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Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network of small, weak blood vessels that are prone to rupture. Steno-occlusive changes in the posterior cerebral arteries (PCA) may contribute to worse outcomes in MMD patients, however, there is a paucity of information on the incidence and natural history of MMD patients with PCA disease. We retrospectively reviewed the charts of patients with MMD treated between 1987 and 2019. Demographics, peri-operative outcomes, and radiological phenotypes were recorded for 450 patients. PCA disease was scored as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe, or occluded). Out of 450 patients, 164 (34.4%) had concurrent PCA disease. In patients with PCA disease, the extent of occlussion was mild in 56 (34%), moderate in 41 (25%), and severe in 67 (40.9%) patients. In total, there were 319 females (70.9%), with a higher proportion of female MMD patients having severe or moderate PCA disease (p=0.038). Patients with severe and moderate PCA disease had higher Suzuki grades (p Over a mean follow-up of 6.94±4.16 years, 28 patients (8.86%) developed new or progressive PCA disease. Bilateral disease was present in 66 patients (14.7%) and was associated with higher Suzuki grades (p PCA disease involvement is associated with higher rates of ischemic peri-operative complications and poor functional outcomes likely due to reduced collateral flow. Progression of PCA disease is not uncommon. Future studies are needed to assess the impact of PCA disease progression on long-term outcomes.

Introduction: We investigated the relationship between the level of cerebral collateral circulation on arterial spin-labeling (ASL) magnetic resonance imaging (MRI) and cerebrovascular reserve (CVR) on acetazolamide (ACZ)-stress single photon emission computed tomography (SPECT) brain scans in internal carotid artery (ICA) stenosis. Methods: This study enrolled 129 patients with severe ICA stenosis (>70%). Collateral circulation was assessed in pulsed ASL images based on the presence of arterial transit artifact (ATA) that late-arriving flow appears as serpiginous high ASL signal within cortical vessels. CVR based on rest-SPECT and ACZ-stress SPECT with Tc-99m-ECD was calculated. The ASL CBF maps were independently assessed by two neuroradiologists blinded to clinical information. The two neuroradiologists graded on two slices of ASL images corresponding to Alberta Stroke Program Early Computed Tomography Score (ASPECTS) location using a 4-point scale for ASL intensity. Results: With ACZ-stress SPECT, the 88/129 (68%) patients showed normal CVR and 41/129 (32%) patients showed decreased CVR. In 73/88 (82%) of the normal CVR group patients, ASL showed ATA in ipsilateral to the stenosis. In 19/41 (46%) of the decreased CVR group patients, ASL showed no evidence of ATA in ipsilateral to the stenosis. Significant positive relationship was observed between the normal CVR group and the ATA showing group in ICA stenosis patients (p = 0.001, chi-square test). The ASL-based ASPECTS scores of brain in the ipsilateral side was lower than the scores in the contralateral side to the ICA stenosis (p < 0.0001, Wilcoxon signed rank test). The ASL-based ASPECTS scores of brain ipsilateral side to the ICA stenosis was lower in the reduced CVR group than normal CVR group (p = 0.005). Conclusion: This study demonstrated the statistically significant positive correlation between good collaterals on ASL MRI and intact CVR in patients with ICA stenosis.

Backgroud Drug-eluting stents (DES) have been proposed for the treatment of infrapopliteal arteries disease. However, the long-term clinical impact of DES treatment in the vascular territory still remains uncertain. Methods and results Pubmed, Embase, Cochrane data, CNKI and Wanfang Data were searched until December 20, 2016 for eligible studies according to identical strategies. Additional data were manually retrieved. STATA ver. 12.0 software were used to Meta-analyze the efficacies of DES and control treatment (BMS or PTA) for infrapopliteal arteries disease. A total of 927 patients from 10 studies (8 randomized controlled trials and 2 cohort studies) were assigned to DESs (n = 484) versus control treatment (n = 443). The results showed that infrapopliteal DES therapy yielded higher primary patency and EFS, while decreased the risk of restenosis at 12-months compared to controls significantly. At 3 years there were no significant differences between two groups, pooled RRs and 95% CI were 1.639 [0.526–5.105], P = 0.394; 1.197 [0.432–3.317], P = 0.729 and 0.992 [0.960–1.024], P = 0.661, respectively. Subgroup analysis showed that infrapopliteal DES therapy using Sirolimus-eluting stents rather than Everolimus-eluting stents provided higher clinic benefits. Infrapopliteal DES therapy yielded no significant difference for TLR, overall survival, Rutherford-Becker class improvement, limb amputation at 12-months and 3-years compared with control treatment. Conclusions The results of the present meta-analysis indicate the non-superiority of infrapopliteal DES therapy over control therapies (BMS/PTA) at 3 years, although short-term benefits at 12 months after DES therapy were evident. Further randomized trials with longer follow-up are required to provide the best scientific evidence regarding the preferred endovascular treatment for patients with occlusive disease of infrapopliteal arteries.

