Crescendo TIAs Research Articles

Spontaneous Vertebral Artery Dissection Presenting with Crescendo TIAs and Headache

We present the case of a man in his thirties who had attended the emergency department with complaint of a distressing headache and associated intermittent facial droop with occasional slurred speech. The patient’s symptoms were bizarre in their nature as they were random, not sustained and he had long intervals when he was asymptomatic and was his normal self. During the course of admission his symptoms evolved resulting in neurological deficits which were more sustained, prompting the need for further imaging beyond the initial plain CT brain which showed no abnormality. This led to the diagnosis of vertebral artery dissection (VAD) complicated with an ischaemic stroke in the posterior inferior cerebellar artery distribution (PICA) on MRI/MRA. Dual anti-platelet treatment was commenced with the patient attaining gradual symptomatic improvement prior to discharge. He has reported some degree of neurological sequelae which he described as intermittent poor coordination on follow up visit in clinic after discharge.

Abstract TP154: Characteristics and Surgical Outcome of Patients With Carotid Stenosis Resistant to Medical Therapy

Background: The recent progress of medical therapy has made the surgical indication for carotid artery stenosis more stringent. Therefore, surgical outcome of patients resistant to medical therapy were compared with those non-resistant to medical therapy. Methods: Between August 2006 and September 2017, 320 consecutive carotid revascularizations (CEA/CAS) were performed in our institute. Resistant (R) group was defined as patients with crescendo TIA, repeated TIA/infarction despite of medical therapy (n=15) or patients with symptomatic mobile plaque (n=5) (total 18; 2 patients overlapped). Other patients with symptomatic (116) and asymptomatic (186) stenosis were defined as non-resistant (N) group (total 302). Clinical characteristics, magnetic resonance (MR) plaque imaging, plaque pathology, and long-term outcomes with survival analysis were investigated. Results: 13 CEA and 5 CAS were performed in R group. 181 CEA and 121 CAS were performed in N group. The periprocedural stroke & death rate was higher in R group (1/18 [5.6%]; CEA 0/13, CAS 1/5 [20%]) than in N group (9/302 [3.0%]; CEA 4/181 [2.2%], CAS 5/121 [4.1%]) but no significant difference was observed. Signal intensity ratio of plaque relative to sternocleidomastoid muscle was significantly higher in R group than in N group (1.9 vs 1.5, p = 0.007; Fig. 1A) in MR plaque imaging study, which was consistent with intraplaque hemorrhage in pathological findings of R group. Estimates of the 4-year event rate of primary end point (stroke/death/MI within 30 days, and any ipsilateral stroke thereafter) using competing risk analysis were 18% for R group and 4.5% for N group (P = 0.022; Fig. 1B). ALL recurrence occurred after CAS. Conclusion: The resistance to medical therapy was likely to be due to severe intraplaque hemorrhage, which might explain relatively poor outcome of CAS in R group. Appropriate indication is critical for good outcome of R group.

EARLY CAROTID ENDARTERECTOMY IN SYMPTOMATIC PATIENTS

Introduction: Stroke is a big social problem. The expediency of surgical treatment is justified as the chances for complete reconvalescence of the neurological deficiency increase. The aim: To analyze available sources of scientific information on the terms of surgical treatment of patients with acute neurological deficiency. Materials and methods: We analyzed 41 English publications in PubMed for 5 years from 2012 to 2017, with the keywords "urgent carotid endarterectomy" and "early carotid endarterectomy". Conclusions: In the classic course of stroke or TIA, the best treatment results are obtained when the CEA is performed 3-7 days after the marker event. CEA should be performed as soon as possible to restore brain revascularization and prevent the fatal progression of the neurological deficiency after crescendo TIA or stroke-in-evolution, despite the fact that the risk of complications and disability after surgery may be higher than 6%.

