Comitant Ocular Deviation in Myasthenia Gravis

Occurrence of comitant ocular deviation in myasthenia gravis (MG) is not well described

Is Carotid Artery Disease Responsible for Perioperative Strokes After Coronary Artery Bypass Surgery?

The coronary and extracranial carotid vascular beds are often simultaneously affected by significant atherosclerotic disease, and stroke is one of the potential major complications of coronary artery surgery. As a result, there is no shortage of reports in the vascular surgery literature describing simultaneous coronary and carotid artery revascularizations. Generally, these reports have found this combination of operations safe, but have stopped short of proving that it is necessary. Intuitively, simultaneous carotid endarterectomy and coronary artery bypass surgery could be justified if most perioperative strokes were the result of a significant carotid stenosis, either directly or indirectly. At first glance this appears to be a fairly straightforward issue; however, much of the evidence on both sides of the argument is circumstantial. One significant problem in analyzing outcome by choice of treatment in patients presenting with both coronary and carotid disease is the multiple potential causes of stroke in coronary bypass patients, which include hemorrhage and atheroemboli from aortic atheromas during clamping. But this controversial subject is now open to discussion, and our debaters have been given the challenge to clarify the evidence to justify their claims

Sulcal Artery Syndrome After Vertebral Artery Dissection

Sulcal artery syndrome is a rare cause of spinal cord infarction. We describe a case of sulcal artery syndrome due to traumatic vertebral artery dissection and review the known literature on this rare syndrome

Open Heart Surgery Does Not Increase the Incidence of Ipsilateral Ischemic Stroke in Patients with Asymptomatic Severe Carotid Stenosis.

BACKGROUND AND PURPOSE: We evaluated the incidence of perioperative stroke following the institution\u27s 2007 practice change of discontinuing combined carotid endarterectomy and open heart surgery (OHS) for patients with severe carotid stenosis. METHODS: In this retrospective cohort study, we compared 113 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both from 2007 to 2011 with data collected from 2001 to 2006 from a similar group of patients. Our aim was to assess whether the practice change led to a greater incidence of stroke. RESULTS: A total of 7350 consecutive patients undergoing OHS during the specified time period were screened. Of these, 3030 had OHS between 2007 and 2011 but none were combined with carotid artery surgery (new cohort). The remaining 4320 had OHS before 2007 and 44 had combined procedures (old cohort). Of patients undergoing OHS during the 10-year period of observation, 230 had severe (\u3e80%) carotid stenosis. In the old cohort (before 2007), carotid stenosis was associated with perioperative stroke in 2.5% of cases. None of the 113 patients having cardiac procedures after 2007 received combined carotid artery surgery; only 1 of these patients harboring severe carotid stenosis had an ischemic stroke (.9%) during the perioperative period. The difference in stroke incidence between the 2 cohorts was statistically significant (P = .002). CONCLUSION: The incidence of stroke in patients with severe carotid artery stenosis undergoing OHS was lower after combined surgery was discontinued. Combined carotid and OHS itself seems to be an important risk factor for stroke

Spectrum and Potential Pathogenesis of Reversible Posterior Leukoencephalopathy Syndrome

BACKGROUND: Controversy still exists over the etiology and pathophysiology of reversible posterior leukoencephalopathy syndrome (RPLS). This large single-center case series aims to describe the clinical and imaging features of RPLS in an attempt to deduce the etiology of the disorder and the mechanisms of brain injury. METHODS: A retrospective chart and imaging review was conducted on 59 cases of RPLS in 55 patients. RESULTS: Five RPLS imaging patterns were observed: posterior predominant (n = 40), anterior predominant (n = 7), diffuse lesion (n = 7), basal ganglia predominant (n = 3), and brainstem/cerebellum predominant patterns (n = 2). RPLS resulted in permanent neurologic deficits in 14 patients and death in 4 patients. Hypertension was seen in 57 (97%) cases, and mean arterial blood pressure exceeded 140 mm Hg in 30 (51%) cases. Follow-up magnetic resonance imaging scans revealed a significant worsening of vasogenic edema in 2 cases, both with persistent hypertension. Magnetic resonance imaging scans revealed areas of ischemia in 14 cases, all within or at areas closely adjacent to vasogenic edema. Diffuse vasculopathy was seen in 8 cases. There was a lack of correlation between the presence of vasculopathy and the degree of vasogenic edema (P = .62), but a correlation was suggested between ischemia and vasculopathy (P = .02). CONCLUSIONS: This study strongly suggests that hypertension-induced vasodilation rather than vasoconstriction-mediated hypoxia is likely the major mechanism responsible for the development of vasogenic edema, and that vasoconstriction may contribute to the development of ischemia in RPLS

Strokes after cardiac surgery and relationship to carotid stenosis.

OBJECTIVE: To critically examine the role of significant carotid stenosis in the pathogenesis of postoperative stroke following cardiac operations. DESIGN: Retrospective cohort study. SETTING: Single tertiary care hospital. PARTICIPANTS: A total of 4335 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both. MAIN OUTCOME MEASURES: Incidence, subtype, and arterial distribution of stroke. RESULTS: Clinically definite stroke was detected in 1.8% of patients undergoing cardiac operations during the same admission. Only 5.3% of these strokes were of the large-vessel type, and most strokes (76.3%) occurred without significant carotid stenosis. In 60.0% of cases, strokes identified via computed tomographic head scans were not confined to a single carotid artery territory. According to clinical data, in 94.7% of patients, stroke occurred without direct correlation to significant carotid stenosis. Undergoing combined carotid and cardiac operations increases the risk of postoperative stroke compared with patients with a similar degree of carotid stenosis but who underwent cardiac surgery alone (15.1% vs 0%; P = .004). CONCLUSIONS: There is no direct causal relationship between significant carotid stenosis and postoperative stroke in patients undergoing cardiac operations. Combining carotid and cardiac procedures is neither necessary nor effective in reducing postoperative stroke in patients with asymptomatic carotid stenosis