Clinical and ultrasonic long-term results of percutaneous transluminal carotid angioplasty. A prospective follow-up of 30 carotid angioplasties.

Experience of the long-term outcome of patients treated with carotid balloon angioplasty is limited. Therefore, we prospectively analyzed the ultrasonic and clinical features of 29 patients with complete follow-up data beyond 24 months, evaluated from 1989 through 1996 from our carotid angioplasty cohort of 106 patients. Mean follow-up time was 33 months. For up to 78 months postangioplasty, 23 patients with 24 angioplasties (77%) had no further neurological sequelae. Single ipsilateral amaurosis fugax or TIA events occurred in 3 patients. Recurrent ipsilateral amaurosis fugax or TIA events were noted twice in 2 patients. No patient suffered an ipsilateral stroke. Fifteen angioplasties (50%) remained with normal ultrasound (stenosis < 50%), mild restenosis (50-70%) occurred in 12 angioplasties (40%), and severe restenosis (> 70%) in 3 angioplasties (10%). Only in 2 of 15 patients clinical complications were related to the occurrence of ipsilateral restenosis above 50%. Until now, rigorous and careful evaluation of patients and clinical and ultrasonic follow-up have been essential for the estimation of the long-term efficacy of carotid angioplasty. It should be noted that carotid angioplasty is a new technique in evolution, with a high potential improving the technical results.

Visually evoked cerebral blood flow velocity changes in different states of brain dysfunction.

BACKGROUND AND PURPOSE: By assessment of metabolically induced cerebral blood flow velocity changes, transcranial Doppler sonography offers the opportunity to evaluate vasoneuronal coupling in different states of brain activation and in critically ill patients. METHODS: With simultaneous transcranial Doppler monitoring of the posterior cerebral artery (PCA) and the middle cerebral artery (MCA), 27 control subjects, 11 patients under general anesthesia, 5 patients in the vegetative state, and 12 patients with aneurysmal subarachnoid hemorrhage were stimulated with a 10-Hz flashlight for 30 seconds. Ten cycles of stimulation were averaged, and a specific flow response (SFR) was computed as the normalized ratio of PCA/MCA mean flow velocity. RESULTS: Maximal SFR was 14.2% in control subjects. Eye closure significantly reduced maximal SFR (11.6% versus 15.4%, P<.01). In subarachnoid hemorrhage, SFR was markedly decreased in the early phase (4.8%, P<.01) but became normal later on. Four of 5 patients with abolished SFR suffered delayed ischemia due to vasospasm. Of 7 patients with preserved SFR, 5 had vasospasm but none had delayed ischemia. No SFR was observed in patients under general anesthesia or in the vegetative state. CONCLUSIONS: Although reflecting fast and local neuronal activity patterns, metabolically induced blood flow response is highly dependent on stimulus-directed attention. In subarachnoid hemorrhage, decreased metabolic flow response suggests severe depression of vasoneuronal coupling, and abolished SFR might indicate increased vulnerability to vasospasm and a higher risk for delayed ischemia.

Lys-plasminogen as an adjunct to local intra-arterial fibrinolysis for carotid territory stroke: laboratory and clinical findings.

To improve the efficacy of local intraarterial fibrinolysis (LIF), we compared different fibrinolytic drugs in a cerebral circulation model in the laboratory. The technical efficacy of fibrinolysis, defined as the clot volume lysed per unit time, was found to be optimal with r-tissue plasminogen activator (TPA) activated lys-plasminogen (= plasmin). Subsequently, 20 patients with stroke due to carotid artery territory occlusion were treated by local intraarterial fibrinolysis using the plasmin regimen. The angiographic data and clinical outcome of these patients were compared with those of 40 patients who received plasminogen activators (urokinase or r-TPA) only. Laboratory and clinical data confirmed that plasmin lysis is superior to treatment using only plasminogen activators.

Isolated symptomatic stenosis of the middle cerebral artery in younger adults. A clinical and ultrasonic follow-up study of eight patients.

We studied 8 symptomatic patients aged 32-56 years with isolated stenosis of the middle cerebral artery who had TIAs or minor strokes. Angiography showed MCA stenosis in the M1 segment in 7 patients, and proximal M1 occlusion that later recanalized with persistent stenosis in 1 patient, without evidence of more widespread atherosclerotic disease. A potential cardiac source of embolism was detected in only 2 patients with mitral valve prolapse. During follow-up for 39-82 months, no further ischemic events occurred, and transcranial Doppler showed unchanged or decreased stenosis in 6 patients. We conclude that isolated MCA stenosis in younger patients may be a unique pathologic entity with a benign long-term course, although previous embolism with partial recanalization appears possible in some patients.