Purpose: We evaluated the correlation between cerebrovascular reserve (CVR) on acetazolamide (ACZ) -stress single photon emission computed tomography (SPECT) brain scans and collaterals on arterial spin-labeling (ASL) magnetic resonance imaging (MRI) in internal carotid artery (ICA) stenosis. Materials and Methods: 86 patients with ICA stenosis (>70%) were enrolled in this study. Including pulsed ASL, MRI was acquired on a 3 tesla system. On ASL, late-arriving flow appears as serpiginous high ASL signal within cortical vessels, which has been termed arterial transit artifact (ATA). Images were interpreted for the presence of ATA. 82/86 ICA stenosis patients underwent SPECT imagings with Tc-99m-ECD in the resting and after ACZ challenge. We observed the presence of intracranial collaterals, which are manifested by ATA, on ASL brain perfusion scan. CVR based on rest-SPECT and ACZ-stress SPECT was calculated. With ACZ-stress SPECT, the 82 patients were grouped as either showing or not showing evidence of decreased CVR. We assessed the relationship between reduced CVR and intracranial collaterals shown as ATA on ASL brain perfusion. Results: In 61/86 (70%) of the ICA stenosis patients, ASL showed ATA in ipsilateral to the stenosis. With acetazolamide stress SPECT, the 27/82 (32%) patients showed evidence of decreased CVR. In 45/55 (81%) of the normal CVR group and 16/27 (59%) of the reduced CVR from the SPECT results, pulsed ASL showed ATA in ipsilateral to the stenosis. Significant positive relationship was observed between normal CVR group and ATA showing group in ICA stenosis patients on ASL brain perfusion (p=0.035, chi-square test). Conclusion: The ATA with ASL imaging as a noninvasive and no contrast demanding technique, can depict slow flow in excellent collateral vessels and has clinical utility in detecting CVR in patients with ICA stenosis.

Objectives: To explore the accuracy of the hemodynamic parameters of the extracranial segment of vertebral artery (EVA) for evaluating the intracranial segment steno-occlusive disease. Methods: A total of 275 consecutive patients who were diagnosed as posterior circulation ischemic stroke with unilateral intracranial VA (IVA) stenosis or occlusion in our hospital from January 2015 to December 2017 were enrolled. All patients were examined by neck vascular ultrasound, CT angiography (CTA) and / or digital subtraction angiography (DSA) within one week. According to the results of DSA or CTA,the patients were divided into mild,moderate,severe stenosis and occlusion groups. The peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI value) of the EVA (V2 segment) were recorded and analyzed. The area under the receiver operating characteristic curve (AUC) of the PSV, EDV, RI values were calculated. The sensitivity, specificity, and accuracy of the above hemodynamic parameters were compared. Results: With the severity of the IVA stenosis, the PSV and EDV of the V2 segment were gradually decreased, and the RI value was gradually increased ( P Conclusion: The ultrasonic hemodynamic parameters of the EVA can accurately diagnose the occlusion of the IVA and distinguish the occlusion site, but the diagnostic accuracy of the severe stenosis is relatively low.

Background: Enabling strategies (ESs) are increasingly used during percutaneous coronary intervention for chronic total occlusive disease (CTO-PCI), enhancing procedural success. Using the British Cardiovascular Society dataset, we examined changes in the use of ESs and procedural/clinical outcomes for CTO-PCI. Methods and Results: ESs were defined as intravascular ultrasound, rotational/laser atherectomy, dual arterial access, use of microcatheters, penetration catheters or CrossBoss, and procedures categorized by number of ESs used. Data were analysed on all elective CTO-PCI procedures performed in England and Wales between 2006 and 2014. Multivariable logistic regression was used to identify predictors of procedural success. During 28 050 CTO-PCIs, there were significant temporal increases in ES use. There was a stepwise increase in CTO success with increased ES use, with 83.8% of cases successful where ≥3 ESs were used. Overall, CTO-PCI success rate for the whole cohort increased from 55.4% in 2006 to 66.9% in 2014 ( P P Conclusions: ES use during CTO-PCI was associated with significant improvements in CTO-PCI success. ES use was associated with increased procedural complications and in-hospital major adverse cardiovascular events, but not with 30-day mortality.

