To define patterns of infarction on computed tomography that are characteristic of embolism, as opposed to hemodynamically or microangiopathically induced brain lesions, a consecutive series of 60 patients with acute brain embolism were studied. Strokes were embolic in origin; that is, hemodynamic and in situ thrombotic stroke mechanisms had been excluded. Embolically active, cardiac disease was proved in 42 and was clinically evident in 13 patients. Five patients had suffered a stroke due to catheter-related embolism. Computed tomography revealed pial artery territorial infarction in 55 patients (92%). In 5, the infarction had the size or location (or both) characteristic of lacunes, although shape and lack of multiplicity raised questions about this interpretation. No patient showed a low-flow type of infarction pattern. These findings strongly support the view that (1) except for in situ thrombosis, pial artery territorial infarctions are indicative of an embolic mechanism, and (2) that the mechanism underlying lacunes is hardly, if ever, embolic.

SUMMARY Percutaneous transluminal coronary angioplasty (PTCA) was performed in 21 patients with acute myocardial infarction (AMI) treated by intracoronary infusion of streptokinase within 8 hours after the onset of symptoms. Streptolysis therapy began a mean of 3.6 1.2 hours (±+ SD) after the onset of symptoms. The vessel was occluded in 14 patients and highly stenosed in seven. After the infusion of 67,300 + 63,200 IU of streptokinase over 26.1 21.5 minutes, patency of the occluded vessels was reached.PTCA as performed 20-60 minutes after the end of streptokinase treatment in 19 patients and 24 and 31 hours after treatment in two patients. The dilation was successful in 17 patients (81%). The degree of vessel obstruction was reduced from 90.2 + 7.3% to 58.6 19.5% (area method) and from 71.4 + 12.4% to 39.2 + 19.7% (diameter method). The improvement was 31.5 18.4% and 32.2 ± 19.3%, respectively. No reocclusion was induced by PTCA. Twenty patients were discharged. One died during hospitalization; at autopsy, the treated vessel was still patent. During the follow-up period, two reinfarctions and one asymptomatic reocclusion occurred.The clinical findings during the hospital course and the follow-up period were compared with those of a control group of 18 patients with AMI and comparable coronary stenoses who were treated only with streptokinase infusion. Four of these patients had a reinfarction during the hospital course, and three died during the follow-up period.PTCA can be performed safely and successfully immediately after intracoronary infusion of streptokinase in patients with AMI. By reducing the subtotal stenosis, this treatment contributes to the reperfusion of the ischemic myocardium, diminishes the risk of a reocclusion and seems to improve the prognosis.

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Complete closure of the pericardium after cardiac operations has the advantage of avoiding injury of the heart and great vessels during reoperation. Between 1985 and 1987, the pericardium was closed with Gore-Tex Surgical Membrane (SM) in a selected series of 110 patients 1 month to 76 years of age. Fifty-three patients had congenital heart lesions and 57 patients had acquired heart disease. Overall hospital mortality was 3/110 cases. In no instance was there a relationship between occurrence of death and pericardial closure with SM. There was one episode of cardiac tamponade on the seventh postoperative day. One patient developed fever and leukocytosis due to a mediastinal hematoma. During a mean follow-up of 15 months, four patients had to be reoperated upon three, four, eight weeks, and eight months after primary operation. The anterior wall of the heart had no adhesion with the SM and the other parts of pericardium could be dissected easily. Scanning electron microscopic examination of the explanted SM patches showed neither cellular ingrowth nor immunocompetent cellular elements. The Gore-Tex Surgical Membrane has the advantages of easy availability and lack of reaction between its surface and the epicardium and pericardium. We believe its routine use should be encouraged in patients with high probability of reoperation after repair of complex cardiac anomalies, implantation of bioprostheses, coronary revascularization for one- or two-vessel disease, and repair of degenerative disease of the ascending aorta.

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The advantages of the present method include further reduction of hospital trauma, preservation of chest wall integrity, early mobilization and rehabilitation of the patient. Surgical technical improvements include avoidance of groin cannulation, simpler equipment, and an easy access in case of reoperation.

Aneurysms of the entire thoracic aorta are usually approached in two to three stages. From 1990 to 1994, we performed one-stage aortic replacement from the root to the diaphragm in 16 patients (8 men and 8 women with a mean age of 55.7 years, range 49 to 73). There were 11 type A dissections, 7 of which were acute. Six patients underwent aortic valve reconstruction; seven had aortic root replacement by Bentall or Cabrol techniques. In two cases, the innominate artery had to be replaced by a vascular graft separately in addition to reimplantation of the supraaortic branches as an island flap into the arch prosthesis. In eight cases, a median sternotomy was used; eight had a bilateral transverse thoracotomy. The procedure was performed under deep hypothermic circulatory arrest in all cases (mean duration 50.5 min, range 38 to 62 min). Two patients, both operated upon for an acute dissection, expired perioperatively: one due to a bronchopneumonia, and one because of a thrombosed Cabrol graft to the right coronary artery. No patient developed bleeding or neurological complications. At a mean follow-up of 26.9 months (1 to 50 months), all patients discharged from the hospital were still alive. Four patients underwent subsequent thoracoabdominal aortic replacement. This experience suggests that complete thoracic aortic replacement can be performed in a single session with an operative risk comparable to that of the conventional two-stage approach. The bilateral transverse thoracotomy affords excellent exposure. The lack of spinal cord ischemia may be the result of spinal cord protection with hypothermic circulatory arrest and use of the open-clamp technique.

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