Reflections on the Carotid Artery: 438 BC to 2009 AD

Barnett, H. J. M.

doi:10.1161/strokeaha.109.557090

Cited by 8 publications

(4 citation statements)

References 39 publications

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“…1 This work may further benefit from the consideration of some significant historical repercussions of neurovascular disease in the ancient world. The Battle of Halule in 691 BC marked a key period in the Ancient Near East.…”

Section: Familial Stroke 2700 Years Agomentioning

confidence: 99%

Familial Stroke 2700 Years Ago

Ashrafian

2010

Stroke

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Familial Stroke 2700 Years AgoTo the Editor:I read with interest the article by Barnett that addressed the ancient descriptions of the carotid artery. 1 This work may further benefit from the consideration of some significant historical repercussions of neurovascular disease in the ancient world. The Battle of Halule in 691 BC marked a key period in the Ancient Near East. It demonstrated the complex power balance fought between the Ancient Assyrian Empire and a unique conglomeration of kingdoms that eventually became the Persian Empire (Figure).Although the Assyrians led by the biblically mentioned Sennacherib initially lost the battle, they were subsequently able to reinvade Babylon 2 years later. This had resulted from the opposing Elamite king Humban-Nimena III (rule, 692 BC to 689 BC) dying from a stroke, described as "his mouth seized so that he could not speak." 2,3 The Assyrians continued to maintain the upper hand as a subsequent Elamite leader, Humban-Haltash I (brother to Humban-Nimena III) ,also died from a stroke. 2 Although the description of stroke may have existed as early as the second millennium BC, 4 the description of the neurovascular disease in the Elamite kings is the first account of stroke within the same family Ͼ2.5 millennia ago. Such neurovascular mortality in successive Elamite kings is likely to have contributed significantly in the determination of the sociopolitical climate of that era. DisclosuresNone.Hutan

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Section: Familial Stroke 2700 Years Agomentioning

confidence: 99%

Familial Stroke 2700 Years Ago

Ashrafian

2010

Stroke

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“…Dr. Barnett went on to contribute probably more than any other single person ever has or will to the scientific understanding of carotid disease and its best treatment. 5,6 Carotid endarterectomy was reviewed in this journal in 2004, including the investigation of carotid stenosis, indications for CEA, various surgical techniques, intraoperative monitoring and anaesthetic considerations, and what was known at that time about carotid angioplasty and stenting. 7 Carotid surgery continues to be the most studied surgical procedure in the history of medicine, and in this update we will review developments and new published information over the past five years.…”

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Carotid Revascularization: An Update

O’Kelly

Butcher²,

Marchak³

et al. 2010

Can. j. neurol. sci.

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research fellow from the University of Toronto, and Dr. Hannibal Hamlin, an attending neurosurgeon at the Massachusetts General Hospital in Boston, excised the atherosclerotic origin of an internal carotid artery in a middleaged woman who had suffered an ipsilateral stroke, and then tied together the proximal and distal artery ends with an "end-to-end" vascular anastomosis. The ensuing case report did not appear in the Journal of Neurosurgery until 1958 1 , four years after the same operation, a segmental arterectomy and reanastomosis, was both performed and reported by Eastcott, Pickering and Rob from St. Mary's Hospital in London, England (the New England Journal of Medicine had a remarkably fast submission to publication time even then).2 Denton Cooley, an American cardiovascular surgeon, provided the first description of an actual carotid endarterectomy, which is plaque removal through an arterial opening, or "arteriotomy", in 1956.3 That same year the first carotid endarterectomies were performed in Canada, the first three patients diagnosed and referred for surgery by Henry Barnett, a neurologist then newly on staff at the Toronto General Hospital (TGH) with an emerging interest in cerebrovascular ABSTRACT: Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.RÉSUMÉ: Mise à jour sur la revascularisation carotidienne. La sténose symptomatique de la partie extracrânienne de la carotide interne comporte un risque élevé d'accident vasculaire cérébral ischémique à court terme, de l'ordre de 20 % à 30 % au cours des trois premiers mois. L'endartérectomie carotidienne (EAC) effectuée en temps opportun diminue efficacement ce risque, bien qu'il y ait un intérêt croissant depuis quelques années pour remplacer cette intervention par l'angioplastie carotidienne et la mise en place d'un stent (ACS), une intervention moins effractive. Dans cette mise à jour, nous revoyons les études récentes et nous faisons des recommandations sur les indications, les méthodes et le moment choisi pour l'intervention chirurgicale ainsi qu'au sujet de l'anesthésie pour l'EAC et nous rapportons les essais contrôlés randomisés publiés récemment q...