Abstract 347: Significant Association Between the Qualifying Neurologic Event and the In-hospital Risk of Stroke or Death Following Carotid Endarterectomy and Carotid Artery Stenting

Objectives: The purpose of this observational study was to analyze the association between the initial neurological status and the risk of any in-hospital stroke or death in patients treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS) under routine conditions in Germany. Methods: Secondary data analysis based on the German statutory quality assurance database for carotid procedures between 2009-2014. The primary outcome was any periprocedural stroke or all-cause death until discharge. To analyze the association between initial neurological status and outcome, a multilevel multivariable regression analyses adjusting for confounders was performed. Results: From a total of 182,033 patients documented between 2009 and 2014, 144,347 patients treated with CEA and 14,794 patients treated with CAS were included in the analysis. In total, there 68% were men and the mean age of the cohort was 70.5±9.1 years. The risk of any in-hospital stroke or death in patients treated with CEA was 2.0% (n=2923/144,347). The raw risk of any in-hospital stroke or death was 1.4% in asymptomatic patients and 3.0% in symptomatic patients treated with CEA. Within the group of symptomatic patients, risk of any in-hospital stroke or death after CEA increased from 1.2% (amaurosis fugax, AFX), 2.3% (TIA), 2.8% (minor stroke), 4.4% (major stroke), 4.8% (crescendo TIA, cTIA) to 9.0% (stroke in evolution, SIE). The risk of any in-hospital stroke or death in patients treated with CAS was 3.6% (n=538/14,794). The raw risk of any in-hospital stroke or death was 1.7% in asymptomatic patients and 6.1% in symptomatic patients treated with CAS. Within the group of symptomatic patients, risk of any in-hospital stroke or death increased from 1.0% (AFX), 4.1% (TIA), 4.1% (minor stroke), 5.4% (major stroke), 5.2% (cTIA) to 11.7% (SIE). Regression analysis revealed that the severity of initial neurologic symptoms was associated with an increased risk of any in-hospital stroke or death in both patients treated for CEA and CAS. Conclusion: Periprocedural risk for any stroke or death did not significantly differ between asymptomatic patients and patients with AFX but between asymptomatic patients and patients with TIA, stroke, cTIA or SIE.

前多血期に主幹動脈閉塞を伴う脳梗塞を発症し，数年後にcrescendo TIAを呈したJAK2V617F 変異遺伝子陽性真性多血症の1 例

前多血期に主幹動脈閉塞を伴う脳梗塞を発症し，数年後にcrescendo TIAを呈したJAK2V617F 変異遺伝子陽性真性多血症の1 例

ID 377 – Somatosensory evoked potentials as a predictor of clinical outcome after emergent recanalization of internal carotid artery occlusion

Objectives Median somatosensory evoked potential (SEP) amplitude monitoring is reliable tool for early cerebral ischemia detection. Aim of the study Set feasibility of routine SEP monitoring in emergent internal carotid artery (ICA) recanalization. Material and methods 05/2013 to 02/2015 were performed 12 emergent ICA recanalisations after acute ischaemic stroke (AIS). Mean age 72.7; ICA occlusion: 6 (50%), 90-99% stenosis: 6 (50%). Inclusion criteria: AIS or crescendo TIA 24 hours, ICA occlusion or stenosis, functional independence before stroke. Exclusion criteria: hemorhagic stroke, ischaemia on CT scan. Median SEP were monitored during carotid surgery. Clinical finding was evaluated 3 months after surgery. Results N20/P25 amplitude was decreased in 5 (41.7%) at symptomatic side (in 1 by > 50%) comparing to asymptomatic. Successful recanalisation: 11 (91.7%), intraluminal shunt was placed in 1 according SEP amplitude decrease intraoperatively. Mean muscle strength: arm: 2.4, leg: 3.3, speech disorder: 8 (66.7%). 3 month outcome: muscle strength: 3.9, 4.4 respectively, speech disorder: 3 (25.0%). Modified Rankin Score 0-1: 8 (66.7%), mRS 2: 3 (25.0%), mRS 6: 1 (8.3%). Conclusion Median SEP is feasible to monitor in emergent ICA recanalizations. Median SEP amplitude seems to be promising marker of good clinical outcome.

