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Cerebral MRI with angio-MR are more effective than CT scan for selecting patients with ischemic stroke for thrombolysis. The use of cerebral MRI has to be available 24h a day and everyday as a standardized emergency procedure. Off-label criteria for thrombolysis after acute ischemic stroke are too restritive and have to be revised. In acute ischemic stroke, imaging that shows the collateral circulation within the hypoperfusion area has to be used to estimate the potential of therapeutic revascularization. When there are contraindications for intravenous thrombolysis, the endovascular approach must be argued individually by neurologists and neurointerventionalists together., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

We describe a case of a young patient admitted for recurrent ischemic stroke caused by a papillary fibroelastoma of the mitral valve and a hyperhomocysteinemia. A papillary fibroelastoma is a benign cardiac tumor which can be associated with serious embolic complications. A moderate plasma level of hyperhomocysteinemia is considered as a risk factor of ischemic stroke. The authors suggest that this association increases the risk of ischemic stroke in their patient. The tumor was surgically removed to avoid new embolic events associated with a vitamin B supplementation. After surgery and acid folic supplementation, no recurrence was observed.

Aim of the Study: Retrospective evaluation of the immediate and mid term mortality and morbidity of carotid surgical revascularisations in a population of octogenarians with severe carotid artery stenosis., Material and Method: Retrospective study of all patients 80 years old and more, consecutively operated for an internal carotid artery stenosis, from January 1991 to December 2003, in the Unit of Vascular Surgery of the Civil Hospices of Strasbourg. We analyzed the perioperative death and stroke rates at 30 days and the mid term survival., Results: We performed 81 carotid revascularisations on 70 patients. The mean age of the population studied was 83.5 (+/-2.8 years), (range 80-92). Twenty-four stenoses (29.6%) were symptomatic (23 transient ischemic accidents, 1 stroke), and 57 stenoses (70.4%) were asymptomatic. The mean degree of stenosis was 89.2+/-8.1% (based on NASCET evaluation). The main cardiovascular risk factor was arterial hypertension (95.7%). The overall perioperative death and stroke rate was 7.1%: 2 deaths, one of them related to a stroke, and 3 strokes (confidence interval: 2.4-15.9%). The perioperative death and stroke rate in the symptomatic stenosis group was 0%, and 8.8% in the asymptomatic stenosis group (p=0.163). No specific risk factor of neurologic events has been found except ASA 3 or higher (RR: 3.84 [1.2-12.1]). The mean follow up was 3.6 years (range 2-11.3), no patient was lost to follow-up. The Kaplan-Meier 5-year survival was 52%. The mean time to death was 3.5 years after the operation. Only 16.7% of these deaths were stroke-related., Conclusions: Multicentric prospective studies, which have determined current recommendations for carotid surgery, did not include patients aged 79 years and older. In this particular population, the good results observed in our institution in the symptomatic carotid stenosis group would support the use of surgical treatment. The perioperative death and stroke rate observed for the asymptomatic group, clearly superior to current recommendations, suggests in our experience and especially for ASA> or =3, an individual evaluation to determinate the best indication.

Intraluminal clot of the internal cervical carotid artery is commonly thought to require emergency surgery: 7 intraluminal clots specially threatening (6 of whom had a long defect--15 mm and more) are demonstrated by intraarterial digital angiography--4 patients experienced mild stroke, 3 major stroke. 3 of whom had previous recurrent T.I.A. (3 transient blindness, 1 hemispheric TIA). Carotid angiography identified 3 severe atherosclerotic stenosis, 3 ulcerated plaques and 1 dissection. One patient with coma carus died quickly. Anticoagulation therapy (6 cases) was made, 4 weeks along, without neurologic complications. Follow-up angiograms showed total resolution (4 cases), partial lysis (1 case) and mild extension (1 case). Delayed endarterectomy was made only for severe carotid atherosclerosis (5 cases). In our experience, intraluminal clot of the carotid artery may not be a surgical emergency but require anticoagulant therapy and delayed surgery if major underlying lesions.

The authors describe the results obtained in a series of 65 patients following extra-intracranial cortical anastomosis. The best indications for this procedure are transitory ischemic accidents which cannot be approached by the direct cervical route. Cases of prolonged or definitive vascular accidents and more especially localized lesions also gave valuable results but these depend upon the condition of the cerebral parenchyma which must be carefully evaluated.

The authors report a series of 135 patients treated between 1984 and 1987, for a ruptured intracranial saccular aneurysm in the Department of Neurosurgery at the Lariboisiere Hospital. The value of C.T. scan and cerebral blood flow measurements (C.B.F.) in predicting the development of vasospasm was studied on 99 cases. The analysis confirmed that the C.T. Scan findings are closely related to vasospasm. A low C.B.F. between the fourth and the eight day following the bleeding was significantly associated with the development of delayed cerebral ischaemia. On the contrary, no relation was found between vasospasm and the C.B.F. measured during the three days following the bleeding. The authors propose to operate without delay on clinical grounds on patients referred during the first three days after the hemorrhage and to decide, on clinical and C.B.F. data, the timing of the intervention for patients admitted after this data, i.e. 35% of their patients.

