Incidence of new brain lesions after carotid stenting with and without cerebral protection.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) may be a useful tool to evaluate the efficacy of cerebral protection devices in preventing thromboembolic complications during carotid angioplasty and stenting (CAS). The goals of this study were (1) to compare the frequency, number, and size of new DWI lesions after unprotected and protected CAS; and (2) to determine the clinical significance of these lesions. METHODS: DWI was performed immediately before and within 48 hours after unprotected or protected CAS. Clinical outcome measures were stroke and death within 30 days. RESULTS: The proportion of patients with any new ipsilateral DWI lesion (49% versus 67%; P<0.05) as well as the number of new ipsilateral DWI lesions (median=0; interquartile range [IQR]=0 to 3 versus median=1; IQR=0 to 4; P<0.05) were significantly lower after protected (n=139) than unprotected (n=67) CAS. The great majority of these lesions were asymptomatic and less than 10 mm in diameter. Although there were no significant differences in clinical outcome between patients treated and not treated with protection devices (7.5% versus 4.3%, not significant), the number of new DWI lesions was significantly higher in patients who developed a stroke (median=7.5; IQR=1.5 to 17) than in patients who did not (median=0; IQR=1 to 3.25; P<0.01). CONCLUSIONS: The use of cerebral protection devices significantly reduces the incidence of new DWI lesions after CAS of which the majority are asymptomatic and less than 10 mm in diameter. The frequent occurrence of these lesions and their close correlation with the clinical outcome indicates that DWI could become a sensitive surrogate end point in future randomized trials of unprotected versus protected CAS.

Ischemic stroke in young HIV-positive patients in Kwazulu-Natal, South Africa.

Cerebrovascular disease occurs in HIV-positive individuals, but no relationship between the two has been established. The authors reviewed a cohort of patients aged 15 to 44 years to evaluate stroke in HIV-positive and negative subjects. Patients who were HIV-positive with no other identifiable etiology were compared to age- and race-matched HIV-negative patients. HIV-positive and HIV-negative groups did not differ in angiographic, cardiac, or serologic tests. A positive HIV test does not provide causal information or diagnosis.

Interatrial block as a predictor of embolic stroke.

Interatrial block (IAB), defined as a prolonged (>/=110 ms) P wave, is remarkably prevalent in general hospital populations and is associated with an enlarged, poorly contractile left atrium. The investigators sought to determine whether there is an increased incidence of IAB in patients with embolic strokes. Patients' medical records were reviewed for evidence of embolic cerebrovascular events and IAB. One hundred four patients were identified. In 61 patients in normal sinus rhythm, 49 (80%) had IAB. This was almost twice the prevalence of 2 previous studies (41% and 47%). Therefore, IAB may represent a new risk factor for stroke.

Fate of left atrial thrombi in patients with atrial fibrillation determined by transesophageal echocardiography and cerebral magnetic resonance imaging.

Patients with atrial fibrillation (AF) and atrial thrombi have an increased risk for cerebral embolism. However, there is little knowledge about the long-term fate of atrial thrombi and the incidence of cerebral embolism in patients receiving continued oral anticoagulation. Forty-three consecutive patients with AF and atrial thrombi were enrolled in the study. Serial and prospective transesophageal echocardiographic studies, cranial magnetic resonance imaging (MRI), and clinical examinations were performed during a period of 12 months. Oral anticoagulation was continued or initiated in all patients. An international normalized ratio of 2.0 to 3.0 was regarded as effective. During follow-up, 56% of the thrombi disappeared (7 [16%] at 1 month, 18 [42%] at 3 months, 21 [49%] at 6 months, and 24 [56%] at 12 months). Patients with the disappearance of thrombi had significantly smaller thrombi compared with patients with persistent thrombi (1.5 +/- 0.8 cm in length and 0.8 +/- 0.5 cm in width vs 1.9 +/- 0.6 cm in length and 1.3 +/- 0.4 cm in width, p = 0.04), reduced echogenicity of thrombi (46% vs 89%, p <0.01), and smaller left atrial (LA) volume (83 +/- 27 vs 116 +/- 55 cm(3)). Seven patients (16%) had embolic lesions during follow-up MRI. Six of these patients (86%) had clinically apparent embolisms, and 1 died from stroke. The only independent predictors of cerebral embolism were an elevated peak emptying velocity of the LA appendage (p <0.01) and previous thromboembolic events (p = 0.02). Patients with AF and atrial thrombi have a large likelihood of cerebral embolism (16%) and/or death despite oral anticoagulation therapy. Thrombus size may predict thrombus resolution under continued anticoagulation.

