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We report a case of postoperative carotid-artery rupture resulting from injury to the vessel by a partially resected thyroid ala and review some aspects of nine additional cases. The site of perforation was often the common carotid below the bulb. Two patients died before treatment. Of eight patients who were treated with carotid ligation, seven survived. Two had neurological sequelae. The incidence of this complication can be reduced by control of factors which impede wound healing, thoughtful skin incisions, and carotid protection with autogenous materials. Treatment is carotid ligation. Other treatment methods are uncertain and subject the patient to the risk of subsequent fatal hemorrhage.

Some cerebral edema always accompanies ischemic infarction and contributes to symptoms in a substantial number of human cases. 1 Although the edema usually is greater with large than with small infarcts, 2 morphologic correlation sometimes is poor. This raises the question in ischemic lesions whether there is a stage of prenecrotic swelling or of swelling independent of necrosis; the corollary question is whether swelling itself contributes to the eventual size of the brain infarct. To investigate this we attempted to induce in rats graded anoxicischemic cerebral lesions; small animals were chosen in order to have sufficient numbers to analyze results. Because of the well-known narrow margin in rats between producing no brain lesion at all and producing death by anoxia, a modification of Levine's 3 technique combining carotid ligation with anoxic exposure was employed. Whereas Levine (and Spector 4 ) exposed animals to severe hypoxia for variable periods of time

Common carotid ligation is one of the more conservative operations for carotidcavernous sinus fistula. Visual impairment following this procedure is rare, and to our knowledge, total blindness in the eye on the affected side has not been reported heretofore. Report of Case A 31-year-old Negro male, who previously had been in good health, presented himself at the Illinois Eye and Ear Infirmary on Jan. 6, 1962, with a history of proptosis of the left eye following an injury 3 weeks earlier. He had received a rather hard blow with a bottle on the left side of the head, but had not lost consciousness or felt weak. A few days after the injury the left eye became red and painful, and shortly thereafter he had diplopia and became aware of a roaring noise in the left ear. The visual acuity in the right eye was 20/20 without correction; that in the

We appreciate the comments of Dr Karis on our article. Certainly, we would have to agree with his conclusions based on the statistics that he uses to support them. On the other hand, we believe that the statistics that we have presented from the literature do demonstrate the superior results of microsurgery in centers where many of these patients are treated. Consequently, we would be uncomfortable in participating in a "definitive, randomized, controlled study." Certainly, there are issues here that can only be resolved by such a study, but we do not believe that these would alter the fundamental conclusion that direct microsurgical intervention is superior to conservative treatment or carotid ligation. Once again, we are grateful for his kind comments, especially in regard to the level of care our patients have received.

Cerebral ischemia was induced in gerbils by bilateral carotid ligation for periods of 10 to 40 minutes. Cerebral blood flow (CBF) was measured by hydrogen clearance. Following ischemia, ultimate clinical and electroencephalogram recovery could be predicted in every case within the first five minutes by recovery could be predicted in every case within the first five minutes by recovery of CBF to at least 100% of the control level. In animals without EEC recovery, the postischemic CBF was always less than 80% of control and progressively declined to zero. Residual flow during ischemia appeared to minimize the likelihood of brain death. The determination of ultimate brain death appeared to coincide with a major circulatory abnormality that is probably microvascular.

Cerebral aneurysms are of greater frequency than is ordinarily considered. The hemorrhage from a ruptured aneurysm is too easily diagnosed as cerebral or meningeal apoplexy, and the origin of the hemorrhage is not verified by necropsy. Cortical herniation into dural sinuses is another condition that occurs rather frequently but is not commonly recognized. It is found in association with increased intracranial pressure. Neither condition often presents localizing diagnostic symptoms, but these may occur and be significant. This report of ten cases of cerebral aneurysm, eight of which were verified by necropsy, is prompted because of the application of internal carotid ligation in two and the discovery of an unusual complication of herniation of the motor cortex into pacchionian bodies in another. Before presentation of the case reports, a few of the significant points pertaining to the two subjects will be discussed briefly. The subject of cerebral aneurysm has recently been

In 1872, Roberts Bartholow, of Cincinnati, wrote a description of the clinical features of intracranial aneurysms arising from the internal carotid artery, which showed evidence of acute clinical observation. Jonathan Hutchinson, a London surgeon, described a case in 1875, and even considered carotid ligation. More recently, McKinney, Acree, and Soltz (1936) reported the clinical and radiological features of eight cases and called attention to the erosion of the optic foramen and widening of the superior orbital (sphenoidal) fissure which occurred in several of them. Jefferson (1938) made a detailed study of the clinical features of a series of 17 cases, which forms the basis of our present knowledge. At this period arteriography was in its infancy. Since then, relatively safe percutaneous angiography has become available and was undertaken in the majority of the present series of 15 patients which form the basis of the present contribution. Aneurysms arising from the