Introduction: Symptomatic internal carotid artery occlusion (ICAO) can lead to subsequent neurologic decline, recurrent stroke, and mortality. We sought to evaluate safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO). Methods: This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral, cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO. Study endpoints included discharge neurologic exam, post-procedural infarct burden, 3-month functional outcomes, and treatment durability. Results: A total of 107 patients with symptomatic, angiographically confirmed cervical ICAO without tandem LVO were identified. Median admission NIHSS was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical-diffusion mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable or improved NIHSS, while at 3-months 65% achieved functional independence (mRS ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1-year. Conclusions: Stenting in selected patients at risk of neurological deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.

Background and Purpose— Positron emission tomography (PET) with radiolabeled 2-nitroimidazoles directly detects hypoxic but viable tissue present in an acute ischemic area in the human brain. This study using PET with 1-(2- 18 F-fluoro-1-[hydroxymethyl]ethoxy) methyl-2-nitroimidazole ( 18 F-FRP170) aimed to determine whether tissue with an abnormally elevated uptake of 18 F-FRP170 exists in human chronic cerebral ischemia because of unilateral atherosclerotic major cerebral artery steno-occlusive disease. Methods— 18 F-FRP170 PET was performed, and cerebral blood flow and metabolism were assessed using 15 O-gas PET in 20 healthy subjects and 52 patients. A region of interest (ROI) was automatically placed in 3 segments of the middle cerebral artery territory in both cerebral hemispheres with a 3-dimensional stereotaxic ROI template using SPM2, and each PET value was determined in each ROI. The ratio of values in the affected versus contralateral hemispheres was calculated for the 18 F-FRP170 PET image. Results— A significant correlation was observed between oxygen extraction fraction and 18 F-FRP170 ratios ( ρ =0.509; P 18 F-FRP170 ratio (19 ROIs: 12%) were significantly greater than those for the individual categories (elevated oxygen extraction fraction, moderately reduced cerebral oxygen metabolism, or reduced cerebral blood flow). Conclusions— Tissues with abnormally elevated uptake of 18 F-FRP170 exist in human chronic cerebral ischemia characterized by a combination of misery perfusion and moderately reduced oxygen metabolism because of unilateral atherosclerotic major cerebral artery steno-occlusive disease.

Background— Coronary perforation (CP) during chronic total occlusion percutaneous coronary intervention for stable angina (CTO-PCI) is a rare but serious event. The evidence base is limited, and the long-term effects are unclear. Using a national PCI database, the incidence, predictors, and outcomes of CP during CTO-PCI were defined. Methods and Results— Data analyzed from the British Cardiovascular Intervention Society data set on all CTO-PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. A total of 376 CP were recorded from 26 807 CTO-PCI interventions (incidence of 1.40%) with an increase in frequency during the study period ( P =0.012). Patient-related factors associated with an increased risk of CP were age and female sex. Procedural factors indicative of complex CTO intervention strongly related to an increased risk of CP with a close relationship between the number of complex strategies used and CP evident ( P =0.008 for trend). Tamponade occurred in 16.6% and emergency surgery in 3.4% of cases. Adverse outcomes were frequent in those patients with perforation including bleeding, transfusion, myocardial infarction, and death. A legacy effect of perforation on mortality was evident, with an odds ratio for 12-month mortality of 1.60 for perforation survivors compared with matched nonperforation survivors without a CP ( P Conclusions— Many of the factors associated with an increased risk of CP were related to CTO complexity. Perforation was associated with adverse outcomes, with a legacy effect on later mortality after CP also observed.