Solid and gaseous cerebral microembolization during off-pump, on-pump, and open cardiac surgery procedures.

BACKGROUND: Neurocognitive dysfunction remains a limitation of cardiac surgery with cardiopulmonary bypass. Intraoperative cerebral microembolization is believed to be one of the most important etiologic factors. Using a new generation of transcranial Doppler ultrasonography, we compared the number and nature of intraoperative microemboli in patients undergoing on-pump and off-pump cardiac surgery procedures. METHODS: Bilateral continuous transcranial Doppler monitoring of the middle cerebral arteries was performed in 45 patients (15 off-pump coronary artery bypass grafting, 15 on-pump coronary artery bypass grafting, and 15 open cardiac procedures). All recordings were performed using a multi-range, multifrequency system to allow both measurement of the number and discrimination of the nature of microemboli in the 3 different groups. RESULTS: The median number (interquartile range) of microemboli in the off-pump coronary artery bypass grafting, on-pump coronary artery bypass grafting, and open procedure groups were 40 (28-80), 275 (199-472), and 860 (393-1321), respectively (P <.01). Twelve percent of microemboli in the off-pump coronary artery bypass grafting group were solid compared with 28% and 22% in the on-pump coronary artery bypass grafting and open procedure groups, respectively (P <.05). In the on-pump groups, 24% of microemboli occurred during cardiopulmonary bypass, and 56% occurred during aortic manipulation (cannulation, decannulation, application, and removal of crossclamp or sideclamp). CONCLUSIONS: Cerebral microembolization is significantly reduced with avoidance of cardiopulmonary bypass. The majority of microemboli occurring during cardiac surgery are gaseous, with a higher proportion of solid microemboli in the on-pump group, and may have a different significance for cerebral injury than solid microemboli. The ability to reliably discriminate gas and solid microemboli may have an important role in the implementation of neuroprotective strategies.

Trombosis venosa cerebral y anticonceptivos orales: estudio de 1 caso / Cerebral venous thrombosis and oral contraceptives: a case study

La enfermedad cerebrovascular es la tercera causa de muerte en el mundo occidental y una de las que tienen mayor morbilidad. Aunque generalmente predomina en grupos de edad avanzada, en los últimos años está creciendo la incidencia de trombosis vascular cerebral en las mujeres menores de 45 años, en muchos casos asociada con el uso de anticonceptivos orales (ACO).La Agencia Española del Medicamento estima el riesgo de tromboembolia venosa en mujeres sanas entre 15 y 44 años de edad que no toman ACO en 5-10 casos por 100.000 mujeres/año. Sin embargo, en las mujeres de ese grupo de edad que toman ACO que contienen al menos 20 µg de etinilestradiol en combinación con desogestrel o gestodeno, este riesgo aumenta hasta cifras de 30-40 casos por 100.000 mujeres/año. Presentamos el caso de una paciente de 26 años de edad que fue diagnosticada de trombosis cerebral del seno sigmoideo con hipertensión intracraneal, en la que el único factor de riesgo encontrado fue el inicio en la toma de ACO (AU)

Prevalence of venous thromboembolism in acute hemorrhagic and thromboembolic stroke.

OBJECTIVE: Deep venous thromboembolism (DVT) is an important health issue in the hospitalized geriatric population that leads to increased length of stay, morbidity, and mortality. Patients with hemorrhagic strokes are usually not placed on prophylactic therapy because of the risk of hemorrhagic extension of the stroke. The purpose of this study was to evaluate the prevalence of DVTs in hospitalized patients with hemorrhagic vs. thromboembolic strokes. DESIGN: Retrospective chart review of data obtained from the Maryland Health Services Cost Review Commission data base for 1999 to determine the prevalence of DVTs in both hemorrhagic and thromboembolic stroke patients hospitalized acutely. Multiple logistic regression was performed to evaluate possible risk factors. RESULTS: There were 1926 patients hospitalized with a primary diagnosis of hemorrhagic stroke and 15599 with thromboembolic stroke. Women in general had more strokes than men did. Older patients were more likely to have strokes as evidenced by the mean ages of 66 and 71 yr for hemorrhagic and thromboembolic strokes, respectively. A total of 37 patients (1.9%) with hemorrhagic strokes had DVTs, whereas 74 patients (0.5%) with thromboembolic strokes had DVTs. Hemorrhagic stroke was an independent risk factor for DVT (odds ratio, 2.60; 95% confidence interval, 1.49-4.55; P = 0.0008). CONCLUSIONS: DVT prevalence and risk was higher among patients with hemorrhagic strokes in comparison with patients with thromboembolic strokes.

