Posterior communicating artery visualization in predicting results of carotid endarterectomy for vertebrobasilar insufficiency.

Retrospectively, 51 patients who related two or more signs or symptoms of vertebrobasilar insufficiency and possessed concomitant carotid arterial disease were identified. The patient population was separated into two groups based on the presence or absence of an angiographically visualized posterior communicating artery during selective carotid artery injection. All patients had undergone unilateral or staged bilateral carotid endarterectomy. Comparison of postoperative clinical outcome with intracerebral angiographic findings exhibited statistically significant improvement in favor of those patients with at least one visualized posterior communicating artery. There was a greater likelihood of severe vertebral artery stenosis in those patients whose symptoms were not relieved by carotid endarterectomy.

Natural history of asymptomatic ulcerative plaques of the carotid bifurcation.

In 79 patients with 91 asymptomatic ulcerating lesions of the carotid bifurcation who were followed an average of 54 months, there were two strokes, one of which was preceded by a warning transient ischemic attack. These data suggest that asymptomatic type A and type B carotid ulcerating lesions do not carry a significant early risk of stroke and do not warrant prophylactic carotid endarterectomy. However, the effect of antiplatelet drugs and anticoagulation in enhancing the development of subintimal hemorrhagic lesions remains uncertain. Further data with serial follow-up, preferably by noninvasive means, will be necessary to define the evolution of asymptomatic ulcerating carotid plaques and eventually permit identification of those lesions that have significant stroke potential.

Prognosis of asymptomatic ulcerating carotid lesions.

To determine the proper approach to asymptomatic carotid bifurcation ulcerated plaque (UP), 79 patients with 91 asymptomatic UPs were identified angiographically, and a 96% follow-up was obtained with a mean duration of three years. The cumulative stroke rate by life-table analysis was 1% at seven years. Sixty-three UPs in 55 patients were classified as small, and of these patients, transient ischemic attacks (TIAs) that were appropriate to the lesion developed in three and stroke in one (7% cumulative symptom rate). Twenty-four UPs in 21 patients were classified as large, and a TIA developed in one patient (9%), but no strokes were observed in this group. The cumulative mortality was 17% at three years and 52% at seven years. Life-table curves of several subgroups were compared and showed no significant differences in either stroke rate or mortality between any of these groups. On the basis of these data, and particularly the seven-year stroke rate of 1%, prophylactic carotid endarterectomy is not justified for asymptomatic carotid bifurcation ulcerations.

Ultrasonic imaging of the carotid arterial system.

The ability of a B-mode, real-time, high frequency ultrasonic imager to diagnose carotid arterial disease was evaluated in 81 carotid arteries. The imager was relatively sensitive in detecting the presence of significant stenosis but was relatively insensitive in its ability to quantitate the degree of stenosis. The imager was unable to detect the presence of ulcerations. The oculoplethysmograph had a greater sensitivity, specificity and accuracy than the ultrasonic imager in diagnosing carotid arterial stenosis in the same group of patients. Ultrasonic imaging appears to be useful as a screening test of cerebrovascular disease when used in combination with the oculoplethysmographic test.