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We report the outcomes of prophylactic cerebral reconstructive surgery aimed at reducing the incidence of perioperative cerebral infarction in patients with intracranial or extracranial occlusive cerebrovascular disease who were scheduled to undergo cardiac surgery. Before the surgery, carotid artery ultrasonography, magnetic resonance angiography (MRA) of the carotid artery, and magnetic resonance imaging (MRI) and MRA of the brain were performed on 875 patients. The high-risk group was defined as: patients with cervical carotid artery stenosis of at least 90%, those with a reduced cerebral perfusion reserve because of occlusion of the internal carotid or middle cerebral artery, and those with a reduced cerebral perfusion reserve because of major intracranial artery stenosis of at least 75%. According to the degree of cardiac reserve, patients in the high-risk group underwent carotid artery stenting (CAS), carotid endarterectomy (CEA), superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, or percutaneous transluminal angioplasty (PTA). Of the 875 patients, 29 (3.3%) were classified in the high-risk group, and 16 underwent prophylactic revascularization and cardiac surgery. Prophylactic revascularization included CAS in 7 patients (including stenting of the intracranial internal carotid artery in 1 patient), CEA in 4, STA-MCA in 4 and PTA in 1. Cardiac surgery was performed on 870 of the 875 patients, and perioperative cerebral infarction occurred in 11 (1.3%). It is uncertain whether our treatment strategy significantly reduced the incidence of perioperative cerebral infarction because of the lack of accurate information on the number of patients with this condition before the present study. However, 73% of patients had a score of 1 or 2 on the modified Rankin Scale 1 month after the onset of cerebral infarction, suggesting that our strategy improved the outcome.

We review our recent experience of carotid endarterectomy (CEA) for 30 patients with severe carotid artery stenosis. In this report, we emphasize the importance of critical management before, during, and after surgery to reduce or remove the incidence of perioperative complications. Especially, we should carefully manage the patients who are at higher risk for hyperperfusion syndrome and those with complications of serious coronary artery disease. We also describe our surgical technique and results.

We analyzed overall outcome after surgical revascularization in 149 patients with moyamoya disease. Of 61 childhood patients, 58 (95.1%) have not experienced further ischemic episode during follow-up periods. Postoperative angiograms showed well-developed collaterals via STA-MCA anastomosis and indirect synangiosis. Total IQs were significantly lower in childhood patients who had cerebral infarction at onset. Of 40 adult patients with ischemic-type moyamoya disease, 35 (87.5%) have not experienced further episodes of stroke. However, 3 (7.5%) patients had cerebral infarction in the contralateral side or in the vertebrobasilar territory, and 2 (5.0%) suffered intracranial bleeding during follow-up periods. Of 34 adults who underwent bypass surgery for hemorrhagic-type moyamoya disease, 7 (20.6%) developed rebleeding. Statistical analysis revealed that STA-MCA anastomosis combined with indirect synangiosis may significantly reduce the risk for rebleeding. Clinical strategies should be decided for adult patients with asymptomatic moyamoya disease.

We review our 15 years of experience with patients with carotid artery stenosis to clarify the incidence of coronary artery disease. Of 197 patients who underwent carotid endarterectomy (CEA) since 1985, 16 (8.1%) had coronary artery disease that required treatment. Eleven patients could safely undergo staged treatments of CEA and coronary artery bypass graft (CABG)/percutaneous transluminal coronary angioplasty (PTCA). Four patients, however, underwent simultaneous CEA and CABG, because both carotid and coronary artery diseases were too serious for safe staged surgery. We present the detailed medical records of these 4 cases. All had tight (more than 90%) stenosis of the internal carotid artery (ICA) and 2 or 3 branches of the coronary artery. They experienced TIA or minor completed stroke as well as unstable angina. One patient also presented chronic heart failure due to severe myocardial ischemia. We performed CEA and then CABG. Would closure was done after all surgical procedures to avoid bleeding due to intraoperative heparinization. Postoperative courses were uneventful in all 4 patients. We performed carotid stenting preceding simultaneous surgery with contralateral CEA and CABG for 1 patient who had bilateral severe carotid stenosis.

We report 32 female patients in whom moyamoya disease was diagnosed when they were younger than 14 years old. Of these, 29 patients underwent bypass surgery during childhood. Two patients became pregnant at the age of 21 and 22, respectively. Careful follow-up was performed to avoid toxemia, hypertension and excessive increase in body weight. MR angiography revealed well-developed collateral flow through the operated extracranial carotid artery system and no moyamoya vessels. Blood flow study, performed prior to pregnancy in 1 case, showed preserved blood flow and reactivity to acetazolamide. Delivery was uneventfully performed through Cesarean section under general anesthesia at full term. Three other patients underwent bypass surgery when they were older than 20 years old. Of these, 1 became pregnant and uneventfully had a normal delivery. We discuss the clinical problems in managing pregnant patients known to have moyamoya disease prior to pregnancy, suggesting strategies for these patients.

We describe 4 patients with spontaneous dissecting aneurysm of the intracranial vertebral artery, which presented with headache and neck pain as the only manifestation. The onset of headache and neck pain was gradual in all patients. Pains were distributed to the unilateral posterior head and neck region and were pulsating in 2 patients (50%) and steady in 2 patients (50%) and lasted for several minutes to several hours. The pains sometimes waxed and waned. The pains of the same kind appeared repeatedly. MRA was useful for detecting the vertebral artery abnormalities, such as string sign and aneurysmal dilatation. One patient was treated surgically because of refractory pain. The other patients were treated nonsurgically, i.e. bed rest and pain control. Follow-up MRA demonstrated healing of the dissection.