Plasma homocyst(e)ine concentrations and the risk of subtypes of cerebral infarction. The Hisayama study.

Moderately elevated plasma total homocyst(e)ine (tHcy) levels have been linked with cardiovascular disease. However, the findings of previous studies regarding the relationship between tHcy levels and subtypes of cerebral infarction (CI) have been conflicting. The aim of the present study was to examine this issue in a community-based case-control study performed in Hisayama Town in Japan. Fasting tHcy levels were compared among 75 CI cases, of which 43 were lacunar (LI), 24 atherothrombotic (ATI) and 8 cardioembolic infarctions (CEI), and 248 age- and sex-matched healthy controls. The mean tHcy concentrations were higher in CI than in controls (13.0 vs. 11.8 micromol/l; p = 0.018). LI and CEI also had significantly higher tHcy levels than did the corresponding controls (12.3 vs. 11.3 micromol/l for LI; p = 0.037 and 16.3 vs. 12.7 micromol/l for CEI; p = 0.036). The same tendency was also observed for ATI, but the difference was only marginally significant probably due to the small number of the cases (13.4 vs. 11.9 micromol/l; p = 0.087). After adjustment for age, sex, hypertension, serum creatinine, total protein, folate and vitamin B(12) levels, the risk of LI was not significant in the second tertile of the tHcy distribution, but significantly increased in the third compared with the first tertile (adjusted odds ratio, AOR, 3.4; 95% confidence limits, CL, 1.3-8.9; p = 0.015), while the risk of ATI was significant even in the second tertile (AOR, 5.0; 95% CL, 1.0-23.7; p = 0.042) and higher in the third tertile (AOR, 7.5; 95% CL, 1.5-38.3; p = 0.015). However, the odds ratios for CEI could not be estimated, as there was no case of CEI in the first tertile. These findings suggest that elevated tHcy is an independent risk factor for all subtypes of CI, but that its impact is higher in ATI and probably in CEI than in LI.

Alterations to haemostasis following cardiopulmonary bypass and the relationship of these changes to neurocognitive morbidity.

Cardiopulmonary bypass (CPB) is routinely utilized to provide circulatory support during cardiac surgical procedures. The morbidity of CPB has been significantly reduced since its introduction 50 years ago; however, cerebral injury remains a potentially serious consequence of otherwise successful surgery. The risk of stroke postoperatively is approximately 1-5%. Incidence rates for neurocognitive deficit, however, vary markedly depending on the detection method, although typically it is reported in at least 50% of patients. The aetiology of this cerebral injury remains open to debate, although evidence shows that ischaemia secondary to microembolism may be the principal factor. Emboli originate from bubbles of air, atheroemboli released on aortic manipulation and thromboemboli generated as a result of haemostatic activation. Significant generation of thrombin occurs during CPB resulting in fibrin formation, although the trigger of this activation is not fully understood. Rather than originating from contact activation as previously thought, the primary trigger may be via the activated factor VII/tissue factor pathway of coagulation, with an additional role of contact activation in amplification of coagulation as well as the fibrinolytic response to CPB. Haemostatic activation is inhibited with systemic heparin therapy. The relationship between haemostatic activation and emboli formation during CPB is not known. Interventions to reduce cerebral injury in the context of cardiac surgery depend, in large part, on the minimization of emboli. This review investigates cerebral injury after cardiac surgery and evidence showing that microembolism is the principal causative agent. Fibrin emboli are postulated to be an important source of cerebral embolism. The mechanism of haemostatic activation during CPB is therefore also discussed.

Acetylsalicylic acid and microembolic events detected by transcranial Doppler in symptomatic arterial stenoses.

