclusion of the study was that the extracranial-intracranial anastomosis did not provide any benefit over the treatment with aspirin. Several objections and shortcomings have been identified in this study. In our evaluation it cannot be concluded that EC-IC bypass surgery is not effective in reducing stroke in all patient populations. MH - *Cerebral Revascularization ; Cerebrovascular Disorders/SURGERY ; Clinical Trials ; Human SO - Surg Neurol 1986 Sep;26(3):218-21 16 UI - 86247754 AU - Tsuda Y ; Kimura K ; Yoneda S ; Hayakawa T ; Etani H ; Kamada T TI - Recurrent transient ischemic episodes after anticoagulation or bypass operation. Hemodynamic or embolic mechanism. AB - Three patients who suffered delayed transient ischemic episodes despite adequate anticoagulation or successful extracranial-intracranial (EC-IC) bypass anastomosis were studied. A hemodynamic mechanism was prominent in 1 patient with moderate orthostatic hypotension. After adequate anticoagulation he had further episodes of transient ischemia, which were finally controlled by an EC-IC bypass. Cerebral blood flow studies revealed flow changes with progression of the arterial lesion from stenosis to occlusion. The bypass was patent postoperatively, which suggested that the ischemia in this patient had been hemodynamic in origin. In the other patient the cerebral ischemic symptoms showed a remarkable improvement after the bypass operation. However, ischemia recurred after the operation until anticoagulants were started. Postoperative cerebral ischemia suggested microemboli, whereas preoperatively, it was presumably a hemodynamic phenomenon. In another patient where microembolism was more apparent, anticoagulation controlled the recurrent ischemia after a bypass operation. A hemodynamic as well as embolic mechanism needs to be considered in a cerebral ischemia which recurs after treatment. MH - Adult ; Anticoagulants/*THERAPEUTIC USE ; Arterial Occlusive Diseases/ *COMPLICATIONS/DRUG THERAPY/RADIOGRAPHY/SURGERY ; Carotid Artery Diseases/ *COMPLICATIONS/DRUG THERAPY/RADIOGRAPHY/SURGERY ; Case Report ; Cerebral Angiography ; Cerebral Ischemia, Transient/*ETIOLOGY ; *Cerebral Revascularization ; Human ; Male ; Middle Age ; Recurrence ; Tomography, X-Ray Computed SO - Eur Neurol 1986;25(4):290-8 17 UI - 86236005 AU - Morgan M ; Besser M ; Dorsch N ; Segelov J TI - Treatment of intracranial aneurysms by combined proximal ligation and extracranial-intracranial bypass with vein graft. AB - Seven patients with internal carotid artery aneurysms, and one patient with a middle cerebral artery aneurysm, were managed by combining proximal ligation with an extracranial-intracranial bypass procedure. Five bypasses were done with an interposed vein graft between the external carotid artery and the distal middle cerebral artery (vein graft), and three were superficial temporal-middle cerebral artery bypasses (superficial temporal artery grafts). As demonstrated in postoperative angiograms, all eight patients had patent bypasses with nonfilling of the aneurysm. One patient developed transient dysphasia, but there were no permanent neurological deficits associated with carotid occlusion. Four patients had resolution of their neurological problems, and another three patients improved. The distribution of flow from vein grafts is more extensive than from superficial temporal artery grafts. This offers increased protection against ischemia, and increases the likelihood of internal carotid artery aneurysm thrombosis by reducing the turbulence in the distal internal carotid artery. MH - Adult ; Aged ; Carotid Artery Diseases/RADIOGRAPHY/*SURGERY ; Carotid Artery, Internal/RADIOGRAPHY/SURGERY ; Case Report ; Cerebral Aneurysm/ RADIOGRAPHY/*SURGERY ; *Cerebral Revascularization ; Female ; Human ; Male ; Middle Age ; Veins/TRANSPLANTATION SO - Surg Neurol 1986 Jul;26(1):85-91 18 UI - 86204044 AU - Collice M ; Arena O ; Riva M TI - Complications after subclavian-cortical middle cerebral artery bypass. AB - Subclavian-cortical middle cerebral artery bypass by saphenous vein interposition is an uncommon recent revascularization technique used for immediate volume flow to the brain or when donor arteries are unavailable or inadequate. We used this technique in four cases of symptomatic common carotid artery occlusion. In the last two cases, severe, reversible neurological complications occurred. We think that these complications are due to this particular technique, and more cautious indications than for traditional extra-intracranial arterial bypass are recommended. MH - Aphasia/ETIOLOGY ; Arterial Occlusive Diseases/ETIOLOGY/RADIOGRAPHY/ SURGERY ; Carotid Artery Diseases/ETIOLOGY/RADIOGRAPHY/SURGERY ; Case Report ; Cerebral Angiography ; Cerebral Revascularization/*ADVERSE EFFECTS ; Coma/ETIOLOGY ; Hemiplegia/ETIOLOGY ; Human ; Male ; Middle Age ; Neurologic Examination ; Postoperative Complications ; Seizures/ ETIOLOGY/RADIOGRAPHY/SURGERY ; Tomography, Emission Computed ; Tomography, X-Ray Computed SO - Neurosurgery 1986 Apr;18(4):483-6 19 UI - 86203994 AU - Batjer H ; Mickey B ; Samson D TI - Potential roles for early revascularization in patients with acute cerebral ischemia. AB - The risk of carotid endarterectomy in acute cerebral ischemic situations is well documented. By using the superficial temporal or occipital artery, it is possible to provide relatively low flow revascularization conduits, potentially avoiding the risk of postoperative hemorrhage. Eighteen patients at The University of Texas Health Science Center at Dallas, Texas, have been treated recently with extracranial to intracranial bypass in the setting of acute neurological deficit, stroke in evolution, or recent completed infarction. Angiographic causes of these deficits included cervical carotid occlusion in 5 patients, carotid siphon disease in 2 patients, middle cerebral stenosis or occlusion in 3 patients, and delayed cerebral ischemia following subarachnoid hemorrhage in 8 patients. Neurological improvement was demonstrated within 24 hours following revascularization in 15 cases (83%); 3 patients were unchanged following bypass, and no patient's condition was worsened. The only case of postoperative intracerebral hemorrhage occurred 1 week following a long saphenous vein graft from the subclavian to the middle cerebral artery. After an average follow-up of 19 months, 7 patients are neurologically normal, 8 patients have mild to moderate deficits, and 3 patients have died. Low flow revascularization procedures appear to be safe in the setting of acute cerebral ischemia and may in selected patients boost regional cerebral blood flow from levels of symptomatic ischemia into a range compatible with normal neuronal function. MH - Acute Disease ; Adult ; Aged ; Carotid Artery Diseases/SURGERY ; Carotid Artery, Internal/SURGERY ; Case Report ; Cerebral Aneurysm/SURGERY ; Cerebral Angiography ; Cerebral Hemorrhage/ETIOLOGY ; Cerebral Infarction/ *SURGERY ; Cerebral Ischemia/*SURGERY ; Cerebral Ischemia, Transient/ SURGERY ; Cerebral Revascularization/*METHODS ; Follow-Up Studies ; Human ; Male ; Neurologic Examination ; Postoperative Complications/ETIOLOGY ; Rupture, Spontaneous ; Subarachnoid Hemorrhage/SURGERY SO - Neurosurgery 1986 Mar;18(3):283-91 20 UI - 86187681 AU - Katz B ; Weinstein PR TI - Improvement of photostress recovery testing after extracranial-intracranial bypass surgery. AB - A patient with carotid occlusive disease experienced episodes of light-induced amaurosis in an eye with changes of venous stasis retinopathy. Though his macula appeared normal on examination, the macular photostress test (MPST) was prolonged. After anastomosis of a superficial temporal artery with the middle cerebral artery his symptoms resolved and his MPST returned to normal. The MPST may serve as a diagnostic stress test for the retinal circulation in cases of carotid disease. MH - Arterial Occlusive Diseases/COMPLICATIONS/*SURGERY ; Blindness/ETIOLOGY ; Carotid Artery Diseases/COMPLICATIONS/*SURGERY ; Case Report ; Cerebral Arteries/SURGERY ; Fluorescein Angiography ; Fundus Oculi ; Human ; Light/ *DIAGNOSTIC USE ; *Macula Lutea ; Middle Age ; Retinal Diseases/DIAGNOSIS/ ETIOLOGY/*PHYSIOPATHOLOGY ; Retinal Vessels ; Temporal Arteries/SURGERY ; *Vision Tests ; Visual Acuity SO - Br J Ophthalmol 1986 Apr;70(4):277-80 21 UI - 86185726 AU - Matar AF TI - Concomitant coronary and cerebral revascularization under cardiopulmonary bypass. AB - The question as to whether a staged or a combined surgical approach is safer in the management of patients with coexistent coronary and extracranial cerebrovascular disease has been widely investigated and debated. Advances in myocardial protection techniques have reduced cardiac morbidity and mortality and have rendered a combined approach as safe as a staged approach, if not safer. There have been no similar advances in cerebral protection, particularly for high-risk patients with bilateral disease. In this series, 32 consecutive patients with coexistent advanced coronary and extracranial vascular disease underwent cerebral and coronary revascularization that used the combined approach. Cerebral revascularization was performed under hypothermic cardiopulmonary bypass on 30 of these patients. There was no operative mortality, no hematoma formation, and no reoperation. Blood loss, length of hospital stay, and total cost were similar to those for isolated coronary bypass procedures. MH - Aged ; Anesthesia/METHODS ; *Aortocoronary Bypass ; Brain/PATHOLOGY ; *Cardiopulmonary Bypass/METHODS ; Carotid Artery Diseases/COMPLICATIONS/ PATHOLOGY/SURGERY ; *Cerebral Revascularization ; Cerebrovascular Disorders/COMPLICATIONS/PATHOLOGY/*SURGERY ; Coronary Disease/ COMPLICATIONS/PATHOLOGY/*SURGERY ; Coronary Vessels/PATHOLOGY ; Endarterectomy ; Female ; Human ; Male ; Middle Age ; Postoperative Complications ; Risk SO - Ann Thorac Surg 1986 Apr;41(4):431-5 22 UI - 86115556 AU - Stewart MT ; Moritz MW ; Smith RB 3d ; Fulenwider JT ; Perdue GD TI - The natural history of carotid fibromuscular dysplasia. AB - Although graduated internal dilatation has proved to be an effective, safe, and durable operation for the treatment of symptomatic patients with fibromuscular dysplasia of the extracranial internal carotid artery, the role of surgical treatment in this entity remains unclear because the natural history is not well defined. Forty-nine patients, aged 29 to 82 years (mean, 58.5 years), with angiographically proven fibromuscular dysplasia of 88 internal carotid arteries have been evaluated since 1969. Twenty patients showed symptoms of focal cerebral or retinal ischemia, 10 patients had nonlateralizing neurologic symptoms, three patients sustained intracerebral hemorrhage, five patients complained of nonischemic symptoms, and 11 patients were asymptomatic. The three patients with intracranial hemorrhage and one person who suffered a massive stroke after angiography died within weeks of admission; no surgical therapy was performed. Initial management of the other patients included four internal carotid endarterectomies in four patients for associated atherosclerosis, one with simultaneous graduated internal dilatation; seven graduated internal dilatations in five patients; and one extracranial-to-intracranial bypass in a patient with occlusion occurring after graduated internal dilatation. Seventy-three nondilated arteries in 42 patients have been followed for up to 16 years (mean, 6.8 years). During this time only three patients have undergone surgical therapy; one carotid endarterectomy was done for an asymptomatic atherosclerotic lesion and two graduated internal dilatations in patients with nonfocal ischemia. Through follow-up of all 49 patients, none has had a new neurologic deficit. Fourteen patients who initially presented with focal ischemia were not treated surgically and all but one are now asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS) MH - Adult ; Aged ; Arterial Occlusive Diseases/*SURGERY ; Carotid Artery Diseases/*SURGERY ; Cerebral Angiography ; Cerebral Ischemia/ETIOLOGY ; Cerebral Revascularization ; Dilatation/METHODS ; Endarterectomy ; Female ; Fibromuscular Dysplasia/COMPLICATIONS/RADIOGRAPHY/*SURGERY ; Follow-Up Studies ; Human ; Male ; Middle Age SO - J Vasc Surg 1986 Feb;3(2):305-10 23 UI - 86114214 AU - Sundt TM Jr ; Pearson BW ; Piepgras DG ; Houser OW ; Mokri B TI - Surgical management of aneurysms of the distal extracranial internal carotid artery. AB - Results, complications, and operative techniques of the surgical management of 20 aneurysms of the distal extracranial internal carotid artery (ICA) in 19 patients are reviewed. The proximity of these aneurysms to the styloid process is not considered as a chance occurrence, and the possibility is raised that these lesions are related to trauma from that structure. False aneurysms from spontaneous dissections are believed to occur only in those dissections that begin distally; they are not found in dissections that begin proximally. Treatment was individualized and dependent upon: 1) the size and location of the aneurysm; 2) symptomatology; and 3) hemodynamic considerations based upon intraoperative cerebral blood flow (CBF) measurements determined from the clearance of xenon-133 injected into the ipsilateral ICA. Methods of treatment included: resection of the the aneurysm with placement of an interposition saphenous vein graft in seven patients; resection of the aneurysm with end-to-end anastomosis of the ICA in five; ICA ligation in three; clipping of the aneurysm in one; and extracranial-to-intracranial bypass in four. One patient sustained a postoperative cerebral ischemic complication from embolization which resulted in a mild permanent impairment in right hand dexterity. There were no other cerebral ischemic complications in the group, largely attributable, it is thought, to the use of intraoperative CBF measurements and continuous electroencephalograms. Four patients had transient dysphagia from traction damage to the pharyngeal and superior laryngeal nerves, and one patient with preoperative difficulty in swallowing required a gastrostomy. Long-term results have been excellent. Use of the operating microscope facilitated the suturing of the distal anastomosis in cases in which the ICA was reconstructed by an interposition vein graft or end-to-end anastomosis. MH - Adult ; Carotid Artery Diseases/RADIOGRAPHY/*SURGERY ; Carotid Artery, Internal/RADIOGRAPHY/SURGERY ; Case Report ; Cerebral Aneurysm/ETIOLOGY/ RADIOGRAPHY/*SURGERY ; Cerebral Ischemia/PHYSIOPATHOLOGY ; Cerebrovascular Circulation ; Female ; Human ; Intraoperative Complications/PHYSIOPATHOLOGY ; Male ; Middle Age SO - J Neurosurg 1986 Feb;64(2):169-82