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The midurethral sling has emerged as an effective, minimally invasive treatment for patients with stress urinary incontinence. Bladder penetration is a known complication that, if unrecognized, may result in retained intravesical mesh. This rare complication can cause patient discomfort as well as become a nidus for infection and bladder calculi. Because of the technique of sling passage, the site of retained sling material is often along the anterior bladder wall, making evaluation and treatment via traditional retrograde cystoscopy prohibitively difficult. We describe a novel and minimally invasive method to remove the sling material using antegrade access into the bladder in conjunction with holmium laser vaporization. In our series of six patients in whom retrograde cystoscopic treatment had failed, all were successfully treated with antegrade cystoscopy and reported improved urinary symptoms. This new technique provides a simple, minimally invasive, and effective method for removal of exposed sling mesh.

Erosion and rupture of surface layers in atherosclerotic plaque can cause heart attack and stroke; however, changes in luminal surface composition are incompletely defined. Laser-induced fluorescence spectroscopy (LIFS), with limited tissue penetration, was used to investigate the surface of unstable carotid plaque and correlated with microscopy, birefringence and gene expression. Arterial matrix collagens I, III and elastin were assessed in unstable plaques (n = 25) and reference left internal mammary arteries (LIMA, n = 10). LIFS in addition to selective histological staining with picrosirius red, Movat pentachrome and immunostaining revealed decreased elastin and increased collagen I and III (P < 0.05) in carotid plaque when compared with LIMA. Within plaque, collagen I was elevated in the internal carotid region versus the common carotid region. Polarized light microscopy detected layers of aligned collagen and associated mechanical rigidity of the fibrous cap. Microarray analysis of three carotid and three LIMA specimens confirmed up-regulation of collagen I, III and IV, lysyl oxidase and MMP-12. In conclusion, LIFS analysis coupled with microscopy revealed marked regional differences in collagen I, III and elastin in surface layers of carotid plaque; indicative of plaque instability. Birefringence measurements demonstrated mechanical rigidity and weakening of the fibrous cap with complementary changes in ECM gene expression., (© 2011 The Authors. Photochemistry and Photobiology © 2011 The American Society of Photobiology.)

Objective: To determine current practice patterns, we mailed a questionnaire regarding urethral stricture evaluation, treatment, and follow-up to members of the American Urological Association (AUA). The minimally invasive methods used for treating and evaluating anterior urethral strictures vary widely among clinicians., Methods: A nationwide survey of practicing members of the AUA was performed by mailed questionnaires. Surveys were mailed to 1262 Urologists, randomly selected from all 50 states. Four-hundred thirty-one urologists (34%) completed the questionnaire and formed the basis for our analysis., Results: Most urologists (63%) treat 6-20 urethral strictures per year. The most common minimally invasive procedures used for managing anterior urethral strictures were dilation (92.8%), cold-knife optical internal urethrotomy (85.6%), endourethral stent (23.4%), laser urethrotomy (19%), and periurethral steroid injection after urethrotomy (7.9%). Most urologists will perform urethrotomy on bulbar strictures up to 2 cm (68.7%) and leave a Foley catheter in place for 1 week or less (86.5%). Technical method of urethrotomy is commonly 1 cut at 12 o'clock (86.3%) or radial cuts (12.1%). Recommended follow-up diagnostic tests after urethrotomy included flow rate (62.9%) and, to a lesser degree (with roughly one-third each), cystoscopy, urethral calibration, and the International Prostate Symptom Score (IPSS). Other tests, such as ultrasonography or urethrography were rarely used., Conclusion: Our survey provides information regarding current minimally invasive management and follow-up practice strategies recommended by members of the AUA for anterior urethral strictures. Many common practices in the treatment of anterior urethral stricture disease are not supported in the literature., (Copyright © 2011. Published by Elsevier Inc.)

Purpose: Voiding cystourethrogram is an invasive test that evokes anxiety. Our primary aim was to determine whether midazolam is beneficial in decreasing anxiety in children who undergo voiding cystourethrogram. Secondary aims were an examination of parent anxiety, health care professional perceptions and post-procedure behavioral outcomes in children after voiding cystourethrogram., Materials and Methods: A total of 44 children were randomized to placebo or oral midazolam before voiding cystourethrogram in double-blind fashion. The Modified Yale Preoperative Anxiety Scale was used to evaluate child behavior before and during voiding cystourethrogram, and the Post Hospitalization Behavior Questionnaire was used to investigate any short-term and intermediate-term behavioral outcomes. The State-Trait Anxiety Inventory was used to evaluate parent personal anxiety during voiding cystourethrogram. A separate questionnaire was administered to radiology staff. Statistical analysis included the 2-sample t and Fisher exact tests., Results: There was no difference in Modified Yale Preoperative Anxiety Scale scores in children randomized to midazolam or placebo. There was also no significant difference in parent anxiety. Radiology care providers identified no reliable benefit when blinded to sedation vs placebo. We did not note any post-procedural behavior issues after voiding cystourethrogram at up to 6 months of followup., Conclusions: Midazolam may not significantly help with child or parent anxiety during voiding cystourethrogram. No reliable benefit was noted according to radiology health care provider perception and there was no significant post-procedural behavior benefit. Midazolam may not provide a significant benefit in decreasing anxiety during voiding cystourethrogram., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: The prevalence of sexual problems among resident physicians has not been investigated., Aim: To explore the sexual behavior of residents and fellows in training and to determine the incidence of sexual dysfunction in this population., Methods: Residents and fellows at our institution were invited to complete a demographic questionnaire, as well as two to three gender-specific validated instruments for the assessment of human sexuality., Main Outcome Measures: The validated survey instruments selected were the International Index of Erectile Function (IIEF), the Index of Premature Ejaculation (IPE), and the Self-Esteem and Relationship Quality (SEAR) survey for male residents, and the Female Sexual Function Index (FSFI) and the Index of Sex Life (ISL) for female residents. Results were compared with established normative data and validated cut-off scores that were available. Pearson correlation coefficient was used to assess for relationships between variables., Results: There were 180 responses (83 female, 97 male, mean age 29 years), for a response rate of 20%. Among men, 90%, 67%, and 98% were in a relationship, married, and heterosexual, respectively. Among women, the same numbers were 80%, 55%, and 96%, respectively. Based on validated cut-off scores for the IIEF and FSFI, 13% of men reported ED (3% reported mild ED, 4% reported moderate ED, and 6% reported severe ED) and 60% of women were classified as "at high risk" for sexual problems, with desire disorders the most prevalent and orgasmic disorders the second most prevalent. There were significant gender differences with respect to the associations between sexual and relationship problems., Conclusions: Sexual problems may be prevalent among residents in training, particularly female residents. Additional, larger studies that assess other quality of life measures and query sexual partners of residents are needed.