Background: Peripheral artery disease (PAD) is a progressive occlusive disease of the arteries and a vascular complication in diabetes. Vascular calcification (VC) is implicated as a potential driver of PAD, and although the exact mechanisms are unclear, the site and location of calcification within the arterial wall contributes greatly. Long considered a passive process, VC is now recognised as a tightly regulated active process balancing the promotion and inhibition of calcification in the arterial wall. There is little evidence however, to demonstrate the effect of calcification on endothelial cell angiogenesis. This study sought to investigate the effects of calcium as a known inducer of calcification on in vitro angiogenesis. Methods: Human Coronary Artery Endothelial Cells were cultured and treated with increasing calcium concentrations (CaCl 2 2.45-3.3 mM) for 24h. Proliferation, migration and tubule formation assays were conducted and real-time PCR assessed angiogenic and osteogenic genes. Alkaline phosphotase (ALP) activity was measured in supernatants following treatment. Results: High concentrations of calcium reduced cell proliferation with a corresponding increase in ALP production suggesting release of osteogenic stimuli adversely affects cell viability. Mid-range concentrations of calcium induced a significant increase in cell migration (1.0 vs 2.4±0.3, p500 fold), and fibroblast growth factor-2 (>150 fold). This increase corresponded with a decrease (1.0 vs 15.02±4.24; p Conclusion: This is the first demonstration investigating the effects of calcium on endothelial cell angiogenesis. These findings suggest that calcium can directly affect genes involved in regulating angiogenesis, and could therefore provide an opportunity to develop potential treatments.

Introduction: Contraindications for intravenous thrombolysis are not infrequent (eg. anticoagulation, recent surgery, unclear last known well). With overwhelming recent evidence supporting the use of endovascular thrombectomy for large-vessel occlusive stroke, we conducted a metaanalysis to compare long-term functional outcome between thrombectomy-alone versus combined IV-tPA and thrombectomy. Hypothesis: Patients with acute ischemic stroke ineligible for IV-tPA treated with thrombectomy-alone have equally favorable long-term functional outcomes to patients treated with combined IV-tPA and thrombectomy Methods: Searched PubMed from 2014-2016 using pre-specified terms for studies that report odds ratio of improvement in mRS score at 90 days comparing thrombectomy vs IV-tPA stratified by whether patients had received IV-tPA. Multivariate adjusted odds ratios were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates were compared between thrombectomy-alone and combined IV-tPA and thrombectomy. Forest plots constructed. Results: Of the 920 studies, 3 studies reported subgroup analysis with 822 participants, 19.5% (N=160) received thrombectomy-alone, 80.5% (N=662) received combined IV-tPA and thrombectomy. Among patients who received thrombectomy-alone, the pooled odds ratio of good functional outcome at 3 months was 2.48 (1.43-4.30), in the combined IV-tPA and thrombectomy group the pooled odds ratio was 1.85 (1.37-2.49). Conclusions: Endovascular therapy was an effective therapy for patients ineligible for IV-tPA presenting with acute ischemic stroke caused by large vessel occlusive disease. While IV-tPA should not be withheld before thrombectomy in IV-tPA eligible patients, prospective studies are needed to select those who may benefit more from thrombectomy-only treatment.

Objective: To determine whether cognition among those with carotid occlusive disease independently affects Quality of Life (QoL). Introduction: Carotid occlusion may result in stroke, TIA, and reduction in cognition. QoL has been studied in stroke patients but less is known about QoL in patients with carotid occlusive disease without stroke or significant depression. Methods: Subjects, selected from an NIH study of carotid occlusive treatment, included those with with history of TIA or a remote history of minor stroke, and excluded those with a history of stroke within 4 months prior, major deficits in ADL’s, and dementia. Because the relationship between depression and OoL is well-established, we excluded with moderate-severe depression. Patients underwent cognitive examination (memory, language, motor, executive function skills), completed depression and QOL questionnaires (Center for Epidemiological Studies-Depression (CES-D), Stroke Specific Quality of Life (SSQOL), and were rated for stroke severity (NIHSS). Age-corrected Z-scores for cognitive tests were calculated and averaged into a composite cognitive Z-score (Cog-Z). The SSQOL scores were averaged across subgroup domains. Correlation analyses were performed to determine univariate relationships between the variables, with significant values put into in a regression model to predict SSQOL. Results: Among 24 subjects (mean age=58.38 (2.01); 10 women), mean Cog-Z was –1.06 SD (Low Average range), mean CES-D score was 10.77 (normal range), mean NIHSS was 0.46 (normal range), and the mean SSQOL score was 3.92 (needing “a little help”). The correlations between NIHSS, history of prior stroke, and SSQOL were nonsignificant. In a regression model including Cog-Z and CES-D, Cog-Z was an independent predictor of SSQOL (Beta=.389, p=.038). Conclusions: In patients with carotid occlusive disease without major stroke, cognitive scores were independently associated with QOL. Even minor reductions in cognition influenced QoL and were distinct from the influence of depression. These data further establish the clinical relevance of cognitive decline among patients with cerebrovascular conditions.