BACKGROUND: In patients with symptomatic carotid artery stenosis, high-intensity transient signals detected by transcranial Doppler (TCD) have been related to particulate microemboli originating at the stenotic lesion. The occurrence of these microembolic events within the Doppler spectrum should be influenced by antithrombotic agents of proven efficacy in these patients mainly by reducing cerebral embolism. METHODS: Seventy-four of 192 consecutive patients with symptomatic arterial stenosis in the anterior circulation and clinical symptoms within the last 30 days underwent 1-hour bilateral TCD monitoring. Patients were selected, if they presented temporal bone windows enabling transcranial insonation, revealed normal Doppler CO2 test excluding hemodynamic impairment, had not received antithrombotic therapy other than acetylsalicylic acid (ASA) before sonographic examination, and gave informed consent to 1-hour monitoring which could be performed immediately on admission/presentation of the patient at the Department of Neurology. RESULTS: Microembolic events were detected in 38 patients (51%). The proportion of patients with events among 26 patients without antithrombotic medication was 73% as compared with 40% in 48 patients receiving ASA at the time of TCD monitoring (p = 0.023). Multivariate analysis including time from ischemia to TCD, presence and start of ASA prevention, degree and localization of stenosis, and presence of a single or recurrent ischemia revealed that absence of an ASA prevention (odds ratio OR 7.1, 95% confidence interval CI 1.6-31.4, p = 0.010), recurrent ischemic events (OR 7.1, 95% CI 1.6-32.7, p = 0.011), and extracranial localization of the stenosis (OR 3.8, 95% CI 1.1-13.2, p = 0.038) were independent predictors for microembolic events. CONCLUSION: In patients with symptomatic arterial stenosis, the absence of an ASA medication is associated with the occurrence of TCD-detected microembolic events, suggesting a relation between these events and ASA-sensitive microemboli from the stenotic lesion.

Cardiovascular events associated with different combined oral contraceptives: a review of current data.

Studies of combined oral contraceptive (COC) use and cardiovascular disease have been conducted against a background of low cardiovascular risk in young women, changing COC composition and changing user selection and monitoring. Studies of myocardial infarction have found inconsistent results, possibly because of differences in the prevalence of risk factors (particularly smoking and raised blood pressure) in the populations studied. In the absence of a history of smoking and other conventional risk factors, current users of modern COCs probably do not have an increased risk of myocardial infarction. Neither are former users at risk. Evidence for important differences in the risk of myocardial infarction between formulations is weak and contradictory. Current users of low estrogen dose COCs have a small increased risk of ischaemic stroke although most of the risk occurs in women with other risk factors (notably smoking, hypertension and probably a history of migraine). Former users of COCs do not have an increased risk of ischaemic stroke. There is insufficient information to determine whether major differences in the risk of ischaemic stroke exist between products. Current users appear to have a modestly elevated risk of haemorrhagic stroke, mainly in women older than 35 years; former users do not. Data examining the risk of haemorrhagic stroke in current COC users with other risk factors are very sparse, as are those relating to the haemorrhagic stroke risk associated with particular COCs. Numerous studies have found, with remarkable consistency, an elevated risk of venous thromboembolism among current users of low estrogen dose COCs. The risk is substantially elevated among women with various inherited clotting factor defects. The effects in COC users with other risk factors for venous thrombosis tend to be less pronounced and more inconsistent. A number of studies have found higher relative risks among current users of low estrogen dose COCs containing desogestrel or gestodene, than among users of similar products containing levonorgestrel. A number of explanations, in terms of bias or confounding, have been proposed for these clinically small differences. At best, empirical evidence for these explanations, is weak. The risk of cardiovascular disease of any description is low in COC users. Women can minimise, and possibly eliminate entirely, their arterial risks by not smoking and by having their blood pressure checked before using a COC (in order to avoid its use if raised blood pressure is discovered). Users may decrease their venous thromboembolic risk by their choice of COC preparation although the effects will be modest.

Atrial fibrillation and stroke: clinical presentation of cardioembolic versus atherothrombotic infarction.

