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Background:  Sjögren's syndrome is a chronic autoimmune disorder that predominantly affects exocrine organs. It is characterized by an organ-specific infiltration of lymphocytes. The involvement of the major cerebral arteries in Sjögren's syndrome has rarely been reported. A recent study reported a case of successful extracranial-intracranial (EC-IC) bypass without complications, even in the active inflammatory state, although the optimal timing of such a bypass remains unclear., Case Description: We here report the case of a 43-year-old woman presenting with acute ischemic stroke due to progressive middle cerebral artery (MCA) occlusion and signs of primary Sjögren's syndrome. During intensive immunosuppressive therapy for active Sjögren's syndrome, the patient was monitored using contrast-enhanced magnetic resonance vessel wall imaging (MR-VWI). A couple of intravenous cyclophosphamide injections combined with a methylprednisolone pulse and antiplatelet therapy resulted in clear resolution of vessel wall enhancement, which suggested remission of inflammatory vasculitis. Nevertheless, she still experienced a transient ischemic attack (TIA) due to decreased regional cerebral blood flow by MCA occlusion, as demonstrated by the conventional time-of-flight MR angiography and single-photon emission computed tomography. Considering the increased risk of further stroke, the decision was made to perform an EC-IC bypass as a treatment for medically uncontrollable hemodynamic impairment. Her postoperative course was uneventful without further repeated TIAs, and continued immunosuppressive therapy for Sjögren's syndrome provided effective management., Conclusions:  Our findings emphasize the diagnostic value of contrast-enhanced MR-VWI in monitoring the effect of immunosuppressive therapy for the major cerebral artery vasculitis and in determining the timing of EC-IC bypass as a "rescue" treatment for moyamoya syndrome associated with active Sjögren's syndrome., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Acute ischemic stroke (AIS) is the third leading cause of death. Arterial stenosis is a common cause of stroke, with a high risk of recurrent stroke. Treatment guidelines for AIS and transient ischemic attack (TIA) are still under debate. Treatment guidelines for progressive stroke or crescendo TIAs do not exist. Percutaneous transluminal angioplasty and stenting (PTAS) is an increasingly attractive treatment option, whose efficacy is yet to be proven. However, stent placement poses both short- and long-term risks such as immediate ischemic events, in-stent stenosis, and stent breakage. Thus the choice of stent type is critical. We report our experience with the LEO + (Balt Extrusion, Montmorency, France) nitinol flexible self-expanding stent for the treatment of progressive cerebrovascular accident or crescendo TIAs., Methods: Twelve patients, presenting with a clinical picture of a crescendo TIA or progressive stroke in evolution not halted by optimal medical care, were treated. Patients had a corresponding major cerebral arterial narrowing and evidence of cerebral infarction on imaging. Patients were followed clinically and radiographically., Results: Twelve patients 17 to 80 years of age were treated during the study period (20 months). Sixteen nitinol flexible self-expandable stents (LEO +) were placed. All patients showed moderate to substantial improvement in neurologic functions after the procedure., Conclusion: PTAS should be considered a treatment option in case of progressive stroke or crescendo TIAs coupled with appropriate anatomical findings. This may allow for a substantial improvement in functional and neurologic status., (Georg Thieme Verlag KG Stuttgart · New York.)

Major improvements have been achieved in endovascular treatment of cerebral aneurysms during the last twenty years. Initial techniques of selective balloon occlusion were progressively replaced by controlled packing of the aneurysmal sac with soft detachable platinum-coils (GDC). In some patients with large or giant aneurysms of the cavernous portion of the internal carotid artery endovascular parent vessel occlusion therapy with balloons is still necessary. In aneurysms of the proximal paraclinoidal segment of the internal carotid artery a combined endovascular and microneurosurgical approach, the "evacuation-trapping"-technique might be helpful. In patients with symptomatic cerebral vasospasm in whom conservative therapy has failed or is not possible balloon angioplasty and or the intra-arterial infusion of papaverine has become a valuable therapeutic alternative. Further follow-up studies are necessary to assess the value and long-term results of endovascular strategies.