Background: Management of the bladder in enterovesical fistulas from benign bowel disease is not well described in the literature and there is no clear consensus., Study Design: A retrospective chart review was done of all patients with benign bowel disease and an enterovesical fistula who underwent definitive surgical management between January 1993 and December 2005. Patients were excluded if they had any history of abdominal cancer or pelvic radiation. Surgical management protocol for enterovesical fistulas included a period of perioperative bowel rest, surgical exploration, separation of the fistulized bowel from the bladder, resection of the diseased bowel segment, and Foley catheter placement for 1 week., Results: Seventy-four patients were eligible for the study. The average patient age was 54.3 years (range 19 to 88 years old). Twenty-six women and 48 men underwent celiotomy and segmental resection of the offending bowel and bowel side of the fistula. The bladder side of the fistula was managed by Foley catheter alone in 68% and by surgical repair in 32%. Fifty-two patients had diverticulitis (70.3%) and 22 had Crohn's disease (29.7%). Mean followup was 26.4 months, and median followup was 6.45 months. One patient developed a colocutaneous and vesicocutaneous fistula after celiotomy. The remaining bladder defects healed within 1 week., Conclusions: Successful surgical management of most enterovesical fistulas from diverticulitis or Crohn's disease requires only resection of the diseased bowel, with minimal need for repair or resection of the bladder side of the fistula. Indwelling Foley catheter placement alone is typically sufficient for bladder healing. Only when there are overt defects into the bladder should formal repair be undertaken.

Objective: To explore the ability of a novel transrectal ultrasonography (TRUS) device (TargetScan, Envisioneering Medical Technologies, St. Louis MO) that creates a three-dimensional map of the prostate and calculates an optimal biopsy scheme, to accurately sample the prostate and define the true extent of disease, as standard TRUS-guided prostate biopsy relies on the operator to distribute the biopsy sites, often resulting in under- and oversampling regions of the gland., Patients and Methods: In a multicentre retrospective chart review evaluating patients who had a TargetScan prostate biopsy between January 2006 and June 2007, we determined the overall cancer detection rate in all patients and in subgroups based on prostate specific antigen level, digital rectal examination, and indication for biopsy. We assessed the pathological significance of cancer detected, defined as a Gleason score of > or = 7, positive margins, extracapsular disease or > 20% tumour volume in the prostatectomy specimen. We also evaluated the concordance in Gleason score between the biopsy and prostatectomy specimen., Results: Cancer was detected in 50 (35.7%) of the 140 patients biopsied, including 39 (47.6%) with no previous biopsies. Of 23 prostatectomy specimens, 20 (87%) had pathologically significant disease. The biopsy predicted the prostatectomy Gleason score in 12 patients (52%), overestimated in two (9%), underestimated in eight (35%), and biopsy Gleason score could not be assigned in one (4%)., Conclusions: Template-guided biopsy potentially produces a higher cancer detection rate and more accurate assessment of grade. Prostatectomy specimens did not have a high rate of pathologically insignificant disease.

Introduction: Little is known about the personal sexual lives of medical students., Aim: To assess sexual habits and determine the presence of sexual dysfunction among medical students., Main Outcome Measures: Demographic and sexual experience data and domain scores on validated sexuality surveys. Instruments selected included the International Index of Erectile Function, the Index of Premature Ejaculation, and the Self Esteem and Relationship Quality Survey for male medical students and the Female Sexual Function Index (FSFI), and the Index of Sex Life for female medical students., Methods: Medical students at our institution were invited to complete a demographic questionnaire and gender- appropriate sexuality surveys. Results were compared with established normative data and validated cut-off scores when available. Linear regression and Pearson coefficient were used to assess relationships between variables., Results: There were 132 responses (78 female mean age 24 years, 54 male, mean age 25 years). Condoms and oral contraceptives were the most popular form of contraception. Among men, 81.5%, 37%, and 93% were in a relationship, married, and heterosexual, respectively. Among women, 64%, 18%, and 95% were in a relationship, married, and heterosexual. Erectile dysfunction was reported by 30% of men. Proxy measures of other sexual problems in men revealed a 28% prevalence of dissatisfaction with sex life, a 28% prevalence of problems controlling ejaculation, an 11% prevalence of orgasmic dysfunction, and a 6% prevalence of low sexual desire. Based on validated FSFI scoring, 63% of women were at high risk of sexual dysfunction. Proxy measures of other problems in women indicated disorders of pain, orgasms, desire, sex satisfaction, lubrication, and arousal in 39%, 37%, 32%, 28%, 26%, and 24% of female respondents, respectively., Conclusions: These data provide insight into the sexual lives of medical students. Rates of sexual dysfunction are higher than expected based on normative data. Further research is required.

Background: Controversy exists about the impact of ischemia on renal function. We evaluated the creatinine clearance of patients having undergone laparoscopic renal extirpative and ablative surgery., Study Design: The records of patients undergoing laparoscopic procedures for renal masses from February 2000 to March 2004 were examined. Creatinine clearance (CrCl) for each patient was determined using the Cockcroft-Gault equation and ideal body weight. We compared CrCl changes of patients undergoing laparoscopic partial nephrectomy (without renal ischemia [LPN-none], with warm ischemia [LPN-warm], and with cold ischemia [LPN-cold]) with patients undergoing laparoscopic radical nephrectomy (LRN) and laparoscopic cryoablation. Patients predisposed to medical renal disease were substratified and evaluated., Results: All patients who underwent LRN or LPN-warm sustained a significant drop in CrCl on the first postoperative day, compared with patients who had LPN without ischemia or cryoablation (p < 0.01). The CrCl decrease correlated directly with warm ischemia time. Six months postoperatively, CrCl changes were no longer significant. Patients with medical renal disease risk factors were more likely to sustain longterm (1 year postoperatively) renal damage if they had renal ischemia, trending toward statistical significance., Conclusions: Ischemia causes acute renal damage, which is apparently reversible in patients without evidence of medical renal disease. Patients with known medical renal disease have substantial longterm changes in renal function associated with unilateral renal ischemia. Considering the insensitivity of creatinine-based renal function metrics, only eliminating ischemic time will realize the goal of maximal nephron preservation, particularly in patients with preexisting medical renal disease.

