Sixty-six patients with greater than or equal to 50% stenosis of an intracranial internal carotid artery (IICA) were followed-up for an average of 3.9 years. Eighteen patients (27.3%) experienced ischemic events; 8 (12.1%) had isolated TIA and 10 (15.2%) a stroke. The observed stroke rate for patients 35 years and older are 13 times the expected infarction rate for a normal population. Patients with tandem extracranial stenosis had a greater risk of stroke than patients with isolated IICA stenosis. Thirty-three patients (50%) died during follow-up and 55% of all deaths were cardiac related. The observed 5 year survival rate was 60% compared to an expected rate of 87%. Patients with IICA stenosis had a higher risk of stroke and death compared to a previously reported referral population with ICA occlusion. IICA stenosis is a marker of extensive cerebrovascular and systemic atherosclerotic disease, especially coronary artery disease.

SUMMARY Ninety-six patients with 2550% unilateral vertebral artery (VA) stenosis were followed up for an average of 4.6 years. In 89 patients (93%) at least one VA origin was involved, while the intracranial VA was affected in 3 patients (3%). Seventy-four patients (77%) had 2=50% stenosis of at least one internal carotid artery, of whom 52 underwent carotid endarterectomy. None of the patients had definite vertebrobasilar transient ischemic attacks (VB TIA). Nineteen patients (19.8%) experienced nonlocalizing symptoms possibly compatible with VB TIA, none of whom had a stroke. Twenty-three patients (24%) had strokes. The only two patients (2%) who sustained a brainstem infarction had fatal strokes and both were known to have basilar artery stenosis in addition to their VA stenosis. The observed stroke rate was 8.5 times the expected infarction rate for a normal population. Forty patients died during follow up. The observed 5-year survival rate was 60% compared to 87% in a matched normal population. Eight deaths (20% of all deaths) were caused by stroke and 21 deaths (52.5% of all deaths) were cardiac related.VA stenosis is most frequently located at the VA origin (93%), and is associated with a low incidence of brainstem infarction. Stroke Vol 15, No 2, 1984 THE PRESENT STUDY describes the stroke and survival rates in a group of patients with angiographically proven vertebral artery (VA) stenosis. Little information is available regarding the natural history of patients with VA occlusive disease. Previous studies suggest that stenosis of the distal VA is more dangerous than stenosis at the VA origin, and that hemodynamic factors may be more important than emboli in producing vertebrobasilar (VB) ischemia.1 " 3 However, lack of precise information about the prognosis in these patients makes recommendations for treatment difficult. The problem is further complicated since the clinical symptoms of VB ischemia are often difficult to define, and non-localizing events such as isolated vertigo may be erroneously labeled as "VB ischemia". MethodsThe records of patients who underwent aortic arch and/or selective vertebral artery angiography at the Cleveland Clinic between 1974 and 1978 were reviewed. The angiographic films of all patients with reported stenosis of at least 1 VA were examined. Ninety-eight patients with ^5 0 % unilateral or bilateral VA stenosis were selected for follow up. Patients with unilateral or bilateral VA occlusion only and patients who underwent VA operative procedures were excluded. Fifty-two patients who underwent carotid endarterectomy (CE) were included in follow up since the benefit of CE in VB ischemia is doubtful.4 These cases were analyzed separately. Follow up was accomplished using a standardized questionnaire and telephone interviews. End points were death or stroke. Vertebrobasilar transient ischemic attacks (VB TIA) were noted but were not sufficient reason for stopping follow up. The recommendations of the ad hoc NINCDS Committee were followed in defining VB From the

Despite knowledge of the bleeding hazard to thrombocytopenic cancer patients undergoing lumbar puncture (LP), a retrospective analysis of physician behavior at one hospital revealed no consistent use of platelet transfusions in patients with less than 20,000 platelets/mm3 on the day of LP. A review of the literature and laboratory cerebrospinal fluid (CSF) data in two institutions, and the performance of an LP experiment revealed that: (1) Batson's epidural venous plexus is an unlikely source and spinal radicular vessels are the most probable source of needle‐induced blood in lumbar puncture; (2) the frequency of encountering needle‐induced blood at LP is high, 73% (3) the frequency of brushing a nerve root, with the associated risk of lacerating the radicular artery or vein on its surface with the bevel of the LP needle, is high and may be on the order of 26%; and (4) while the passage of an LP needle, obturator in place, through a blood filled vein may carry red cells into a red cell‐free medium, this does not always occur. These new considerations argue for more consistent adherence to the already published recommendation of platelet transfusion immediately prior to LP in patients with low platelets. This issue is of particular relevance to the rapidly growing population of thrombocytopenic cancer patients with extended survival on multiple chemotherapeutic regimens requiring lumbar puncture.