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The authors report the utility of the Echo-doppler and Doppler CW exams before and after the surgical therapy of the chorioretinal and optic nerve's hypoperfusion conditions. They have studied 112 patients affected by these pathologies and evaluated the blood flow's modifications. This exam is even usefull for the patient's selection before surgery without any serious complications.

Carotid endarterectomy is the most frequently employed surgical intervention in the treatment of strokes due to atherosclerosis obstruction of the blood flow in extracranial carotid district. The presence of cerebrovascular clinical symptoms is accepted indication for surgical treatment. For the patients without symptoms there is, however, not yet a complete agreement on the treatment modalities. The authors believe that, due to the low morbidity and mortality of carotid endarterectomy, a surgical approach can be used in patients in which is present a degree of stenosis > 75% and, moreover, in patients where the degree of stenosis is > 50%, but in which the atherosclerotic plaque is non homogeneous due to the presence of ulceration or hemorrhage. Non invasive ultrasonic techniques constitute the mainstay of the diagnostic procedures for carotid artery disease and in recent years they have led to improved sensitivity and ability in differentiating between the operable carotid stenoses and the inoperable obstructions. With these techniques it is possible to arrive to a 90% diagnostic accuracy. Also the recently introduced angio-RM has comparable results, but the high costs do not make it possible to use it in screening procedures. Many doubts are present regarding the possibility of evaluating the occurrence of neurologic deficits during the surgical procedures. Local anaesthetic techniques are somewhat popular among vascular surgeons in that they allow an immediate evaluation of the neurologic activity of the patients during surgical treatment. However reports have been published in the literature of neurologic deficits arising after the period of test occlusion.

Subclavian steal syndrome and innominate steal syndrome are well-known reasons of cerebral vascular insufficiency. Today this pathology can be corrected by extra-anatomic by-passes. In our experience in recent years (1980-1986) these by-pass (in our patients carotid-subclavian and subclavian-subclavian by-pass) gave very good outcomes. These are simple and poor-risk operations. Their patent after many years is very good.

From March 1980 to March 1987, at the Department of Vascular Surgery of the University of Padua, 217 patients underwent 252 carotid revascularizations with routine use of an intraluminal shunt (IS) for symptomatic (70%) or asymptomatic (30%) internal carotid artery (ICA) atherosclerotic stenosis. All carotid endarterectomies (CEs) were routinely performed with patch graft angioplasty to prevent restenosis. In the immediate post-operative period, no patient presented permanent or transient neurological deficits; no patient died. In the early post-operative course there was a 0.9% (2 patients) stroke rate and 0.4% (1 patient) mortality rate. These results suggest that the selective use of the IS on the basis of EEG changes is able to reduce the perioperative morbidity and mortality to nearly zero.

Carotid endarterectomy (CE), when performed in patients with previous stable stroke followed by complete or almost complete recovery, seems to be affected by a higher peroperative risk. From January 1982 to March 1988, we performed 230 CE in 207 patients, 188 (81.8%, Group 1) in patients with TIA or an asymptomatic plaque and 42 (18.2%, Group 2) in patients with previous strokes. The need for a temporary indwelling shunt has been evaluated with the measurement of carotid back pressure and, in the last 100 CEE, with the monitoring of somatosensory evoked responses (the shunt has however been used routinely anyway in the very first part of our experience). The incidence of carotid back-pressure values and of positive somatosensory evoked responses were similar in the two groups of C.E., even if the differences in the prealable evaluation were not statistically significant. The shunt has been nevertheless used more frequently in Group 2 (40.5 vs 28.2%). Statistical analysis has been performed with the chi 2 method. The incidence of permanent and transient neurologic deficits and of the peroperative mortality due to neurological and non-neurological causes was, respectively, 0.5, 2.6, 1.6, 0% (Group 1) and 2.4, 7.3, 2.4, 2.4% (Group 2) (non-significant). If we exclude the first 50 operations (in which technical and/or anaesthesiological problems may have influenced the neurological outcome of the patients operated upon), the previous values become, respectively, 0,07*, 0,7, 0% (Group 1) and 0, 5,5*, 0, 2,7% (Group 2) (*p less than 0,01, the only significant difference).(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative changes of blood pressure in carotid artery surgery is frequently observed. The Authors, on the base of a review of the literature and examining their own experience related to a consecutive series of 40 cases verify the incidence of this event. Different modality in the onset of postoperative hypertension and hypotension are evaluated. The risks of neurological complications due to the acute hemodynamic modifications are considered.

Arterial hypertension as a consequence of carotid endarterectomy is a relatively frequent event and potentially dangerous because of the development of central postoperative neurological deficiency. The main pathogenetic theories are reviewed, with reference to hypotensive phenomena and preventive action also. Stress is laid on the importance of recognising potential risk factors, such as the use of anaesthetics which interfere with cerebral flow self-regulation mechanisms, diabetes and atherosclerosis.

In patients with cerebral transient ischemic attacks or stroke myocardial infarction is the leading long-term cause of death. Despite the importance of coronary artery disease, patients with cerebrovascular insufficiency are seldom evaluated for the detection of ischemic heart disease and usually the cardiological evaluation is limited to the patients with angina or previous myocardial infarction. In order to identify asymptomatic coronary artery disease 74 consecutive patients with cerebral ischemia, and without symptoms or electrocardiographic signs of ischemic heart disease, underwent a maximal exercise treadmill test according to the Bruce protocol. An exercise Thallium myocardial scintigraphy was performed in patients with positive exercise test. A control group of 74 asymptomatic subjects underwent the same study protocol. The study population (Group I) included 57 men and 17 women; the age ranged from 22 to 72 years (mean age 54 years). An adequate exercise test was obtained in 67 patients. Exercise test was positive (ST-segment depression greater than or equal to 1.5 mm) in 19 cases (28%). The end points were exhaustion in 15 patients, ST-segment depression greater than 3 mm in 2 and systolic blood pressure greater than 240 mmHg in 2. The exercise Thallium myocardial scintigraphy was normal in 2 and abnormal in 17: reversible perfusion defects were detected in 12 cases and fixed defects in 5. In the control group (Group II), comparable for age and sex, exercise test was positive in 4 cases (5%; p less than 0.01 percentage of positive exercise tests in Group I vs Group II); the exercise myocardial scintigraphy was normal in 1 and abnormal in 3 subjects.(ABSTRACT TRUNCATED AT 250 WORDS)