Purpose: Gunshot wounds to the scrotum and testis are rare. Blast injury from gunshot wounds can result in blast defects that are difficult to close. We reviewed our experience with reconstruction of the testis tunica albuginea to determine the efficacy of graft reconstruction., Materials and Methods: We retrospectively reviewed the chart and trauma database from 1992 to 2002 and identified 17 patients with gunshot wounds to the testis. In 6 patients the injured testes were nonviable and orchiectomy was performed. Nine of the remaining 11 injured testes were reconstructed with free grafts., Results: Nine of the 17 patients explored had a ruptured testis with a blast defect of the testis tunica albuginea, precluding primary closure. Preoperatively in 4 of 4 patients testis rupture was sonographically detected by heterogeneous echogenicity. On scrotal exploration all nonviable extruded seminiferous tubules were débrided. In 2 patients a polytetrafluoroethylene Gore-Tex patch graft was sewn to the remaining tunica edges. Within 3 weeks the 2 testes became infected, requiring orchiectomy. In the remaining 7 patients a free graft of tunica vaginalis was harvested and sewn to the tunica edges. After testis reconstruction Doppler ultrasonography of the testis demonstrated good arterial blood flow at 2 weeks in 7 of 7 cases and at 3 months in 4 of 7. Mean testis volume at 2 and 12 weeks was 22.5 and 21.4 cm3, respectively (p = 0.55)., Conclusions: The ruptured testis from gunshot wounds can be successfully reconstructed with a free graft of tunica vaginalis. Testis reconstructions with synthetic grafts have a high infection rate and should be avoided.

Objective: The aim of this study was to present the clinical and radiological characteristics, surgical management, and outcome in a large series of patients with aneurysms of the distal anterior cerebral artery (DACA) managed in the microsurgical era., Methods: The records of 1109 patients with anterior circulation aneurysms managed at the authors' institution between 1970 and 1998 were reviewed., Results: Fifty-nine patients (5.3%) were identified with 67 DACA aneurysms. Seventy-three percent of the patients were women. The mean age of all patients was 47 years. Multiple aneurysms were identified in 51% of all patients, most commonly on the middle cerebral artery. Thirty-six patients had ruptured DACA aneurysms and 23 had unruptured aneurysms. In those with ruptured aneurysms, the admission grade was Grade I in 10 patients (27.8%), Grade II in three patients (8.3%), Grade III in 10 patients (27.8%), Grade IV in seven patients (19.4%), and Grade V in six patients (16.7%). Frontal lobe hematomas occurred in 28% of the patients with ruptured aneurysms and carried a poor prognosis. In those with unruptured aneurysms, 11 were incidental and 12 were identified after a subarachnoid hemorrhage from another aneurysm. The mean diameter was 10 mm in ruptured aneurysms and 5.8 mm in unruptured aneurysms. Fifty-eight patients underwent surgery and one patient was treated with endovascular coiling. Six patients, all with ruptured aneurysms, died. Seventy percent of survivors with ruptured aneurysms had a favorable outcome., Conclusion: DACA aneurysms possess a number of characteristics that distinguish them from the more common intracranial aneurysms. With modern neurosurgical and endovascular techniques, an acceptable operative morbidity and mortality can be achieved.

Objectives: To evaluate the time required for each component of laparoscopic radical prostatectomy (LRP) performed by a single surgeon to identify the factors that expedite the learning curve. LRP is a technically demanding procedure with a lengthy learning curve., Methods: The LRP procedure was divided into 12 steps, and the time for each step was prospectively recorded during the first 50 consecutive patients undergoing LRP by a single surgeon. The operations were divided into five groups of 10, and the average times for each step were compared and correlated with surgeon observations and changes in surgical technique., Results: Statistically significant progressive improvement was seen in the total time of the LRP procedure (269.4 minutes in period 1 versus 205.4 minutes in period 4, P < 0.05). Regarding the specific steps, improvement occurred in the time needed for dissection of the vas deferens and seminal vesicles (51.8 minutes for period 1 versus 25.3 minutes for period 4, P < 0.01 and 31.2 minutes for period 5, P < 0.03), apical incision (16.7 minutes for period 1 versus 6.3 minutes for period 4, P < 0.03 and 5.7 minutes for period 5, P < 0.02), and division of the rectourethralis (13.5 minutes for period 1 versus 3.4 minutes for period 5, P < 0.05). The time needed for vesicourethral anastomosis remained unchanged throughout the study (average 48.5 minutes)., Conclusions: With experience, the operative times for defined components of LRP improve. Patient selection for a low body mass index and smaller prostate may expedite the procedure. Application of a fixed retractor system, early identification of the vas deferens beneath the peritoneum in a more lateral position, and slow meticulous dissection and ligation of the dorsal vein complex are factors that may expedite the learning curve for LRP.

Objective: Patients with multiple sclerosis (MS) have a relatively high incidence of tic douloureux (TD) and often do not tolerate medical therapy well. The minimally invasive nature of percutaneous retrogasserian glycerol rhizotomy (PRGR) renders it ideal for first-line surgical treatment of TD. We sought to ascertain the benefits of PRGR in patients with MS and to determine whether hypalgesia after PRGR correlates with efficacy., Methods: We assessed 97 glycerol procedures performed in 53 patients followed prospectively for treatment of TD associated with MS. Factors assessed included degree of pain relief, postoperative hypalgesia, procedural morbidity, medication use, time to pain recurrence, and number and type of subsequent procedures., Results: Complete pain relief was obtained in 78% of patients after the initial glycerol injection, and partial relief was obtained in 13% of patients. Long-term follow-up (mean, 81 mo) demonstrated a recurrence rate of 59%, with a mean time to recurrence of 17 months. Actuarial recurrence rates were 50% at 12 months and 60% at 24 months. Twenty-four patients underwent a second or subsequent PRGR for recurrent pain and achieved similar rates of pain relief and time to recurrence. Facial sensory loss was associated with a higher likelihood of pain relief (P < 0.05), with longer time to pain recurrence (P < 0.05), and with decreased use of medication after surgery (P < 0.01.), Conclusion: PRGR is an effective, low-morbidity surgical procedure in the management of TD complicating MS. The presence of facial sensory loss after PRGR is associated with prolonged efficacy.