The aim of the study was to compare demographic characteristics, anamnestic findings, cerebrovascular risk factors, and clinical and neuroimaging data of cardioembolic stroke patients with and without atrial fibrillation and of atherothrombotic stroke patients with and without atrial fibrillation. Predictors of early diagnosis of cardioembolic vs. atherothrombotic stroke infarction in atrial fibrillation patients were also determined. Data of cardioembolic stroke patients with (n=266) and without (n=81) atrial fibrillation and of atherothrombotic stroke patients with (n=75) and without (n=377) were obtained from 2000 consecutive patients included in the prospective Sagrat Cor-Alianza Hospital of Barcelona Stroke Registry. Risk factors, clinical characteristics and neuroimaging features in these subgroups were compared. The independent predictive value of each variable on early diagnosis of stroke subtype was assessed with a logistic regression analysis. In-hospital mortality in patients with atrial fibrillation was significantly higher than in non-atrial fibrillation patients both in cardioembolic (32.6% vs. 14.8%, P<0. 005) and atherothrombotic stroke (29.3% vs. 18.8%, P<0.04). Valvular heart disease (odds ratio (OR) 4.6; 95% confidence interval (95% CI) 1.19-17.68) and sudden onset (OR 1.8; 95% CI 0.97-3.63) were predictors of cardioembolic stroke, and subacute onset (OR 8; 95% CI 1.29-49.42), COPD (OR 5.2; 95% CI 1.91-14.21), hypertension (OR 3. 63; 95% CI 1.92-6.85), hypercholesterolemia (OR 2.67; 95% CI 1.13-6. 28), transient ischaemic attack (OR 2.49; 95% CI 1.05-5.90), ischaemic heart disease (OR 2.30; 95% CI 1.15-4.60) and diabetes (OR 2.26; 95% CI 1.14-4.47) of atherothrombotic stroke. In conclusion, some clinical features at stroke onset may help clinicians to differentiate cerebral infarction subtypes in patients with atrial fibrillation. Atrial fibrillation is associated with a higher in-hospital mortality both in cardioembolic and atherothrombotic stroke patients.

Association of left ventricular hypertrophy and chronic atrial fibrillation with the incidence of new thromboembolic stroke in 2,384 older persons.

In a prospective study of 2,384 persons, mean age 81 years, at 44-month follow-up, new thromboembolic stroke developed in 510 of 2,384 persons (21%). The Cox regression model showed that significant independent risk factors for new thromboembolic stroke were atrial fibrillation (risk ratio 3.2), left ventricular hypertrophy (risk ratio 2.8), prior stroke (risk ratio 2.2), and male gender (risk ratio 1.2).

Clinical application of asymptomatic embolic signal detection in acute stroke: a prospective study.

BACKGROUND AND PURPOSE: The detection of asymptomatic embolization with the use of Doppler ultrasound has a number of potential applications in patients with acute stroke. It may provide information on the stroke pathogenesis in individual cases, identify patients with continued embolization, and allow localization of the active embolic source. METHODS: We recruited 119 patients with acute anterior circulation infarction within 72 hours of stroke onset. Transcranial Doppler recordings were possible in 100 (84.0%). Bilateral 1-hour middle cerebral artery (MCA) recordings were made and saved on digital audiotape for blinded offline analysis. When embolic signals were detected during screening of the first recording, simultaneous recording was performed from the ipsilateral MCA and common carotid artery for an additional 30 minutes. In all patients with embolic signals at screening and in matched negative controls, recordings were repeated on days 4, 7, and 14. RESULTS: Embolic signals were detected in the symptomatic MCA in 16 patients (16%). They were more common in patients with carotid stenosis (P<0.0001), occurring in 50% of this group. They were rare in patients with cardioembolic stroke (4.5%) and were not detected in patients with lacunar stroke. In the 16 patients with embolic signals, the proportion with embolic signals fell over time (P=0. 0025), but they were still present in a third at 2 weeks. In 10 patients, localization of the embolic source was possible by simultaneous recording from the MCA and the ipsilateral common carotid artery. CONCLUSIONS: Continued asymptomatic embolization is common after stroke in patients with carotid artery disease and is still present in a significant proportion at 2 weeks. The technique may identify patients at risk of further stroke for more aggressive antiplatelet therapy; this needs to be tested in large prospective studies. The technique may also allow localization of the active embolic source.

Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies, and cerebral palsy.

