Conclusion:For the primary Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) end point of the composite of stroke, death, and myocardial infarction, there are no significant differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) by symptomatic status. Periprocedural stroke and death rates are significantly lower for CEA in symptomatic patients. Nearly twice as many strokes occurred in asymptomatic patients with CAS vs CEA (15 vs 8), but this did not reach statistical significance.Summary: This is a secondary analysis of CREST data. CREST investigated the safety and efficacy CAS vs CEA in patients with high-grade carotid stenosis. A symptomatic patient was defined as having had appropriate symptoms Յ180 days of randomization. The primary end point of CREST was a composite of stroke, myocardial infarction, or death within the periprocedural period or ipsilateral stroke up to 4 years. There were 1221 symptomatic and 1181 asymptomatic patients entered into CREST. For all patients, the periprocedural aggregate of stroke, myocardial infarction, and death did not differ between CAS and CEA (5.2% vs 4.5%; hazard ratio [HR], 1.18; 95% confidence interval [CI], 0.82-1.68; P ϭ .38). Rates of stroke and death, however, were higher for CAS vs CEA (4.4% vs 2.3%; HR, 1.90; 95% CI, 1.21-2.98; P ϭ .005). For symptomatic patients, periprocedural stroke and death rates were 7.0% Ϯ 0.9% for CAS and 3.2% Ϯ 0.7% for CEA (HR, 1.89; 95% CI, 1.11-3.21; P ϭ .02). For asymptomatic patients, stroke and death rates were 2.5% Ϯ 0.6% for CAS and 1.4% Ϯ 0.5% for CEA (HR, 1.88; 95% CI, 0.75-4.42; P ϭ .15). Results were better in patients aged Ͻ80 years vs those Ͼ80 years.Comment: Every reasonable analysis of government-sponsored randomized trials continues to indicate that CEA is superior to CAS for treatment of patients with symptomatic carotid stenosis if the goal of the procedure is to prevent stroke. Very significant questions remain about the treatment of asymptomatic patients. The large majority of patients undergoing carotid intervention in the United States do so for asymptomatic carotid stenosis. And yet, we really do not know the natural history of this disease in the modern era with more advanced antiplatelet mediations, statin medications, and better blood pressure control available now than was available 20 years ago. However, these medications will only be effective if the patients take them. What is needed is a three-arm trial in asymptomatic patients with carotid artery stenosis: medical management alone vs medical management combined with CEA vs medical management combined with CAS. The anticipated number of events, the number of patients required, and the number of centers required will likely be large for such a study. However, given the demographics of carotid interventions in the United States, the potential public health and economic effect of the results of such a trial would be felt immediately.

A predictive shunting instrument utilizing GCS score, lateral ventricle blood, ICP measurement, and the presence of hydrocephalus may predict those patients at risk for VPS or identify those patients requiring additional CSF drainage strategies.

The pathogenesis of sporadic amyotrophic lateral sclerosis (ALS) remains unknown. Neurophysiological studies provide evidence of hyperexcitability of the motor cortex or of impairment of inhibitory intrahemispheric modulation of the corticomotoneuron in ALS. In this paper, we used TMS to elicit transcallosal inhibition of the motor cortex in ALS patients in order to investigate whether interhemispheric inhibitory mechanisms subserved by callosal fibres are also disturbed in ALS. Twenty-five patients with ALS and 18 controls were recruited for the study. Resting Motor Threshold (RMT), Silent Period (SP) and interhemispheric inhibition (IHI) were recorded. No significant difference was detected regarding RMT or the duration of SP between patients and controls. IHI was detected in all controls. IHI was totally absent in eight patients, in another eight patients IHI did not reach a significant level and in the remaining nine patients was normal. The degree of IHI was significantly lower in ALS patients than in controls (p = 0.001). In conclusion, altered IHI in ALS patients is in line with the general pattern of reduced corticomotoneuron inhibition, being thus, one of the factors which may lead to chronic overexcitation of pyramidal cells.

Obesity may represent a significant cardiovascular risk factor even in normotensive individuals. Other predictors of LVMI were ageing and daytime PP.