Hemodynamically relevant lesions of the innominate artery can be treated either by extraanatomic bypass or by intrathoracic repair. 32 patients were retrospectively evaluated after ascending aorta to innominate artery interposition graft. In all except 6 cases additional bypass-procedures to extracranial vessels were necessary for complete revascularisation. The patency rate was 100% after a mean follow up period of 871 days. Only one patient suffered from a perioperative stroke with upper extremity paresis which resolved after 2 weeks. There were 3 wound complications which required reoperation. In conclusion we believe that direct intrathoracic repair for innominate artery occlusion can be recommended as a treatment of choice with a high long-term patency rate.

The authors describe the case of a patient with transient ischemic attacks (TIAs) from the ipsilateral occluded internal carotid artery (carotid stump syndrome). The patient was submitted to surgical resection of the stump with relief of the symptoms. Thromboembolism from the stump via the anastomotic supply is responsible for the TIAs and is worsened by the blood flow turbulence at this level.

The introduction of early aneurysm surgery in subarachnoid hemorrhage in the beginning of the eighties diminished the frequency of rebleeding. However, there are some objectives against early surgery due to its supposed higher morbidity. The present retrospective data elucidates the advantage of early aneurysmal surgery. In 1990 and 1991 we treated 175 patients with subarachnoid hemorrhage, of which 9 had no vascular malformation. In 166 patients a total of 190 aneurysmal malformations could be found. Of 60 patients with preoperative good clinical grades I and II (according to Hunt and Hess) 59 patients (99%) showed good or very good results classified by the Glasgow Outcome scale (GOS). Only one patient did not survive. Even in 61% of patients with poor grade aneurysms (III to V by Hunt and Hess) the outcome was good to very good; 15 patients (14%) survived with a distinct neurological deficit (grade 3 by GOS). Only one patient remained in a vegetative state. The total mortality of these 106 patients with grades III to V (Hunt and Hess) was 24%, among them 15 patients with preoperative grade V (Hunt and Hess). Overall it can be established, that there are no definite disadvantages of early aneurysmal surgery. The benefits of early surgery are a minimized risk of rebleeding, some effects of ameliorated conditions for intensive care treatment still have to be proven. Not only patients in good clinical condition (I and II by Hunt and Hess) show a good prognosis, even for patients with poor grade aneurysms (III to V by Hunt and Hess) a very good or at least good result can be achieved in 61%.

From 250 patients suffering from cerebral ischemia who were subjected to microsurgical anastomosis STA-MCA between 1979 and 1986 there was chosen a group of patients who were examined retrospectively at a period of 1-7 years after surgery. Some patients were examined clinically at average post-operation periods of 10-20 days, several months, 1.5 year and 4 years. Results of angiography and CT examination both before and after operation were also taken into consideration. From patients examined in this way there was selected a group with less severe forms of the disease, mainly Prolonged Reversible Ischaemic Neurological Deficit, with a Completed Stroke, and next a group of patients who showed worsening of the neurological condition after operation--transient or permanent and a group of patients who died some time after operation. The results of examination were subjected to statistical analysis. On the base of this the author attempts to answer the question whether, with present diagnostic technique limited to clinical examination, angiography and CT examination, groups of patients can be selected in which operative risk will be reduced to a minimum and the result of operation will be advantageous to the patient.

There are presented the results of control clinical examination and control angiography in a group of 150 patients with signs of cerebral ischaemic syndrome. These patients were treated by superficial temporal artery - cortical branch of middle cerebral artery microneurosurgical anastomosis. Clinical and angiographic examination was carried out shortly after operation and after an extended period since operation. On the basis of these results the question of qualification of patients for operation is discussed, as well as the risk factor. The problem of long-term patency of the anastomosis of the superficial temporal artery with medial cerebral artery is discussed. Attention is directed to the influence of haemodynamic factors in extra-intracranial circulation, to the shape and other qualities of the anastomosis. This problem is discussed on the base of laws governing the flow of fluid in tubes of varying cross-section. In the opinion of the author microneurosurgical anastomosis of the superficial temporal artery and medial cerebral artery plays a large part in prophylaxis and less in treatment of cerebral vascular incidents.