Background: Dural cavernous angiomas are uncommon benign vascular malformations which may present intraoperative difficulties in hemostasis when the diagnosis is not suspected preoperatively. Preoperative diagnosis can be difficult when angiomas show atypical features and share imaging characteristics with other entities., Methods: A patient presented with a radiographically aggressive lesion, subsequently identified as a dural cavernous angioma. The lesion is reviewed and its clinical, radiographic, and pathological features are compared with other vascular malformations., Case Report: A 40-year-old man presented with new onset seizures and an enhancing lesion infiltrating the floor of the right middle cranial fossa. Due to its aggressive radiographic appearance, initial considerations included chondrosarcoma, meningioma or metastasis. Pathological examination, however, revealed the lesion to be a cavernous angioma of dura., Conclusion: This uncommon lesion may present a diagnostic challenge with significant intraoperative implications. T2 sequence hyperintensity in a relevant lesion should raise suspicion of an hemangioma. It is important to be aware of this entity and its potential to mimic other entities on radiographic grounds.

Objective: To describe a novel therapeutic strategy for the treatment of "blister-like" aneurysms of the distal internal carotid artery (ICA). Direct surgical treatments of these fragile lesions have been associated with generally poor outcomes., Methods: Two consecutive patients presenting with acute subarachnoid hemorrhage from "blister-like" aneurysms were treated with preliminary balloon occlusion of the ICA, followed by surgical trapping of the ICA beyond the aneurysm., Results: The treatment resulted in complete thrombosis of both aneurysms with no clinical complications., Conclusion: This combined endovascular-neurosurgical approach offers a controlled, safer alternative to primary surgical therapy of "blister-like" aneurysms.

The aim of this prospective study was to assess the feasibility and diagnostic relevance of repetitive dynamic (contrast-enhanced) CT measurements of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) in the first 3 weeks after aneurysmal subarachnoid hemorrhage (SAH). In 15 patients with SAH, 59 dynamic CT studies including 944 regions of interest (ROI) were analyzed. The results were correlated with the clinical course and time after the event and the occurrence of vasospasm. Values for the entire series were 33.8+/-19.3 ml/100 g/min (CBF), 3.3+/-1.3 ml/100 g (CBV), and 7.3+/-3.9 s (MTT). Significant differences in CBF and CBV were found between ROI in grey and white matter, with time after the event, between patients with significant and absent or minor vasospasm, and between patients with and without a presumed vasospasm-related infarct.

Object: The authors reviewed their 20-year experience with giant anterior communicating artery aneurysms to correlate aneurysm size with clinical presentation and to analyze treatment methods., Methods: In 18 patients, visual and cognitive impairment were quantitated and clinical outcome was categorized according to the Rankin scale. Statistical analysis was performed using Fisher's exact test., Conclusions: At least 3.5 cm of aneurysm mass effect was required to produce dementia in the patient (p = 0.0004). Dementia was usually caused by direct brain compression by the aneurysm rather than by hydrocephalus. Optic apparatus compression occurred with smaller aneurysms (2.7-3.2 cm) when they pointed inferiorly. Aneurysm neck clipping was possible in half of the cases. Special techniques, including temporary clipping, evacuation of intraluminal thrombus, tandem and/or fenestrated clipping, and clip reconstruction were often required. Occlusion of or injury to the anterior cerebral artery (ACA) was the main cause of poor outcome or death. Proximal ACA occlusion, even of dominant A1 segments with small or no contralateral A1 artery, was an effective treatment alternative and was well tolerated as a result of excellent leptomeningeal collateral circulation.

Cerebral aneurysms are composed principally of collagen, a birefringent protein which is responsible for withstanding the forces of blood pressure. The known correlation between collagen birefringence and its mechanics provides the basis for using polarizing microscopy to evaluate the strength of collagen, layer by layer across the aneurysmal wall. In order to obtain better quantitative measurements, several birefringent enhancement stains were investigated. We concluded that sirius red F3B, at a concentration of 0.05% in saturated picric acid, is an excellent stain to enable measurement of both birefringence and directional organization on the same tissue sections. Six aneurysms from autopsy, fixed at 120 mmHg, and one surgical specimen were cut at 4 microns to provide sets of tangential sections. The polarizing optics emphasizes the multi-layered structure of the aneurysmal wall with the mean fiber alignments distinguishing one layer from another. Birefringence measurements showed that the outer third of the wall had mainly higher strength collagen, although not as high as nearby artery adventitia. The inner layers of the aneurysms had intermediate values, similar to the artery media and subendothelium. Our results are consistent with a model of aneurysmal enlargement that requires the reorganization of higher strength outer fibers while new collagen is added to the inner layers.

Background and Purpose: Carotid endarterectomy (CE) has been shown to be beneficial in patients with symptomatic high-grade (70% to 99%) internal carotid artery stenosis. To achieve this benefit, complications must be kept to a minimum. Complications not associated with the procedure itself, but related to medical conditions, have received little attention., Methods: Medical complications that occurred within 30 days after CE were recorded in 1415 patients with symptomatic stenosis (30% to 99%) of the internal carotid artery. They were compared with 1433 patients who received medical care alone. All patients were in the North American Symptomatic Carotid Endarterectomy Trial (NASCET)., Results: One hundred fifteen patients (8.1%) had 142 medical complications: 14 (1%) myocardial infarctions, 101 (7.1%) other cardiovascular disorders, 11 (0.8%) respiratory complications, 6 (0.4%) transient confusions, and 10 (0.7%) other complications. Of the 142 complications, 69.7% were of short duration, and only 26.8% prolonged hospitalization. Five patients died: 3 from myocardial infarction and 2 suddenly. Medically treated patients experienced similar complications with one third the frequency. Endarterectomy was approximately 1.5 times more likely to trigger medical complications in patients with a history of myocardial infarction, angina, or hypertension (P<0.05)., Conclusions: Perioperative medical complications were observed in slightly fewer than 1 of every 10 patients who underwent CE. The majority of these complications completely resolved. Most complications were cardiovascular and occurred in patients with 1 or more cardiovascular risk factors. In this selected population, the occurrence of perioperative myocardial infarction was uncommon.