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“…Attempts to strengthen our observations by pooling data with other studies were made but have been largely disappointing. 22 There are too many dissimilarities in protocol design (including allowing "surgical discretion" to determine which patients should be randomized), rigor in confirming entry criteria and outcomes, definitions, review of all films by expert neuroradiologists, funding for confirmatory studies, and operative complications. Similarly I have become uneasy about the common practice of seeking to refine the truth by metaanalyses.…”

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confidence: 99%

“…22 Endarterectomy is a procedure that will never be free of stroke risk and should be performed only by experts or under experts' supervision. There is no existing proof that CE should be offered to asymptomatic persons.…”

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confidence: 99%

More Personal Reflections on Life Part III

Barnett

2010

Can. j. neurol. sci.

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Two parts of my recollections have been published. The first relates to my early days, how I found myself in Medical School. 1The second is a summary of what research I found myself pursuing.2 In brief summary of my research pursuits, my earliest novel scientific contribution involved the identification with Al Jousse of post-traumatic syringomyelia 3 and then the revelation that there was a fifth recognizable variety of syringomyelia. All but the type associated with spinal cord tumors depend on the subarachnoid space for its supply of intra-syringal fluid and does not arise from any ventricular communication. Later my interest shifted to stroke neurology and I had the good fortune in consort with Fraser Mustard to establish for the first time and with reasonable certainty that aspirin as a platelet inhibitor could prevent ischemic stroke. 5,6 Data from clinical trials demands careful patient scrutiny and critical review of all of their investigative studies. This resulted in two new causes of stroke being identified. First was the fact that cerebral ischemic events were occasionally caused by emboli from ulcerative lesions on prolapsing mitral valves. 7 The report of our series was much debated because cardiologists regarded the lesion readily found by echocardiography as rather common and many had not noted cerebral complications. In time pathologists and surgeons reported on the offending lesion with attached thrombi and the doubt diminished. Finally a Mayo Clinic group was able to confirm our epidemiological study. 8Prolapsing mitral valves is now recognized as an occasional cause of cerebral ischemia and one to be sought when commoner causes are not identifiable.The second recognized cause of stroke came from our observation that ischemic events may persist despite arterial (in this case carotid) occlusion. 9 The stump of an occluded artery may persist and angiography allows recognition within it of loose thrombotic material. With neuropathologist John Kaufmann we recorded the details and pathological findings in a small series of what we called The Stump Syndrome.10 A few were dealt with by surgical "stumpectomy" or stump ligation. The stroke complication rate was too high and in time we recommended albeit emperically only anti thrombotic therapy.Thirty years, the last of my practice life were now devoted to evaluating the role of surgery in stroke prevention: Cerebral bypass anastomoses were shown not to be effective 11 carotid stenosis in the range of 70-95% is the prime indication for carotid endarterectomy (CE) for men and women as reported in the "severe" phase of the NASCET study.12 Muted but definite benefit is found in patients with near-occlusion 13 and when the stenosis is 50-69% (moderate); 14 . But in women it requires other risk factors 15 . Patients with ocular symptoms alone also require other risk factors or they will not benefit. 16Symptomatic elderly males free of other organ failure are exceptionally good candidates for CE, enjoying the highest risk/ benefit ratio. 17 In symptomatic st...

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Reflections on the Carotid Artery: 438 BC to 2009 AD

Cited by 8 publications

References 39 publications

Familial Stroke 2700 Years Ago

Familial Stroke 2700 Years Ago

Carotid Revascularization: An Update

More Personal Reflections on Life Part III

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