Abstract 57: Safety of Early and Urgent Carotid Endarterectomy (CEA) in Symptomatic Carotid Artery Stenosis (sCAS): An International, Multicenter Study

Background&Purpose: Although the latest AHA recommendations suggest that CEA should be performed within two weeks of the index event in patients with sCAS, only a minority of patients undergoes surgery within the recommended time-frame because of a perceived higher incidence of complications. The aim of this international, multicenter study was to prospectively evaluate the safety of early CEA in patients with SCAS in “everyday clinical practice” settings. Subjects&Methods: Consecutive patients with non-disabling (modified Rankin Scale grade<3) acute ischemic stroke (AIS) or TIA due to sCAS (≥70%) underwent early (≤14 days from symptom onset) CEA at five tertiary care stroke centers during a two-year period. Primary outcome events included any stroke, myocardial infarction (MI) or death occurring during the 30-day follow-up period and were defined according to the International Carotid Stenting Study criteria. Secondary outcome events included cranial nerve palsy (CNP) and neck hematoma (NH). Results: A total of 165 patients with sCAS (mean age 69±10years; 69% men; 70% acute ischemic stroke, 30% TIA; crescendo TIA 6%; contralateral internal carotid artery occlusion 8%) underwent early CEA during the study period. The median elapsed time from symptom onset to carotid revascularization was 8 days (range 1-14). A total of 20 (12%) patients underwent urgent CEA (within two days from symptom onset). The primary outcomes of stroke and MI were 4.8% (95%CI: 1.5%-8.1%) and 0.6% (0%-1.8%) respectively. All strokes included cerebral infarctions that occurred in the territory of the symptomatic internal carotid artery (ICA). The combined outcome event of non-fatal stroke, non-fatal MI or death was 5.5% (2.0%-9.0%). The rates of CNP and NH were 6.7% and 3.6%. Crescendo TIA, contralateral ICA occlusion and urgent CEA were not associated (p>0.2) with a higher rate of peri-procedural events. Conclusions: Our findings indicate that the risk of early CEA in consecutive unselected patients with non-disabling stroke or TIA due to sCAS is acceptable when the procedure is performed within 2 weeks as well as within 2 days from symptom onset.

A Stroke/Vascular Neurology Service Increases the Volume of Urgent Carotid Endarterectomies Performed in a Tertiary Referral Center

Increasing evidence supports that urgent carotid endarterectomy (CEA), defined as CEA during the index hospitalization, may be undertaken in select patients with acute carotid-related neurologic symptoms to prevent recurrent ischemic events. We aimed to determine the effect of a stroke/vascular neurology service on the volume of urgent CEAs performed and assess perioperative outcomes. A retrospective review from a single tertiary referral center between June 2005 through December 2011 revealed 393 patients who underwent CEA. We identified the number of urgent CEAs before (June 2005-August 2008) and after (September 2008-December 2011) a stroke/vascular neurology service was implemented, as well as asymptomatic CEAs and symptomatic but electively performed CEAs. Demographic data as well as 30-day adverse outcomes (transient ischemic attack [TIA], stroke, myocardial infarction, and mortality) were analyzed for each group. In patients undergoing urgent CEA, TIA and stroke severity were assessed by a stroke neurologist using the ABCD2 TIA score and National Institutes of Health Stroke Scale (NIHSS), respectively. The χ2 test was used to compare differences between the urgent CEA volume before and after a stroke/vascular neurology service. Fisher's exact test was used to analyze perioperative outcomes. Demographics and comorbidities were similar between the 2 groups. The proportion of urgent CEAs performed increased significantly after initiation of a vascular neurology service (4.1% [7 of 172] vs. 22.2% [49 of 221], P<0.0001). Per annum, urgent CEAs increased from 5.3% (4/75) in 2005 to 39.6% (25/63) in 2011. A vascular neurology service did not increase the number of nonurgent referrals. Urgent CEA indications were ocular ischemic events 4% (2/49), cerebral ischemic/infarction events 35% (17/49), crescendo TIAs 6% (3/49), acute stroke 45% (22/49), and stroke-in-evolution 10% (5/49). Mean NIHSS was 3.5 (range 0-24); mean TIA score was 5 (range 1-8). Although there were no statistical differences in 30-day outcomes, there was a trend toward a higher combined complication rate (stroke, death, myocardial infarction) in the urgent compared with the symptomatic but electively performed CEA group (7.1 % [3/49] vs. 2% [1/49]; P=.36). However, patients undergoing urgent CEA with an NIHSS<10 had no perioperative complications. Collaboration with a vascular neurology team increased the volume of urgent CEAs over a 3-year period. In patients with mild-to-moderate strokes (NIHSS<10), urgent CEA perioperative outcomes approximate those for electively performed CEAs, suggesting improved care through a multidisciplinary approach.