Thrombi in the fetal circulation of the placenta cause a pattern of clustered fibrotic villi called fetal thrombotic vasculopathy (FTV), which has been associated with serious injuries to neonates, especially brain injuries. Correlation of FTV with visceral thrombi in autopsy specimens might lead to a more accurate estimate of the prevalence of somatic thrombi as a significant and underrecognized cause of prenatal injury or perinatal death, and show the potential validity of placental FTV as an indicator of thrombotic lesions in the fetus and newborns who survive. Clinicopathologic correlation was used to perform a 3-year retrospective autopsy review. We identified 16 cases (19%) among 84 perinatal autopsy specimens in which placental FTV was associated with stillbirth, intrapartum, or neonatal death. Two liveborn neonates survived 2.5 hours, and one for 24 hours; there was one intrapartum death, and the rest were stillborn. Clinical evidence of severe central nervous system (CNS) injury to two of the liveborn infants was evident at birth. Twelve stillborns died from 12 to 48 hours before delivery. Placental FTV had features of organization that clearly antedated the fetal death. Autopsy findings confirmed somatic thrombi in six cases (37.5%) of the 16 with FTV, including cerebral thrombi or infarcts (three cases), renal thromboemboli (three cases), and pulmonary thromboemboli (two cases). One mother had history of deep vein thrombosis, and four of eight tested had abnormal coagulation test results. Placental FTV indicates a significant probability of thrombi in the fetus and represents an important, possibly underrecognized cause of perinatal mortality and neonatal injury. Parental coagulopathy as a significant factor in prenatal injury and death deserves more comprehensive study. The placenta remains an undervalued and underutilized surgical specimen in the evaluation of perinatal injury, especially cerebral palsy.

Brain "embolism" detected by magnetic resonance imaging during percutaneous mitral balloon commissurotomy.

PURPOSE: The common finding of thrombi between the bifoil balloons when they were extracted after mitral dilation prompted us to look for evidence of minor brain embolisms using the sensitive technique of BMRI (brain magnetic resonance T2-weighted imaging). METHODS: BMRI was performed within 48 hr before and after a percutaneous mitral balloon commissurotomy (PMBC) in each of the 63 patients in this study. RESULTS: There was evidence (hyperintensity foci: HI) of a previous asymptomatic brain embolism in 38 of 63 patients before PMBC and a new HI appeared in 18 of 63 patients after the procedure. New HI signals were found exclusively in the white matter in 8 of 18 patients and in only 3 of 18 were HI signs larger than 1 cm. One patient, with an HI signal > 1 cm in the thalamus and another < 1 cm in the brain stem, presented diplopia accompanied by other minor clinical signs. The differences in HI rate among four subgroups (1, older vs younger than 43 years; 2, sinus rhythm vs atrial fibrillation; 3, echo score < 8 vs > 8; 4, patients from western countries vs the others) were not statistically significant, probably because the number of patients in each subgroup was low. Patients in atrial fibrillation had slightly more (not significant) HI before PMBC (15/20, 75%) than patients in sinus rhythm (23/43, 53%), but after PMBC their HI frequencies were similar (atrial fibrillation: 5/20, 25%; sinus rhythm: 13/43, 30%). CONCLUSION: Brain microembolism is frequent during PMBC, but is often anatomically limited and free from clinical signs in most cases. Brain embolism seems to be related mainly to the procedure itself and not the features of the patient.

Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome.

OBJECTIVE: Although cannulation of the femoral artery is used routinely for thoracic aortic operations with hypothermic circulatory arrest, retrograde perfusion through the descending aorta carries the risk of cerebral malperfusion or embolism. We have, therefore, routinely used a central cannulation technique for distal arch and descending aortic operations since 1995. In this study, we compared neurological outcome in consecutive patients undergoing femoral versus ascending aortic perfusion for these aneurysms. METHODS: Between 1987 and 1998, 61 patients underwent aortic resection with circulatory arrest, but without retrograde cerebral perfusion, for lesions of the aortic arch and descending aorta. Thirty-one patients had fusiform true aneurysms, 19 had aortic dissection and 11 had extensive saccular or false aneurysms. Thirty-two patients (52%) were perfused via the femoral artery (group A), and 29 patients (48%) from the ascending aorta (group B). Operative mortality and morbidity, and neurological outcome, were reviewed. RESULTS: There were no differences between the groups in mean age, pathology, abdominal and peripheral vascular disease, net perfusion time, or circulatory arrest time. There were four hospital deaths (three in group A and one in group B; P = 0.61), including one neurological death in group A, group A suffered a higher incidence of neurological events (nine patients: 28%) than group B (two patients: 7%; P = 0.03). Temporary focal neurological deficits occurred in both groups (two patients in group A, 6% and two patients in group B, 7%; P > 0.99), but permanent injury occurred exclusively in group A (seven patients: four with monoplegia, one with hemiplegia, and two with diffuse cerebral injury with one death; P = 0.01). CONCLUSIONS: Anterograde perfusion using a proximal aortic cannula provides a low risk of cerebral embolism and allows extensive aortic resection with low morbidity.