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In a couple of recent randomized trials, the benefits of unilateral carotid endarterectomy (CEA) have been reevaluated in symptomatic patients with severe stenosis. In contrast, the operative indication, procedure, and perioperative management of bilateral CEAs for patients with bilateral carotid artery stenosis are still controversial. In this report, we reviewed 7 patients who underwent bilateral CEAs at out institute during the last 10 years, with regard to the clinical feature, angiographical findings, operative procedure, surgical results and long-term prognosis. The patients ranged from 52 to 73 years in age, and included six males and one female. Clinical symptoms were asymptomatic in 1 patient, transient ischemic attack in 2, reversible ischemic neurological deficits in 2, minor completed stroke in 1, and major completed stroke in 1. The angiographical carotid artery stenosis in the dominant side of symptomatic cases was 50% in 3, 70% in 1, 90% in 2, and ulceration in 4 cases. The stenosis in the non-dominant side of symptomatic cases was 60% in 1, 70% in 3, 90% in 2, and 4 cases with ulceration. One case among the asymptomatic cases had bilateral 80-90% stenosis. We staged bilateral CEAs, in the dominant side first except in one case among the symptomatic cases and on the more severely stenotic side first in the asymptomatic cases. During CEA, an external shunt was placed in 1 case, but no internal shunt was used in any of the cases. Perioperative complications were found in 2 patients, transient bilateral hypoglossal nerve palsy and local hemorrhage in the other case. Totally, all of 7 cases (14 consecutive CEAs) have been performed with satisfactory results. No mortality and no permanent morbidity has resulted. In the follow-up period (mean: 38.3 month), 1 patient was found to have developed cerebral infarction in the ipsilateral carotid artery territory. From our own small experience and from that in the literature, CEAs for bilateral carotid artery stenosis should be performed in the dominant side first. Then, after a certain period, from 2 to 6 weeks, the CEA should be performed in the non-dominant side.

Eleven patients with chronic subdural hematoma (CSDH) with bleeding tendency (BT) were surgically treated in the last 12 years. To study the clinical problem of CSDH with BT, 11 surgical cases were divided into 3 groups, Group A; CSDH with primary BT (1 case of hemophilia A), Group B; CSDH with BT secondary to a basic disease (3 cases of leukemia, 2 cases of malignant tumor with DIC, 1 case of chronic renal failure and 1 case of liver cirrhosis), Group C; CSDH with BT by anticoagulants (warfarin) (2 cases of replacement of mitral valve, 1 case of A-C bypass). Evacuation of the hematoma was performed by means of one or two burr holes with irrigation of the hematoma cavity and a drainage tube was placed in the subdural space. The outcome was excellent in Groups A and C. In Group B, two patients with DIC due to gastric cancer and prostatic cancer died, and 3 patients with leukemia recovered dramatically from CSDH, but the poor course of the disease itself resulted in death. The outcome of other patients in Group B was excellent. Since CSDH with BT is often fatal, those patient had usually been treated conservatively. However, from this analysis, we stress that CSDH with BT should be surgically treated after checking the blood conditions carefully to determine whether or not the patient has need for surgery.