No abstract

Background— Carotid angioplasty and stenting (CAS) is increasingly being used for treatment of symptomatic and asymptomatic carotid artery disease (CAD). To evaluate the efficacy of cerebral protection devices in preventing thromboembolic complications during CAS, we conducted a systematic review of studies reporting on the incidence of minor stroke, major stroke, or death within 30 days after CAS. Summary of Review— We searched for studies published between January 1990 and June 2002 by means of a PubMed search and a cumulative review of reference lists of all relevant publications. In 2357 patients a total of 2537 CAS procedures had been performed without protection devices, and in 839 patients 896 CAS procedures had been performed with protection devices. Both groups were similar with respect to age, sex distribution, cerebrovascular risk factors, and indications for CAS. In many studies the periprocedural complication rates had not been presented separately for patients with symptomatic and asymptomatic CAD. The combined stroke and death rate within 30 days in both symptomatic and asymptomatic patients was 1.8% in patients treated with cerebral protection devices compared with 5.5% in patients treated without cerebral protection devices (χ 2 =19.7, P <0.001). This effect was mainly due to a decrease in the occurrence of minor strokes (3.7% without cerebral protection versus 0.5% with cerebral protection; χ 2 =22.4, P <0.001) and major strokes (1.1% without cerebral protection versus 0.3% with cerebral protection; χ 2 =4.3, P <0.05), whereas death rates were almost identical (≈0.8%; χ 2 =0.3, P =0.6). Conclusions— On the basis of this early analysis of single-center studies, the use of cerebral protection devices appears to reduce thromboembolic complications during CAS. These technical aspects should be taken into account before the initiation of further randomized trials comparing CAS with carotid endarterectomy.

Background and Purpose Patients with internal carotid artery occlusions and highly impaired cerebrovascular reactivity have been identified as having an increased risk of stoke. It is still unclear, however, whether cerebral hemodynamics may be restored in the course of time by the development of collaterals.Methods During a 5-year period we assessed cerebrovascular reactivity in 452 carotid occlusions by transcranial Doppler CO 2 testing. Ninety-eight patients could be reinvestigated at least once after 2 to 58 months (mean follow-up time, 26 months).Results On admission, patients with recent transient ischemic attack or stroke (S3 months) as well as patients with contralateral carotid stenoses of 80% diameter reduction or greater and occlusions revealed a significantly higher incidence of impaired CO 2 reactivity (P<.0001 andP<.01, respectively). During follow-up, 64% of the patients with no or minor contralateral carotid stenoses, but only 22% of the patients with bilateral carotid occlusions, showed a spontaneous im-

No abstract

In a prospective clinical investigation of 20 patients with primary Sjögren's syndrome (SS), neurological complications, not attributable to other diseases were detected in 14 patients (= 70%). Dysfunction of the peripheral nervous system (PNS) was nearly twice as frequent as central nervous system (CNS) complications. PNS involvement was dominated by symmetric sensory neuropathies, carpal tunnel syndromes, cranial nerve palsies (above all trigeminal sensory neuropathy) and pupillary dysfunction. CNS impairment was represented by cortical atrophy (n = 4), hemiparesis (n = 1) and aseptic meningitis (n = 1). Though CNS complications were rare, psychometric testing revealed diminished cognitive capacity in 14 patients. In addition to the characteristic sicca syndrome patients suffered from musculoskeletal pain and recurring abnormal sensation which frequently lead to the misdiagnosis of functional disorders. Additionally the frequent occurrence of psychiatric symptoms such as nervosity and depression support the impression of a psychosomatic pattern with no organic basis.

Ten multiple sclerosis patients, all with a rapid deteriorating disease profile, were treated with 12 mg/m2 of the cytostatic agent mitoxantrone, administered every 3 months. This dosage is only 25% of what a patient with a solid tumour would normally receive during the same time period. In all treated patients the deterioration was stopped following the initial dosage; in four out of ten patients there was even an immediate improvement of the neurological status. Eight out of nine patients showed an improvement after 1 year as compared with their enrollment status; the other one remained stabile. In correlation with the clinical improvement, the mean P100 latencies of visual evoked potentials showed a reduction after 1 year. However, the changes identified through magnetic resonance imaging were even clearer than those seen clinically. At admission, this group of patients presented with a total of 169 gadolinium (Gd)-enhancing lesions. Only 10 lesions were enhancing in nine patients 12 months after the initiation of treatment. It appears that mitoxantrone accelerates the disappearance of Gd-enhancing lesions and prevents the development of new ones. Minimal side effects such as mild nausea and a slight faintness were evident in six patients and then for only 1-2 days.

Background: Evidence is accumulating that carotid angioplasty and stenting (CAS) might become an alternative to carotid endarterectomy (CEA) for the treatment of high-grade carotid artery disease (CAD). Evaluating the efficacy of this novel technique in single institutions in addition to performing further large trials can help to guide optimal patient management in everyday practice. Methods: In this study we compared the early outcome of 100 prospectively followed patients who underwent CAS with a retrospectively reviewed group of 142 patients that underwent CEA over the same time period. Only patients who had received pre- and postsurgical evaluations by a neurologist were included. According to the criteria set forth by the large trials the occurrence of minor or major strokes, myocardial infarction and death within 30 days was analysed. Results: Both groups had similar age and sex distributions, as well as cerebrovascular risk factors. In the group of CAS patients 63 (63%) and in the group of CEA patients 92 (65%) had a symptomatic carotid stenosis, respectively. For symptomatic patients the overall complication rate (any stroke or death) was 6.5% (3 minor and 3 major strokes) in the surgical and 8% (2 minor strokes, 2 major strokes, and 1 death) in the non-surgical group (n.s.). For asymptomatic patients there was one minor stroke (2%) in the surgical and no stroke or death in the non-surgical group. As a frequent non-neurological complication the post-procedural course was complicated by groin hematoma requiring surgery in 3 CAS patients, and neck hematoma requiring additional surgery in 3 CEA patients. Conclusions: Within our academic institution we found comparable complication rates for CAS and CEA in patients with symptomatic or asymptomatic high-grade CAD. Although these early results are promising and support the notion that CAS may become an alternative treatment option for CAD in everyday practice, the long-term efficacy of CAS has to be evaluated critically by means of further prospective studies.

Two adults presented with hydrocephalus due to idiopathic obstruction of the bilateral foramina of Monro, manifesting as clinical signs of chronically elevated intracranial pressure. No inflammation was present. The primary surgical treatment was neuroendoscopic reconstruction of the right foramen of Monro. A 37-year-old man had a spontaneous perforation of the septum pellucidum. The patient required a ventriculoperitoneal shunt, although postoperative ventriculography proved free passage of cerebrospinal fluid from the lateral ventricle into the third ventricle. A 62-year-old man underwent additional septostomy and third ventriculostomy, and the neuroendoscopic intervention relieved the presenting symptoms without additional treatment. The biopsy specimens showed no evidence of malignancy in either case. Neuroendoscopic intervention is an alternative treatment in the management of hydrocephalus due to idiopathic obstruction of the foramen of Monro. The procedure is less invasive than open microsurgical reconstruction and can even avoid ventriculoperitoneal or ventriculoatrial shunting.