Background and Purpose: This study reports the surgical results in those patients who underwent carotid endarterectomy in the North American Symptomatic Carotid Endarterectomy Trial (NASCET)., Methods: The rates of perioperative stroke and death at 30 days and the final assessment of stroke severity at 90 days were calculated. Regression modeling was used to identify variables that increased or decreased perioperative risk. Nonoutcome surgical complications were summarized. The durability of carotid endarterectomy was examined., Results: In 1415 patients there were 92 perioperative outcome events, for an overall rate of 6.5%. At 30 days the results were as follows: death, 1.1%; disabling stroke, 1.8%; and nondisabling stroke, 3.7%. At 90 days, because of improvement in the neurological status of patients judged to have been disabled at 30 days, the results were as follows: death, 1.1%; disabling stroke, 0.9%; and nondisabling stroke, 4.5%. Thirty events occurred intraoperatively; 62 were delayed. Most strokes resulted from thromboembolism. Five baseline variables were predictive of increased surgical risk: hemispheric versus retinal transient ischemic attack as the qualifying event, left-sided procedure, contralateral carotid occlusion, ipsilateral ischemic lesion on CT scan, and irregular or ulcerated ipsilateral plaque. History of coronary artery disease with prior cardiac procedure was associated with reduced risk. The risk of perioperative wound complications was 9.3%, and that of cranial nerve injuries was 8.6%; most were of mild severity. At 8 years, the risk of disabling ipsilateral stroke was 5.7%, and that of any ipsilateral stroke was 17.1%., Conclusions: The overall rate of perioperative stroke and death was 6.5%, but the rate of permanently disabling stroke and death was only 2.0%. Other surgical complications were rarely clinically important. Carotid endarterectomy is a durable procedure.

Background: Endarterectomy benefits certain patients with carotid stenosis, but benefits are lessened by perioperative surgical risk. Acetylsalicylic acid lowers the risk of stroke in patients who have experienced transient ischaemic attack and stroke. We investigated appropriate doses and the role of acetylsalicylic acid in patients undergoing carotid endarterectomy., Methods: In a randomised, double-blind, controlled trial, 2849 patients scheduled for endarterectomy were randomly assigned 81 mg (n=709), 325 mg (n=708), 650 mg (n=715), or 1300 mg (n=717) acetylsalicylic acid daily, started before surgery and continued for 3 months. We recorded occurrences of stroke, myocardial infarction, and death. We compared patients on the two higher doses of acetylsalicylic acid with patients on the two lower doses., Findings: Surgery was cancelled in 45 patients, none were lost to follow-up by 30 days, and two were lost by 3 months. The combined rate of stroke, myocardial infarction, and death was lower in the low-dose groups than in the high-dose groups at 30 days (5.4 vs 7.0%, p=0.07) and at 3 months (6.2 vs 8.4%, p=0.03). In an efficacy analysis, which excluded patients taking 650 mg or more acetylsalicylic acid before randomisation, and patients randomised within 1 day of surgery, combined rates were 3.7% and 8.2%, respectively, at 30 days (p=0.002) and 4.2% and 10.0% at 3 months (p=0.0002)., Interpretation: The risk of stroke, myocardial infarction, and death within 30 days and 3 months of endarterectomy is lower for patients taking 81 mg or 325 mg acetylsalicylic acid daily than for those taking 650 mg or 1300 mg.

Background: Previous studies have shown that carotid endarterectomy in patients with symptomatic severe carotid stenosis (defined as stenosis of 70 to 99 percent of the luminal diameter) is beneficial up to two years after the procedure. In this clinical trial, we assessed the benefit of carotid endarterectomy in patients with symptomatic moderate stenosis, defined as stenosis of less than 70 percent. We also studied the durability of the benefit of endarterectomy in patients with severe stenosis over eight years of follow-up., Methods: Patients who had moderate carotid stenosis and transient ischemic attacks or nondisabling strokes on the same side as the stenosis (ipsilateral) within 180 days before study entry were stratified according to the degree of stenosis (50 to 69 percent or <50 percent) and randomly assigned either to undergo carotid endarterectomy (1108 patients) or to receive medical care alone (1118 patients). The average follow-up was five years, and complete data on outcome events were available for 99.7 percent of the patients. The primary outcome event was any fatal or nonfatal stroke ipsilateral to the stenosis for which the patient underwent randomization., Results: Among patients with stenosis of 50 to 69 percent, the five-year rate of any ipsilateral stroke (failure rate) was 15.7 percent among patients treated surgically and 22.2 percent among those treated medically (P=0.045); to prevent one ipsilateral stroke during the five-year period, 15 patients would have to be treated with carotid endarterectomy. Among patients with less than 50 percent stenosis, the failure rate was not significantly lower in the group treated with endarterectomy (14.9 percent) than in the medically treated group (18.7 percent, P=0.16). Among the patients with severe stenosis who underwent endarterectomy, the 30-day rate of death or disabling ipsilateral stroke persisting at 90 days was 2.1 percent; this rate increased to only 6.7 percent at 8 years. Benefit was greatest among men, patients with recent stroke as the qualifying event, and patients with hemispheric symptoms., Conclusions: Endarterectomy in patients with symptomatic moderate carotid stenosis of 50 to 69 percent yielded only a moderate reduction in the risk of stroke. Decisions about treatment for patients in this category must take into account recognized risk factors, and exceptional surgical skill is obligatory if carotid endarterectomy is to be performed. Patients with stenosis of less than 50 percent did not benefit from surgery. Patients with severe stenosis (> or =70 percent) had a durable benefit from endarterectomy at eight years of follow-up.

Objective: To develop guidelines on the suitability of patients for carotid endarterectomy (CEA)., Options: For atherosclerotic carotid stenosis that has resulted in retinal or cerebral ischemia: antiplatelet drugs or CEA. For asymptomatic carotid stenosis: CEA or no surgery., Outcomes: Risk of stroke and death., Evidence: Trials comparing CEA with nonsurgical management of carotid stenosis., Values: Greatest weight was given to findings that were highly significant both statistically and clinically., Benefits, Harms and Costs: Benefit: reduction in the risk of stroke. Major harms: iatrogenic stroke, cardiac complications and death secondary to surgical manipulations of the artery or the systemic stress of surgery. Costs were not considered., Recommendations: CEA is clearly recommended for patients with surgically accessible internal carotid artery (ICA) stenoses equal to or greater than 70% of the more distal, normal ICA lumen diameter, providing: (1) the stenosis is symptomatic, causing transient ischemic attacks or nondisabling stroke (including retinal infarction); (2) there is no worse distal, ipsilateral, carotid distribution arterial disease; (3) the patient is in stable medical condition; and (4) the rates of major surgical complications (stroke and death) among patients of the treating surgeon are less than 6%. Surgery is not recommended for asymptomatic stenoses of less than 60%. Symptomatic stenoses of less than 70% and asymptomatic stenoses of greater than 60% are uncertain indications. For these indications, consideration should be given to (1) patient presentation, age and medical condition; (2) plaque characteristics such as degree of narrowing, the presence of ulceration and any documented worsening of the plaque over time; (3) other cerebral arterial stenoses or occlusions, or cerebral infarcts identified through neuroimaging; and (4) surgical complication rates at the institution. CEA should not be considered for asymptomatic stenoses unless the combined stroke and death rate among patients of the surgeon is less than 3%., Validation: These guidelines generally agree with position statements prepared by other organizations in recent years, and with a January 1995 consensus statement by a group of experts assembled by the American Heart Association.

