Concerning progression of carotid disease after endarterectomy

Abstract

palsy (PSP). Although we did not discuss this particular neuro-ophthalmologic sign, we had observed apraxia of eyelid opening [I], eyelid closure [ 5 ] , or both in 5 of 25 patients with PSP. These patients were unable to either open or close their eyes to command despite normal eyelid tone and strength but were able to do so reflexively or spontaneously. Onepatient, a 77-year-old man with a twelve-year history of PSP, had both disabling apraxia of eyelid opening and apraxia of phonation. During the past two and one-half years he has been unable to phonate voluntarily or to command, but according to his wife he speaks clearly and loudly during sleep. This was confirmed during a sleep study, which also revealed moderate central and obstructive sleep apnea. Direct laryngeal examination revealed normal function of vocal cords, however. On a detailed apraxia test battery, he had only slight orolingual apraxia and was able to "mouth" words well, but was unable to phonate.The mechanism of apraxia of eyelid opening and of phonation in PSP is unknown. Perhaps it relates to "freezing" or "start-hesitation" manifested by slowness of initiation of movement. The term akinesia of eyelidfunction was suggested by Cogan and Goldstein [I}. This eyelid abnormality should be differentiated from blepharospasm resulting from involuntary forceful contraction of orbicularis oculi, which also is seen in PSP and other extrapyramidal disorders 13, 41. In addition to eyelid abnormalities and supranuclear vertical gaze palsy, patients with PSP show other important neuroophthalmologic signs such as impaired fast component of optokinetic or caloric-induced nystagmus, reversal of normal eyes-closed preponderance of caloric-induced nystagmus, hypometric and bradykinetic saccades, ocular fixation defect with square-wave jerk, "cogwheel" pursuit, and internuclear ophthalmoplegia. In early stages of the disorder, oculocephalics, calorics, Bell's phenomena, and lateral eye movements may be preserved, but as the disease progresses, in addition to the supranuclear eye abnormalities, patients may develop nuclear ophthalmoplegia. Although recognition of these neuro-ophthalmologic abnormalities is helpful in differentiating PSP from idiopathic Parkinson's disease and other neurodegenerative disorders, similar eye abnormalities have been reported in otherwise typical parkinsonian patients [Z]. 3%). Until now, nearly all vascular treatment centers have found the average annual stroke rate on the operated side significantly reduced when compared with that on the nonoperated side. In the small series of Norrving and colleagues, the fact that stenosis recurred ten times more frequently than in other published series leads one to suspect that surgical technique may be the main causative factor in these disappointing results. Reliable information and data regarding the spontaneous course of carotid artery disease are readily available. In the 04 patients of Norrving and colleagues, both the average annual incidence of stroke and the postoperative progression ...