RR23. A Stroke/Vascular Neurology Service Increases the Volume of Urgent CEAs Performed in a Tertiary Referral Center

Patients presenting with carotid-related acute neurological symptoms are at hightened risk of stroke. Urgent CEA (uCEA) during the index hospitalization is indicated in select patients. We aimed to determine the effect of a dedicated vascular neurology team on the volume of uCEAs and assess outcomes. CEAs (n=436) performed at a tertiary center between 2005-2011 were analyzed. Chi-square was used to compare the uCEA volume pre- (June 2005-Aug. 2008) and post- (Sept. 2008-Nov. 2011) implementation of a vascular neurology service. Fisher's exact and t-tests were used to analyze perioperative outcomes. The proportion of uCEAs performed increased significantly after initiation of a vascular neurology service (4.1% [7/172] vs. 22.2% [49/221], P < .0001). Per annum, uCEAs increased from 5.3% (4/75) in 2005 to 39.6% (25/63) in 2011 (Fig). uCEA indications were stroke-in-evolution 10% (5/49), crescendo TIAs 6% (3/49), acute stroke 45% (22/49), and cerebral/ocular TIAs 39% (19/49). Mean National Institutes of Health Stroke Scale (NIHSS) was 3.5 (0-24); mean TIA score was 5 (1-8). A trend towards a higher combined stroke/death rate in the urgent compared to the elective symptomatic CEA group group was present (7.1 % [3/49] vs. 2% [1/49]; p = .36); however, patients undergoing uCEA with an NIHSS<10 had no perioperative complications. Collaboration with a vascular neurology team increased the volume of uCEAs over a three year period. In patients with mild strokes (NIHSS<10), uCEA outcomes approximate those for electively-performed CEAs.

PS78. Stroke in Evolution and Crescendo TIA in Carotid Disease: The Need for Emergency Surgical Treatment According to a Predefined Protocol

Objectives: Carotid revascularization is routinely performed for patients with severe carotid stenoses. Although neurologic complication is uncommon, decline in cognition following interventions, particularly memory, has been reported. However, there is inconsistency in cognitive evaluations and one methodological difficulty in assessing memory changes is that identical tests are applied so that practice effects may improve performance and obscure underlying decline. The aim of this study is to assess memory change using parallel forms with different stimuli in which the actual information is not repeated across sessions. Methods: Twenty six patients underwent MRI evaluations and neuropsychological assessments before and after carotid revascularization procedures. Neuropsychological battery included measures assessing general function (MMSE), depression, attending/executive function/psychomotor speed, and memory. Memory was measured using parallel forms of Rey Auditory Verbal Learning Test (RAVLT) and the critical measure was the difference in performance on the delayed recall sub-measure of RAVLT, which involved repeating the word list after a 20-minute delay. Results: A total of 26 patients (20 CEA and 6 CAS) with a mean age of 72 years (Range 60-86) were evaluated. The average education was12.9 years (Range 10-18), and average MMSE 27.8 (range 22-30). Four patients had procedure-related microemboli including 2 CAS patients. There was a subtle, but significant decline in the delayed recall following interventions (t(25) 2.32, p 0.029). Among 14 patients (53.8%) who declined, three had CAS procedures. Patients who had preoperative neurologic symptoms had a tendency of postoperative memory decline. Conclusions: Memory function deterioration following carotid interventions is a major concern. Patients should be counseled about potential delayed memory decline. Further studies investigating clinical risk factors for these changes are warranted.

How should I treat concomitant post-endarterectomy carotid pseudoaneurysm and contralateral symptomatic stenosis?

A 74-year-old male patient complaining of crescendo TIAs, hypertension and hyperlipidaemia.Duplex ultrasound scan MR angiography.Pseudoaneurysm stemming from the ICA.An open or endovascular procedure for the right pECCA repair, or a left CEA or CAS.

PS90. Carotid Artery Endarterectomy (CEA) for Stroke in Evolution (SIE): Technical and Long-term Clinical Outcome in a Tertiary Referral Vascular Centre. When to Master Silence?

Scheduling of CEA in symptomatic carotid artery stenosis (SCAS) remains controversial. No consensus exists on management of crescendo TIAs (cTIA) or SIE. We endeavour to evaluate 5-year survival rates and freedom from stroke in patients with SCAS <14days, cTIA and SIE.

Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery

Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke. We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel-Haenszel meta-analysis. Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus > or = 1 week, OR=1.2, 0.9 to 1.7, P=0.17; <2 weeks versus > or = 2 weeks, OR=1.2, 0.9 to 1.6, P=0.13). Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.

Is the urgent carotid endarterectomy in patients with acute neurological symptoms a safe procedure?

The aim of the present case-control study was to assess patients with acute neurological symptoms requiring urgent carotid endarterectomy (CEA) and compare the outcome of the procedure in this group with that achieved in stable patients. Twenty-eight CEAs were performed in patients with an acute neurological deficit and 302 in stable patients from December 2006 to April 2008. Those selected for urgent surgery fulfilled the following criteria: acute onset of hemispheric neurological symptoms or crescendo TIAs, significant carotid pathology, the absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions. Perioperative mortality in the stable patients' cohort was 0.33%. One patient died during the hospital stay because of myocardial infarction. Perioperative neurological events were observed in 2.2%: one ipsilateral stroke in stage II A, one contralateral stroke in stage I A, and a prolonged neurological deficit with complete restitution at the time of discharge in five patients. No mortality or neurological morbidity was encountered in those who underwent urgent CEA. Compared to stable patients with stage I, II or IV disease, neither mortality nor morbidity was increased in those who underwent urgent CEA. Urgent CEA after non-disabling stroke or crescendo TIAs is a safe procedure with a favorable outcome.

Progressive moyamoya syndrome associated with de novo formation of the ipsilateral venous and contralateral cavernous malformations: case report

Background Association of moyamoya disease with multiple vascular malformations is extremely rare. Case Presentation A 33-year-old man, who had been affected with moyamoya syndrome with TIA during the past 3 years, was admitted to our hospital because of crescendo TIAs with numbness in his right hand and dysarthria. Magnetic resonance angiography showed apparent progression of the steno-occlusive changes bilaterally. We then planned surgical revascularization on the symptomatic side. At the time of readmission for surgery, an asymptomatic small intracerebral hemorrhage in the right frontal cortex was found, which presented on MRI as a CCM. Cerebral angiogram showed avascular lesion corresponding to the location of CCM as well as a newly formed venous malformation on the left side. One month later, STA-MCA anastomosis with pial synangiosis was performed without complications. Significant improvement in CBF on the left hemisphere was confirmed by postoperative single-photon emission CT. There were no ischemic changes on a postoperative MRI, and STA-MCA bypass was apparently patent by MRA. The TIA completely disappeared after surgery, and the patient was discharged without neurologic deficit. Persistence of the CCM and venous malformation were confirmed by T2*-weighted image and 3-dimensional contrast-enhanced gradient echo/SWI 4 months after surgery, respectively. Conclusion The association of moyamoya syndrome with CCM and venous malformation is extremely rare. The coincidence of the progressive moyamoya syndrome with these newly formed vascular malformations may give a clue to the underlying mechanism of the progression of this rare entity.

Carotid endarterectomy in patients with acute neurological symptoms: a case-control study

The aim of this study was to retrospectively evaluate our experience in urgent carotid endarterectomy (CEA) in patients with acute neurological symptoms comparing them with results obtained in stable symptomatic patients in a case-control study. From January 1996 to December 2005, 3336 consecutive CEAs were performed at our department. In 70 cases CEA was carried out in patients with acute neurological deficit; in all these patients, clinical presentations were recent (<24 h) or crescendo (defined as two or more episodes in 24 h, with complete recovery after each episode) TIAs (group 1). The control group was randomly obtained from our historical database and consisted of 352 stable symptomatic patients operated on in the same period (group 2). Early (30-day) results in the two groups were compared by chi(2) and Fisher exact tests; follow-up data were analysed by life-table analysis (Kaplan-Meier test) and results in subgroups were compared by means of log-rank test. Considering mortality and any neurological morbidity, the patients of group 1 showed a cumulative rate of death and neurological complication significantly higher than those in group 2 (5.4% and 0.3%, respectively; P=0.005); however, when analysing 30-day disabling strokes and deaths, the patients of group 1 had a cumulative complication rate of 1.4%, whereas in group 2 the corresponding figure was 0.3% (P=n.s.). In patients of group 1, univariate analysis and logistic regression for multivariate analysis for 30-day risk of stroke and death did not show any influence of comorbidities, clinical status, anatomical and surgical features. Estimated cumulative 36-month survival was significantly better in group 2 than in group 1. Considering the absence of ipsilateral stroke at 36 months, there were no differences between the two groups; however, analysing the estimated absence of any neurological events, both ipsilateral and contralateral, at 36 months, patients of group 1 had a higher risk than those of group 2. Urgent CEA in patients with recent/crescendo TIA and appropriate carotid artery lesion, carries good early and long-term results, which, however, remain slightly poorer than those obtained in symptomatic patients with a stable neurological status.