The purpose of this study was to examine how the prognosis of patients who presented with a recent ischemic event referable to a 70% to 99% stenosis of one carotid artery (ipsilateral) was altered by stenosis and occlusion of the contralateral carotid artery. The benefit of performing carotid endarterectomy on the recently symptomatic artery, in the presence of contralateral artery disease, was also examined. A total of 659 patients were grouped into one of three categories according to the extent of stenosis in the contralateral carotid artery: less than 70% (559 patients), 70% to 99% (57 patients), and occlusion (43 patients). Strokes that occurred during the follow-up period were designated as ipsilateral if they arose from the same carotid artery as the symptom for which the patient had been entered into the study. Medically treated patients with an occluded contralateral artery were more than twice as likely to have had an ipsilateral stroke at 2 years than patients with either severe (hazard ratio: 2.36; 95% confidence interval (CI): 1.00-5.62) or mild-to-moderate (hazard ratio: 2.65; 95% CI: 1.43-4.90) contralateral artery stenosis. The perioperative risk of stroke and death was higher in patients with an occluded contralateral artery (4.0% risk) or mild-to-moderate (5.1% risk) contralateral stenosis. Regression analyses indicated that the results were not affected by other risk factors. An occluded contralateral carotid artery significantly increased the risk of stroke associated with a severely stenosed ipsilateral carotid artery. Despite higher perioperative morbidity in the presence of an occluded contralateral artery, the longer-term outlook for patients who had endarterectomy performed on the recently symptomatic, severely stenosed ipsilateral carotid artery was considerably better than for medically treated patients.

Three contemporary trials that are studying patients who have symptomatic carotid disease have proven beyond doubt that CE is extremely beneficial in reducing the risk of future stroke in patients with high-grade stenosis (greater than 70%). The relative risk of major stroke is reduced by at least 80% at 2 years of follow-up. That such a remarkably positive result for surgery was not predicted is a consequence of the unanticipated malignant natural history of TIAs and minor stroke in severe carotid disease. Previous epidemiological studies had underestimated the risk of future stroke by almost threefold. The current studies also highlight the remarkable power of prospective clinical trials to evaluate the effectiveness of a surgical procedure. In the case of NASCET, only 659 patients were required to prove the benefit of CE, whereas, innumerable previous anecdotal cases had failed to provide a convincing answer. However it must be remembered that the benefit from CE is dependent on a low rate of perioperative morbidity and mortality, a strict measure of the degree of stenosis on angiography, recency of ischemic events, and unequivocal carotid symptoms. The ongoing study of patients with moderate degrees of carotid stenosis holds the promise that in the very near future precise guidelines, which have been properly evaluated by careful scientific scrutiny,, will be available to guide surgeons in the proper management of all patients who present with symptomatic carotid disease.

Hunterian proximal artery occlusion was used in the treatment of 160 of 335 patients harboring giant aneurysms of the anterior circulation. One hundred and thirty-three of these aneurysms arose from the internal carotid arteries, 20 from the middle cerebral arteries, and seven from the anterior cerebral arteries. Ninety percent of the patients had satisfactory outcomes. The safety of internal carotid artery occlusion has been greatly enhanced by preoperative flow studies and by test occlusion with an intracarotid balloon to identify those patients who require preliminary extracranial-to-intracranial bypass, which was used in all of the middle cerebral occlusions. The anterior cerebral artery had magnificent leptomeningeal collateral flow that prevented infarction even without cross flow. Obliteration of the aneurysm by thrombosis was complete, or nearly so, in all but four patients whose treatment was completed. Analysis of poor outcome in 16 patients revealed that hemodynamic ischemic infarction was known to occur after only two of the carotid occlusions.

Purpose: The timing of carotid endarterectomy (CE) after a recent nondisabling stroke remains controversial. Delaying surgery in such cases may needlessly place patients at risk for a recurrent stroke that may be major and disabling. This study examines the prognostic implications of performing early endarterectomy compared with delayed endarterectomy in patients from the North American Symptomatic Carotid Endarterectomy Trial., Method: This retrospective, subgroup analysis involved 100 surgical patients with severe (70% to 99%) angiographically defined carotid artery stenosis, who were diagnosed with a nondisabling hemispheric stroke at entry into the trial. Forty-two CEs were performed within 30 days (early group, ranging 3 to 30 days), and 58 were performed beyond 30 days (delayed group, range 33 to 117 days) after stroke. The risk of subsequent stroke after CE was compared between the two groups., Results: Baseline clinical characteristics were comparable in both the early and delayed groups. In the delayed group more lesions were identified ipsilateral to the symptomatic side on the preoperative computed tomography scans. The postoperative (30 days after endarterectomy) stroke rate was 4.8% in the early group and 5.2% in the delayed group, yielding a relative rate of 0.92 (95% confidence interval, 0.16 to 5.27; p = 1.00). No deaths occurred after operation in either group. At the end of 18 months, the rates of any stroke or death were 11.9% and 10.3% for the early and delayed groups, respectively, resulting in a relative rate of 1.15 (95% confidence interval, 0.38 to 3.52; p = 1.00). No association was found between an abnormal preoperative computed tomography scan result and the subsequent risk of stroke when early operation was used., Conclusion: Early CE for severe carotid artery stenosis after a nondisabling ischemic stroke can be performed with rates of morbidity and mortality comparable to those who receive delayed endarterectomy. Delaying the procedure by 30 days for patients with symptomatic high-grade stenosis exposes them to a risk of a recurrent stroke, which may be avoidable by earlier surgery.

Recurrent subarachnoid hemorrhage (SAH) in the early period following successful clipping of a cerebral aneurysm is unusual. The authors report a unique case of distal basilar artery dissection and fatal SAH on the 6th day postoperatively. It is concluded that this complication was related to vascular trauma inflicted by repositioning the aneurysm clips during a seemingly uneventful procedure for a basilar artery tip aneurysm.

