The importance of arteriographic interpretation in occlusion or pseudo-occlusion of the carotid artery.

Carotid arteriography can be misleading in that roentgenographic occlusion of the internal carotid artery (ICA) may be suggested when the artery is actually anatomically patent. The distinction of occlusion versus pseudo-occlusion is crucial in recommending proper treatment. Aroused by the misinterpretation of two arteriograms by our radiology departments, a review of 780 arteriograms done on 780 patients during a three year period was begun. Of these, eight (1.0 per cent) symptomatic patients had conflicting arteriographic reports, with the radiologists reporting complete occlusion and the authors describing pseudo-occlusion. Established arteriographic criteria for pseudo-occlusion of the ICA are emphasized. These eight patients underwent carotid arterial exploration and all were found to have patent ICA. After successful carotid endarterectomy, seven of the eight patients have remained asymptomatic and have had no hemodynamically significant stenosis on noninvasive testing in the follow-up period, ranging from two to 38 months. Therefore, in evaluating patients with carotid territory symptoms, knowledge of the established arteriographic criteria for ICA pseudo-occlusion should alert the physician to the possibility of ICA patency. If this is suspected, the patient should undergo exploration of the carotid artery with subsequent endarterectomy if patency is demonstrated.

Intraplaque hemorrhage: its significance in cerebrovascular disease.

Recently, carotid plaque factors, specifically intraplaque hemorrhage, have been studied with respect to the production of cerebrovascular symptoms. Ninety-five carotid endarterectomies were performed and the plaques that were removed were examined for intraplaque hemorrhage. Patients were separated into three groups: those with specific neurologic symptoms, those with nonlateralizing symptoms, and those who were asymptomatic. In the group of patients who presented with specific neurologic symptoms, correlation was made between the age of the intraplaque hemorrhage and the timing of symptoms. The vast majority of patients with specific neurologic symptoms exhibited carotid plaque hemorrhage, but patients with nonlateralizing symptoms and those who were asymptomatic also demonstrated an unexpectedly high percentage of intraplaque hemorrhage. Moreover, our results show a poor relationship between the timing of symptoms and the age of the intraplaque hemorrhage. These data do not refute the concept that intraplaque hemorrhage may play a role in the production of cerebrovascular symptoms, but they do refute the notion that the mere presence of hemorrhage causes specific neurologic symptoms and they also refute the previous report that demonstrates a good correlation between the timing of symptoms and the age of the intraplaque hemorrhage.

Carotid endarterectomy: results using regional anesthesia.

One hundred and sixty-five carotid endarterectomies performed using regional anesthesia are reviewed. Simple neurologic monitoring of an awake patient enables accurate determination of whether the patient requires an internal carotid artery shunt. Shunts were used in only 10 per cent of cases. Low stroke (3.6) and low mortality (1.2) rates support the safety of this technique.

Acquired tracheoesophageal fistula.

This is a case of an acquired tracheoesophageal fistula induced by a large foreign body in a 5-yr-old child. The foreign body, a large plastic ear from a doll, was lodged in the esophagus and its presence remained unknown for weeks, until tracheoesophageal fistula actually developed. The foreign body was removed endoscopically; after the child was given intravenous nutrition and the infection was brought under control, the communication was divided and repaired.

Pericardial angiosarcoma simulating pericardial effusion by echocardiography.

A fast-growing angiosarcoma caused incapacitation of a boy and death in a period of three months. The growth of the tumor was well documented by a series of echocardiograms. The heart was well encased by a thick layer of purplish vascular neoplasm enveloped mostly by thin pericardium, with some additional few foci of extracardiac metastasis. The heart weighed 2,000 gm. It is worthy to note that another cause of an echo-free space may be the presence of a pericardial tumor, rather than pericardial effusion.

Rupture of the bronchus: Case report of successful resection and anastomosis in a 13-month-old infant.

An unusual case of rupture of the bronchus in a 13-month-old child is reported. It is believed that this is the youngest reported case of successful repair and it is documented by an 11-year follow-up.