Cerebral function during carotid endarterectomy can reliably be monitored using somatosensory evoked potentials (SEP). Transcranial Doppler sonography (TCD) is a noninvasive method providing on-line data about cerebral hemodynamics. The combination of both techniques during carotid surgery is helpful in evaluating the hemodynamic ("input") and the functional ("output") consequences of carotid clamping within a short time. In the present report, combined TCD and SEP monitoring early detected left hemispheric ischemia in a 68-year-old woman subjected to left carotid endarterectomy. The impairment of cerebral perfusion occurred before carotid clamping due to an intraoperative thrombosis of the left internal carotid artery as could be revealed after declamping. A temporary shunt was not inserted. Postoperatively, the patient had a new transient neurological deficit. In this case, TCD correctly indicated cerebral ischemia as confirmed by SEP recording. For carotid artery surgery, combined TCD and SEP may be helpful in detecting those patients who will profit from temporary shunting if this is not done routinely.

Surgery of the extracranial cerebral vessels nowadays under right indication and operative technique is one of the most satisfying areas of vascular surgery. Our present status of indication is shown in table 1; it should be pointed out that the classical indication is a lesion of the internal carotid artery with a Transitoric Ischemic Attack, but also in cases of progressive stroke with acute carotid occlusion the operation will be successful relentless of any time limit as long as the patient is conscious. For the extrathoracal bypass procedure we now prefer the subclavio-subclavian bypass to the formerly performed carotio-subclavian bypass.

Cerebrovascular diseases show a worldwide increase (in the U.S.A. alone about 400,000 new diseases every year) and the average age of the affected patients decreases significantly. The extra-intracranial anastomoses has proved to be a prophylactic measure for preventing a cerebral infarction after TIA and an efficient therapy for the improvement of the situation of the apoplectic patients. Since, however, in cerebrovascular diseases the donor artery is usually also affected, a modification of the method and a simplification of the surgical technique have been developed. In this modification, an interponate for bridging the cerebral vessels and the main stem of the donor artery is used and because of its optional length the region affected by the insufficient blood circulation can be directly supplied. A report is given on the technique this of method, the reduction of the duration of the operation and the effectiveness of the intervention.

The simple surgical method to correct internal carotid artery kinking is presented. The artery is straightened and fixed to the surrounding tissues without arteriotomy and without interrupting the blood flow. The technique is simple and complication-free in kinks of lesser degree.

Altogether 169 operations of patients with occlusion or stenosis of the brain arteries and brain magistral arteries are reviewed. In 151 patients the cause of disease was atherosclerosis. No one of the patients has died. According to the thorough investigation consisting of panangiography, dynamic scintigraphy, sonography, ophthalmodynamometry, CT and other clinical investigations, either extra-intra-cranial shunts (STA MCA), or endarterectomies were carried out. The indications for these operations were elaborated with regards to the cause of tandem changes in arteries or to bilateral atherosclerotic changes of the brain arteries. Out of the total 169 operations, 30 endarterectomies were performed. Only two post-surgical complications have appeared, one of them post STA MCA operation and the other after endarterectomy.

Cerebrovascular moyamoya, occurring as a result of a sudden cerebrovascular insufficiency, represents an occlusive process - usually bilateral - at the termination of the internal carotid artery and the circulus arteriosus cerebri (circle of Willis). In this disease, a web of small collateral blood vessels in the post-stenotic area is seen in carotid angiography. We report on a female of 35 years of age with moyamoya confirmed by cerebral angiography whose anamnesis was typical of the condition. Surgical treatment consisted of anastomosis from the left superficial temporal artery to a cortical artery to enhance blood flow through the moyamoya network on the left side. The anaesthetic procedure followed by us is presented as an example of anaesthetic management of all surgical interventions in patients with moyamoya. The following factors are considered to be important: Avoidance of hypertensive as well as of hypotensive phases normoventilation; sufficient protection against mental stress; closely meshed long-term supervision. (In German literature, the "moyamoya syndrome" is also known as Nishimoto-Takeuchi-Kudo-Suzuki's-disease).

The importance of brain protection in surgical handling of supra-aortic arteries may be derived from the specific nature of cerebral blood flow and from the pathophysiology of damaged cerebral vessels. There is a wide range of special protective methods which have proved to be effective, including strict observance of established rules on surgical indication and tactics, maintenance of circulatory homoeostasis, heparinisation, and use of an intra-luminal shunt. Results obtained from operations on 486 patients for occlusion of supra-aortic arteries are discussed, with particular emphasis being laid on the need for intra-operative EEG monitoring. Reference is also made to measures of brain protection in the postoperative phase.