Background and Purpose: Carotid plaque ulceration is used as one of the determinants in deciding which patients should be submitted to carotid endarterectomy. Uncertainties about its importance persist. Its detection by angiography is an important consideration., Methods: The detection of ulceration by angiography was compared with observations during endarterectomy in the first 500 patients recruited into the North American Symptomatic Carotid Endarterectomy Trial. This represents the first multicenter compilation of data on this subject and the largest series of patients with both arteriographic and direct surgical observation., Results: Sensitivity and specificity of detecting ulcerated plaques were 45.9% and 74.1%, respectively. The positive predictive value of identifying an ulcer was 71.8%. These results remained unchanged with differing degrees of carotid stenosis and were confirmed by analyses based on receiver operating characteristic (ROC) methodology. The area under the ROC curve (Az) was estimated to be 0.61 (95% confidence interval, 0.55 to 0.67)., Conclusions: These observations from a multicenter study confirm that little agreement exists between angiography and surgical observation in detecting carotid plaque ulceration.

Objective: To determine whether carotid endarterectomy prevents deterioration of functional status among patients with transient ischemic attacks or nondisabling strokes and ipsilateral carotid stenosis of 70% to 99%., Design: Multicentered randomized controlled trial with an average 18-month follow-up., Setting: Fifty clinical centers in North America., Patients: A total of 659 patients presenting with recent transient attacks of nondisabling stroke and ipsilateral atherosclerotic carotid stenosis of 70% to 99% were included. Patients were stable neurologically at the time of entry. No patient was lost to follow-up., Intervention: Vascular surgeons and neurosurgeons were prescreened for low perioperative complication rates. Patients were randomly allocated to carotid endarterectomy plus continuing medical care (n = 328) or medical care alone (n = 331), including antiplatelet therapy., Main Outcome Measures: All patients were assessed by neurologists for the occurrence of stroke and functional status at scheduled intervals after entry., Results: In addition to a previously reported risk reduction for ipsilateral stroke for patients assigned to carotid endarterectomy, there was an absolute risk reduction (and relative risk reduction [RRR]) for functional status impairment of 5.6% (RRR, 69%) for vision, 4.6% (RRR, 87%) for comprehension of language, 8.3% (RRR, 88%) for fluency of speech, 4.3% (RRR, 84%) for swallowing, 6.0% (RRR, 53%) for lower-limb function, 9.3% (RRR, 75%) for upper-limb function, 7.4% (RRR, 60%) for shopping, and 10.5% (RRR, 50%) for visiting outside usual residence (P < .05, two-tailed, for all items)., Conclusions: Carotid endarterectomy reduced the risk for impairment of function among patients with recent symptomatic cerebral ischemia and ipsilateral high-grade carotid stenosis.

Background and Purpose: The importance of carotid plaque ulceration as a cause of cerebral ischemic symptoms remains uncertain. Moreover, its prominence in symptomatic patients with severe carotid stenosis is unknown., Methods: The association between angiographically defined plaque ulceration and risk of subsequent stroke was assessed using Cox proportional hazards regression in 659 patients with severe (70% to 99%) carotid stenosis from the North American Symptomatic Carotid Endarterectomy Trial., Results: Treatment assignment (medical versus surgical) and degree of ipsilateral stenosis were identified as having a significant influence on the results. The risk of ipsilateral stroke at 24 months for medically treated patients with ulcerated plaques increased incrementally from 26.3% to 73.2% as the degree of stenosis increased from 75% to 95%. For patients with no ulcer, the risk of stroke remained constant at 21.3% for all degrees of stenosis. The net result yielded relative risks of stroke (ulcer versus no ulcer) ranging from 1.24 (95% confidence interval, 0.61 to 2.52) to 3.43 (95% confidence interval, 1.49 to 7.88). Conversely, for surgically treated patients with antecedent presence of an ulcerated plaque, the risk of stroke increased slightly at the highest degrees of stenosis. Overall, carotid endarterectomy reduced the risk of ipsilateral stroke at 24 months by at least 50%. Similar results were obtained for risk of major ipsilateral stroke and risk of all strokes and death., Conclusions: The presence of angiographically defined ulceration for medically treated symptomatic patients is associated with an increased risk of stroke. The risk of stroke more than doubles at higher degrees of stenosis. Carotid endarterectomy is beneficial in substantially reducing the risk of stroke, regardless of plaque ulceration and degree of severe carotid stenosis.

Background: Without strong evidence of benefit, the use of carotid endarterectomy for prophylaxis against stroke rose dramatically until the mid-1980s, then declined. Our investigation sought to determine whether carotid endarterectomy reduces the risk of stroke among patients with a recent adverse cerebrovascular event and ipsilateral carotid stenosis., Methods: We conducted a randomized trial at 50 clinical centers throughout the United States and Canada, in patients in two predetermined strata based on the severity of carotid stenosis--30 to 69 percent and 70 to 99 percent. We report here the results in the 659 patients in the latter stratum, who had had a hemispheric or retinal transient ischemic attack or a nondisabling stroke within the 120 days before entry and had stenosis of 70 to 99 percent in the symptomatic carotid artery. All patients received optimal medical care, including antiplatelet therapy. Those assigned to surgical treatment underwent carotid endarterectomy performed by neurosurgeons or vascular surgeons. All patients were examined by neurologists 1, 3, 6, 9, and 12 months after entry and then every 4 months. End points were assessed by blinded, independent case review. No patient was lost to follow-up., Results: Life-table estimates of the cumulative risk of any ipsilateral stroke at two years were 26 percent in the 331 medical patients and 9 percent in the 328 surgical patients--an absolute risk reduction (+/- SE) 17 +/- 3.5 percent (P less than 0.001). For a major or fatal ipsilateral stroke, the corresponding estimates were 13.1 percent and 2.5 percent--an absolute risk reduction of 10.6 +/- 2.6 percent (P less than 0.001). Carotid endarterectomy was still found to be beneficial when all strokes and deaths were included in the analysis (P less than 0.001)., Conclusions: Carotid endarterectomy is highly beneficial to patients with recent hemispheric and retinal transient ischemic attacks or nondisabling strokes and ipsilateral high-grade stenosis (70 to 99 percent) of the internal carotid artery.