Indications for and perioperative management of emergency carotid endarterectomy—report on six cases

Emergency carotid endarterectomy (CEA) can be indicated to restore neurological functions or help prevent further stroke in impending stroke patients. We report on our experience of emergency CEA and perioperative patient management in six patients who underwent emergency CEA. We operated on 32 patients with carotid artery stenosis in the last 4 years, 6 of whom were classified as “emergency” patients. Two patients had a crescendo TIA, two had stroke in evolution, and the remaining two had acute severe stroke. In all cases, CEA was performed within 48 h of the last ischemic attack. Postoperatively two patients, each with crescendo TIA and stroke in evolution, and one acute severe stroke patient made a full recovery. One patient with acute stroke died from hypovolemic shock caused by gastrointestinal bleeding. The final postoperative neurological status, as graded by the modified Rankin scale, was Grade 0, of which we had four patients and Grade 2, which described one of our patients. No patient suffered further stroke after CEA in long-term follow-up. Transient postoperative complications occurred in two patients, and angina pectoris in the other. Emergency CEA is beneficial for patients with Crescendo TIA and stroke in evolution in perioperative and long-term follow-up. Postoperatively, however, blood pressure, coronary artery disease, and hemorrhagic complications such as gastrointestinal bleeding must be carefully managed.

５．脳梗塞超急性期の主幹動脈病変に対する外科的治療―特に頚動脈内膜切除術の意義と限界―

In this report, I reviewed lireratures and our clinical experiences of surgical revascularization ; carotid endarterectomy (CEA), intracranial embolectomy, and EC-IC bypass on emergency basis after ischemic cerebral stroke. Especially, in the cases with symptomatic and critical stenosis/complete occlusion of the internal carotid artery (ICA), current topics about efficacy and treatment algolism of emergency or ultra-emergency CEA in this clinical category. In summary ; 1) Crescendo TIAs and stroke in evolution are characteristic symptoms of the critical ICA stenosis and these cases will be absolute indication for emergency CEA. Significance of these symptoms should be more emphasized for early diagnosis in this clinical category. 2) Ultra-emergency thrombolysis and CEA should be the only successful procedure in the serious ICA occlusion group. Proper and quick examination system for true diagnosis, especially for evaluation of effectiveness and risk of surgical revascularization, must be considered.

治療抵抗性にて脳梗塞に移行したｃｒｅｓｃｅｎｄｏ ＴＩＡの２例

治療抵抗性にて脳梗塞に移行したｃｒｅｓｃｅｎｄｏ ＴＩＡの２例

Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency

Eighty-three patients underwent 85 intracranial to extracranial pedicle bypass anastomosis procedures to the posterior circulation. There were 15 patients with occipital artery (OA) to posterior inferior cerebellar artery (PICA) anastomosis, 20 patients with OA to anterior inferior cerebellar artery (AICA) anastomosis, and 50 patients with superficial temporal artery (STA) to superior cerebellar artery (SCA) anastomosis. All patients had transient ischemic attacks (TIA's) suggestive of vertebrobasilar ischemia. Twenty-seven patients had crescendo TIA's or stroke in evolution and were considered to be clinically unstable. All patients had severe bilateral distal vertebral artery or basilar artery disease. Twenty-two patients had bilateral vertebral artery occlusion and three had basilar artery occlusion. In this series, 69% had complete resolution of symptoms; the mortality rate was 8.4% and the morbidity rate 13.3%. Clinically stable patients did better than unstable patients. The STA-SCA anastomosis was well tolerated and technically less demanding than the OA-PICA or OA-AICA anastomosis procedures. Patients with symptomatic severe bilateral vertebral or basilar artery disease have a grave prognosis and the option of a surgical arterial pedicle revascularization procedure should be offered to them.