A subclavian-steal-syndrome of a congenital origin is a rare observation. The authors report on a 27 years old female patient with characteristic symptoms. The vascular deformity consisted of a right-sided aortic arch, a right descending aorta, separate origins of the anonymous and the right carotid arteries, and an aplasia of the proximal parts of the left carotid and the left subclavian arteries. A combined dacron-venous-bypass was placed from the ascending aorta to the left arm-neck arteries and thus cerebral circulation was improved and the patient got free from symptoms. Special problems of morphology and hemodynamics are discussed on the hand of arteriograms.

Techniques of microsurgical revascularization are reviewed. A series of 5 cases, submitted to 6 anastomosis of the superficial temporal artery is presented.

At the University Hospital of Cologne-Lindenthal 260 patients underwent carotid endarterectomy during a period of 10 years. 9 patients died, representing an operative mortality rate of 2.9%. 80% of our patients with an acute stroke died. We see no indication for surgery in acute stroke. Postoperatively, 20 patients had a neurologic deficit, transient deficits occurred in 3,6% (11 patients) permanent deficits in 3% (9 patients). Carotid endarterectomy may be complicated by cranial nerve damage. The importance of these injuries is evident if bilateral carotid endarterectomy is being considered.

Diagnostic procedures for cerebral ischemia make clear strategies mandatory. Careful recording of case history, internal and neurological investigation either substantiate or make unlikely TIA and stroke. CT scan not only differentiates bleedings, tumors etc from ischemia but also can give very valuable information about the underlying vascular pathology. Multiple lacunes are characteristic of cerebral microangiopathy. Territorial and branch occlusion infarcts mostly indicate embolic occlusion of pial vessels from either cardiac or arterial sources. Endzone and borderline infarctions are seen with high grade stenosis or occlusion of the internal carotid artery. The identification of embolic sources necessitates cardiological (including echocardiography) and angiological (Doppler sonography and in selected cases angiography) investigations. Therapeutic and prophylactic measures depend on the etiology of TIA and stroke and are briefly dealt with.

Between 1982 and 1984, 181 operations of the carotid artery were performed--180 of these in primary awake patients--36 in stage I (19.9%), 72 in stage II (39.8%), 72 in stage IV (39.8%) and only one in stage III (0.6%). 144 patients (79.6%) tolerated clamping of the carotid artery very well. In 37 patients (20.4%) clamping was not tolerated (two patients, in whom the control of cerebral function was not possible, were submitted to the latter group). In three of 181 patients clamping-intolerance started at the end of operation, more than 30 minutes after clamping. Clamping intolerance in these cases was found to be confined to pulmonary and cardiac factors, no shunt was used, but operation was brought to an end as quickly as possible. Complications were present in 15 patients (8.3%), three of them resulting in death (hospital mortality rate 1.7%), 2 of them in permanent loss of function (morbidity rate 1.1%). Only in 2 patients (asystolism with consecutive successful reanimation in one case, and thoracotomy due to enlargement of surgical procedure in the other case) a primary general anaesthesia would have facilitated surgery. Surgery of the carotid artery under local anaesthesia is considered to be a guarantee for a secure intraoperative surveillance followed by a low postoperative complication rate. In a few cases more difficult surgical procedures have to be accepted in account of that.

Fifteen months after an EIAB an aneurysm spurium develop 4 mm proximal to the anastomosis. The development of the aneurysm is discussed.

62 patients with SHA were treated in the Hospital of the UNICAMP during 1984/85; all were diagnosticated with CT and/or angiography. Only 52 patients were submitted to surgery. Out of these, only 18 patients (35%) presented VS preoperatively. Until the 6th day after beginning of the hemorrhage, 34 patients non presenting VS were operated, 7 (20%) of these suffered clinical deterioration after surgery. The mortality rate lies by 23% (12 patients), 41% of them (5 patients) presented) VS preoperatively. Of the 10 patients non operated 3 died.