Unlabelled: Extra-intracranial by-pass between a branch of the external carotid artery and a branch of middle cerebral artery has been used since 1972 in the treatment of cerebral ischemia., Material and Methods: 40 patients have been operated on (34 men and 6 women) aged from 28 to 68. Clinical data were TIA's or PRIND in 11 patients and stroke in 29 patients. The left hemisphere was involved in 25 cases and the right one in 15 cases. No patient was operated on in emergency; operation was performed after 2 or 3 weeks in most cases. The branch of external carotid artery was the superficial temporal artery in 36 patients and the occipital artery in 4 patients. As for the cerebral artery, were used the anterior temporal artery (9), the middle temporal artery (2), the posterior temporal artery (15), the angular artery (6), a frontal artery (15) and a parietal artery (1). In 8 patients, two anastomosis were performed using both branches of STA. Patency of the by-pass was confirmed in most cases by means of angiography, performed early after operation, and if possible one year later.

Extra-intra-cranial anastomosis introduced in 1967 by Yasargil and Donaghy consists in using a branch of the external carotid artery to anastomose it on one of the cerebral cortex. This procedure is indicated when there exists an obliterating lesion not in reach of a local technique. On clinical grounds two situations may exist: --the first is a regressive ischemic episod and the operation is then preventive; --the second is a confirmed deficit, non regressive: thecurative value of such an operation must then be discussed. The author reports his 5 year experience: 51 patients were operated amounting to 60 anastomoses. Eighty percent of the operated patients have a patent anastomosis. The operative risk is small (1 death, 1 worsening). The clinical criteria are discussed (Acta chir. belg., 1979, 78, 85-93).

This is a report about the author's surgical experiences with extra-intracranial anastomosis. Special attention is drawn to various technical measures for avoiding postoperative complications. It seems very important to leave around the temporal superficial artery a mantle of connective tissue to preserve the vascular supply of the vessel wall and to facilitate safe manipulation of the artery. Further more the report deals with the bloodflow direction in the temporal superficial artery in relation to the middle cerebral artery- the flow should be directed to the trunk of the middle cerebral artery in order to effect an optimal perfusion of the supplying area of the middle cerebral artery. Approx. 8 to 10 mm should hold the incision in both arteries, end of temporal superficial and side of middle cerebral, to attain a wide opened junction between both arteries and to prevent obstruction. Attention is called to the risk of skin necrosis when using both, frontal and parietal branches of the temporal superficial artery. High value is set on covering the bone and dura deficiency with muscle lobe to prevent spreading and fistula of cerebral spinal fluid.

When a physician is faced by a patient suffering from transient ischemic attacks, the diagnosis is almost invariably determined by the clinical history. It becomes necessary to eliminate certain other medical conditions including migraine, focal epilepsy and cardiac disorders. Once he is satisfied with the diagnosis of TIA, then he must consider whether to employ medical or surgical therapy or a combination of both. It must be recognized that TIAs are not benign events since more than 50 p. 100 of individuals who develop completed strokes will have antecedent TIAs. Identification of the pathogenetic mechanism becomes important in choosing the specific therapy. Where the origin of the attacks is clearly thromboembolic, secondary to atherosclerosis, surgical intervention may be appropriate if the lesion is readily accessible. However, consideration of surgery is also determined by the risk of post-operative stroke or death at the hands of less experienced surgeons. The risk of stroke in a patient who is having frequent TIAs may be reduced initially by utilizing anticoagulants for a limited period. Long-term medical therapy requires the use of anti-platelet agents which have been shown to have a more beneficial effect in preventing strokes in men. The evidence for protection in females is less satisfactory. Surgical treatment should be followed by long-term medical therapy since it is very unlikely that only one lesion is present in a high-risk patient. It is still clear that the best way to manage cerebro-vascular accidents is to prevent them. This requires education of the public, as will as physicians, with respect to risk factors and the value of various modes of therapy.

40 temporo-sylvian anastomoses were controlled using Doppler ultrasonic examination. The results are compared to post-operative arteriograms. The Doppler examination has proved to be highly accurate when compared to contrast arteriography in the survey of extra-intracranial anastomosis. This non invasive procedure can easily be repeated. However the size of the revascularized area cannot be estimated. The simultaneous isotopic studies of regional cerebral blood flow could provide a means of quantifying the results of the anastomoses.

The introduction of vascular micro-surgical techniques has allowed to treat cerebral ischemia, through extra-intra-cranial anastomosis, when the causative arterial lesions have a surgically unfavorable location. Thirty patients underwent brain revascularization through extra-intra-cranial micro-anastomosis between the superficial temporal artery (branch of the external carotid artery) and a cortical branch of the middle cerebral artery. Twenty five patients had definite sensitive and motor deficits. Five patients, on the other hand, underwent preventive surgery because of transient cerebral ischemia. In our series, the global rate of the microanastomosis patency is 78%. When the anastomosis is patent, 85% of the cases with motor deficits are cured or improved. The results are even more favorable in case of transient cerebral ischemia, for the anastomosis in such cases was always patent. None of these later patients had ischemia attacks with a one-year follow-up.