There is no consensus as to the most appropriate monitor for detecting ischemia during carotid endarterectomy. Accordingly, simultaneous 16-channel continuous electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring were performed in 64 normocapnic patients undergoing carotid endarterectomy and anesthetized with isoflurane or halothane-nitrous oxide (supplemented with fentanyl). Recordings were obtained before, during, and for 15 min after cross-clamping of the internal carotid artery. Internal shunt was not used in any patient, regardless of EEG and SSEP changes. Significant amplitude reduction in the cortical component of the primary negative peak (greater than 50%) in SSEP occurred in 6 patients, and an increase in central conduction time (CCT) (greater than 1 ms) occurred in 5 patients. Major EEG changes occurred in 6 patients, 4 of whom also had SSEP changes. Two patients had transient neurologic deficits postoperatively, with both having SSEP changes (amplitude reduction greater than 50%), whereas one had EEG changes. Based on these observations, the relative sensitivity and specificity for EEG and SSEP (amplitude reduction greater than 50%) in detecting postoperative neurologic deficits were 50% and 92% for EEG and 100% and 94% for SSEP, respectively, differences that were not statistically significant. Regarding SSEP, the use of latency change (CCT) as a criterion was associated with a sensitivity of 0% (P = 0.046 from sensitivity of amplitude) and a specificity of 87% (P = 0.17 from specificity of amplitude).(ABSTRACT TRUNCATED AT 250 WORDS)

Visually apparent EEG changes associated with clamping the internal carotid artery appeared in 55 of 176 consecutive patients (31%) undergoing carotid endarterectomy without shunt. Attenuation of higher frequency activity was the most common change. Changes were moderate in 33 patients (19%) and major in 22 (12.5%). Major changes usually commenced earlier than less severe alterations. EEG changes resolved within 10 minutes of clamp release in 36 of 55 patients (65%) after an average clamp time of 36.25 minutes. Changes occurred more commonly when pre-operative EEGs were abnormal contralateral to clamping and when the contralateral carotid artery was more than 90% stenosed. Of the inhalational anesthetics employed with nitrous oxide and oxygen, isoflurane was associated with the lowest incidence of clamp-associated EEG change. Post-operative strokes occurred in 2 of 22 patients (9%) with major clamp-associated EEG changes, none of 33 patients with moderate changes and none of 121 without changes. However, the mechanism of this relationship remains in doubt.

We constructed and discussed a mathematical model of intracranial saccular aneurysms based on the static mechanics of hollow vessels and were able to focus on three variables that are fundamental to the process of enlargement and rupture of these lesions. They are blood pressure (P), wall strength (sigma), and total wall substance (VT), which, if assigned values of 150 mm Hg, 10 MPa, and 1.0 mm3, lead to model-predicted values of 8 mm for the diameter and 40 micron for the wall thickness for the critical geometry of aneurysmal rupture. These are quantitatively similar to published measurements. The model is based on the assumption of a uniform thin spherical shell for the saccular aneurysm. The interrelationship of the variables, expressed in the equation for critical size at rupture (dc) (i.e., dc = [4 sigma VT/(pi P)]1/3), draws attention to the need for quantitative studies on aneurysmal geometry and on the stereology of the structural fraction of the aneurysmal wall. We concluded that tissue recruitment from around the initial site or hypertrophy of the wall tissue is commonly involved in the aneurysmal process. We identify the paradox of elastic stiffness and stability, which are characteristic of autopsy specimens in the laboratory, in contrast to plastic behavior and irreversible strain, which are essential to the natural process of enlargement of saccular aneurysms.

The cactus alkaloid 3,4-dimethoxyphenethylamine and its naturally occurring N-methylated homologs inhibited the deamination of tyramine and tryptamine by rat brain monoamine oxidase. In contrast, the beta-hydroxylated derivatives of this series failed to inhibit the action of monoamine oxidase on both tyramine and tryptamine.

In this series of intracerebral hematomas from aneurysmal rupture, gathered from several neurosurgical services, certain morphological features were studied in detail. Patients with very large hematomas tended to have poor neurological grades on admission to hospital and their immediate discharge outlook was correspondingly poor. Ruptured middle cerebral and pericallosal artery aneurysms were relatively common causes of intracerebral hematomas. Patients with temporal lobe hematoma did relatively well; those with parietal hematoma did poorly. The larger the hematoma the less chance there was of developing cerebral vasospasm but the more likely was pre-operative brain herniation. The survival was more closely linked to size and location of the hematoma than to the location of aneurysm or the degree of midline shift.

Seventy-four consecutive patients who had undergone carotid endarterectomy procedures were examined with intravenous digital subtraction angiography (IV-DSA) and duplex ultrasonography (DUS) at intervals ranging from 1 to 14 months postoperatively. Ninety-one percent of the DUS and 74% of the DSA images were of diagnostic quality. The two modalities agreed in the assessment of the endarterectomy appearance in 84% of the arteries, with 85% showing no evidence of significant residual disease. There were no arteries with severe restenosis or complete occlusion. In the 10 vessels in which the two modalities disagreed in disease assessment, the IV-DSA images were often degraded by artifact or vessel overlap leading to underestimation of disease. The authors conclude that DUS is the examination of choice for routine follow-up studies of carotid endarterectomy.

A review of 100 cases of carotid-ophthalmic aneurysms has been undertaken to detail their associated visual signs and the effect of surgical treatment on visual function. Thirty-two patients (25 of 61 with intact aneurysms, 7 of 39 with ruptured aneurysms) had visual abnormalities. Visual field abnormalities were found in all these patients, and visual acuity was impaired in every patient except 1. These aneurysms were often difficult to treat surgically, and a wide variety of techniques were used. A satisfactory neurological result was obtained in 26 of the 32 patients (81%), with a satisfactory visual result in 24 of the 29 survivors (83%).

Seventy-five patients were treated between March 1976 and June 1980 for classical idiopathic tic douloureux. Fifty-five patients underwent percutaneous trigeminal rhizotomy (PTR) and twenty-four had posterior fossa microvascular decompression (MVD) of the trigeminal nerve. Four patients had both procedures. In the PTR group, 4% were immediate failures, 42% had a delayed recurrence of pain, while 54% remained totally pain free with an average follow-up of 30 months. In the MVD group, 12% were immediate failures, 17% had a delayed recurrence of pain, and 71% have remained free of pain with a average follow-up of 28 months. Neither procedure can be regarded as ideal surgical treatment for patients with pain refractory to medical treatment. Percutaneous rhizotomy has an established place because of its safety, particularly in elderly patients. A high rate of recurrent pain is to be expected. Microvascular decompression has appeal in younger patients because of its non-destructive nature but the long term efficacy of the procedure is not known.