We analyzed perioperative strokes in 658 carotid endarterectomies with the purpose of explaining the pathogenesis from the morphologic aspect of the infarct on cerebral computed tomograms. All endarterectomies were performed with continuous electroencephalographic monitoring. Of the 42 ischemic strokes (6.4% of all endarterectomies), 34 could be studied. Seven infarcts were hemodynamically induced (five watershed infarcts, two patients with bilateral ischemia); all seven occurred during surgery. Twenty-three of the remaining 27 infarcts were within the territory of the middle cerebral artery (20) or anterior cerebral artery (three) and were probably of thromboembolic origin; 13 of these 23 occurred during surgery (57%). If intraoperative stroke was heralded by permanent electroencephalographic changes, these were not related to the moment of cross-clamping. In four patients the computed tomogram was normal. We believe these facts favor the hypothesis that thromboembolism is the most important factor in the pathogenesis of perioperative stroke associated with carotid endarterectomy under conditions of optimal cerebral monitoring. (Stroke 1989;20:324-328)
To determine the hemodynamic and clinical consequences of an atherosclerotic obstructive lesion of the innominate artery on the cerebral circulation, 20 patients with an innominate artery lesion underwent neurologic examination and ultrasonic duplex scanning before and after right arm exercise. The patients were divided into two groups: Group 1, 12 patients with 40-80% stenosis and Group 2, eight patients with 80-100% stenosis. A significant difference between the groups was noted in both the hemodynamic and clinical manifestations. All 12 Group 1 patients compensated for the increased demand for blood of the right arm through the innominate artery itself, and only one showed symptoms of vertebrobasilar insufficiency associated with right arm exercise. In all eight Group 2 patients, compensation through the innominate artery failed; six (75%) showed symptoms of vertebrobasilar insufficiency after exercise. Dynamic duplex scanning is well suited to investigate stenotic lesions of the innominate artery, the effects of arm exercise on the development of cerebral symptoms, and the source of blood flow to the arm. Dynamic duplex scanning proved to be useful in selecting patients who may be candidates for direct arterial surgery. (Stroke 1988;19:958-962)
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