✓ The authors report their initial experience with the use of interposition saphenous vein grafts between the external carotid artery and the proximal posterior cerebral artery. The indications, results, and technical aspects of the operation are reviewed. All patients accepted for surgery were at high risk for a posterior circulation infarct, and all patients with ischemic symptomatology had continued to progress while on anticoagulant drugs or anti-platelet agents. Thus, all patients were at high risk, and 11 of the 14 patients operated on were confined to bed before surgery. Intraoperative graft flows varied from 35 to 170 ml/min, and postoperative graft flows ranged from 75 to 311 ml/min in the patent grafts. There were three early graft occlusions and two late graft occlusions; these all occurred in patients with relatively low flows at the time of surgery (40 ml/min or lower). Subdural hygroma was the next most frequent complication to graft occlusion. It was thought to be caused by the pulsating graft anastomosed to a major vessel through a small opening in the basal arachnoid, which provided a new path for cerebrospinal fluid flow in patients with a degree of preexisting atrophy. One patient with a large aneurysm in the posterior circulation underwent proximal intracranial clipping of the vertebral artery and bypass grafting simultaneously. There were seven excellent results and two good results in nine patients in whom the graft remained patent. In the five patients with graft occlusion, there were two minor strokes, two major strokes, and one death.
Thoralf M. Sundt Jr., David G. Piepgras, O. Wayne Houser and J. Keith Campbell
John L. D. Atkinson, Thoralf M. Sundt Jr., O. Wayne Houser and Jack P. Whisnant
✓ A retrospective angiographic analysis was designed to extrapolate the frequency of angiographically defined asymptomatic intracranial aneurysms in the anterior circulation from a relatively unbiased clinical series. A total of 9295 angiograms were reviewed from January, 1980, to January, 1987, and, based on these, 278 patients with minimal bias for the presence of an aneurysm were selected. Three patients were found to have incidental aneurysms; thus, the angiographic frequency of patients with asymptomatic aneurysms in this series was 1%. This patient population is skewed toward the older age groups and probably over-represents the incidence of these aneurysms in the population at large. Comparing current subarachnoid hemorrhage statistics and the low frequency of asymptomatic aneurysms suggests that a larger percentage of these aneurysms than was previously thought subsequently rupture. This study contrasts sharply with previous reports quoting a high incidence of aneurysms, and significantly alters the concept and treatment of this disease.
Correlation of angiographic, clinical, and surgical findings
O. Wayne Houser, Thoralf M. Sundt Jr., Colin B. Holman, Burton A. Sandok and Robert C. Burton
✓Angiograms of patients who underwent carotid artery surgery were correlated with the surgical findings, cerebral blood flow measurements, and the following manifestations of cerebral ischemia: amaurosis fugax, transient cerebral ischemia,small completed infarct, generalized cerebral ischemia, and progressing stroke. The degree of carotid stenosis and presence of ulcerating plaques and soft thrombi could be predicted accurately; tiny ulcerations were not angiographically identifiable in the presence of severe stenosis. Generalized cerebral ischemia corresponded closely with severe degrees of bilateral carotid stenosis or unilateral occlusion in conjunction with contralateral stenosis. Internal carotid to middle cerebral artery slow flow was found in many patients with a progressing stroke or an unstable neurological state. Retrograde ophthalmic flow was found frequently in symptomatic patients with high-grade stenotic lesions at the origin of the internal carotid artery. Localized alterations included small vessel occlusion, retrograde collateral flow, avascular areas, focal slow flow, and reactive hyperemia and were correlated with symptoms of focal cerebral ischemia.
Thoralf M. Sundt Jr., Bruce W. Pearson, David G. Piepgras, O. Wayne Houser and Bahram Mokri
✓ 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 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.