Background and purpose: Moyamoya disease (MMD) is a unique cerebrovascular occlusive disease that is characterized by progressive stenosis and negative remodeling of the distal internal carotid artery (ICA). We hypothesized that caveolin-1, a protein that controls the regulation of endothelial vesicular trafficking and signal transduction, is associated with negative remodeling in MMD. Methods: We prospectively recruited 77 consecutive patients with MMD (49 bilateral and 28 unilateral MMD) diagnosed by conventional angiography. Seventeen patients with intracranial atherosclerotic stroke and no RNF213 mutation served as controls. Distal ICA outer diameters were examined with high-resolution MRI. We evaluated whether the degree of negative remodeling in MMD patients was associated with RNF213 polymorphism, caveolin-1 levels, or various clinical and vascular risk factors. Results: The RNF213 variant was observed in 49 (63.6%) patients with MMD. The serum caveolin-1 (ng/mL) level was lower in MMD patients than in controls (0.47±0.29 vs. 0.86±0.68, P =0.034). The mean ICA diameter was 2.48±0.98 mm (range 0.00-4.76) for the 126 affected distal ICAs in MMD patients and 3.84±0.42 mm for asymptomatic ICAs in controls. After adjusting for possible confounders, male sex (coefficient, 0.396; P =0.029), clinical presentation with ischemic stroke (coefficient, -0.733; P P Conclusion: Our findings suggest that caveolin-1 may play a major role in arterial negative remodeling in MMD patients. Future studies exploring caveolin-1 as a therapeutic target in MMD are warranted.

Stroke is the fourth leading cause of death in the United States. Intracranial atherosclerotic disease accounts for 8%-10% of ischemic stroke in the United States. So far, surgical bypass has not proved to be superior to medical therapy. As both medical and endovascular therapies for intracranial atherosclerosis evolve, so too do the guidelines for treatment. Initial reports on the results of stent placement for symptomatic high-grade intracranial atherosclerotic disease were encouraging; however, recent trials suggest that initial medical management may be preferable. Currently, intracranial angioplasty and stenting for symptomatic intracranial atherosclerosis is now more controversial. Further trials are necessary to help determine which patients are ideal for endovascular therapies.

Beraprost is used to treat peripheral chronic arterial occlusive disease. However, the efficacy and safety of beraprost in patients with pulmonary hypertension (PH) due to left ventricular systolic dysfunction (PH-HFrEF) remains unknown. The primary objective of this study was to determine the effects of beraprost on PH-HFrEF. We prospectively recruited patients with PH-HFrEF as determined by echocardiography and right cardiac catheterization. Beraprost sodium was given orally (1 μg/kg/d) added to the usual treatment, and patients were evaluated at 1-year follow-up. Twenty-five patients were recruited with baseline systolic pulmonary artery pressure (PAP) of 49.5 ± 10.8 mm Hg. Systolic PAP results at 3, 6, 9, and 12 months were 39.1 ± 8.1, 30.4 ± 5.2, 27.7 ± 3.0, and 27.0 ± 4.7 mm Hg, respectively, which were all significantly lower than systolic PAP at baseline (P

Background and Purpose— Large artery intracranial occlusive disease (LAICOD) is a predominant cause of ischemic stroke in China. Carotid intima-media thickness (CIMT) and presence of carotid plaque are also related to subsequent ischemic stroke. However, the correlation between these and LAICOD is less clear. Methods— This was a community-based cross-sectional study. All subjects underwent carotid duplex ultrasonography and transcranial Doppler. Mean CIMT value of bilateral common carotid arteries was used. Plaque was defined as a focal CIMT of >1.5 mm. LAICOD in transcranial Doppler was defined by peak systolic velocity and age, and presence of turbulence or musical sound was also considered. Results— For the 537 subjects studied (mean age, 54.7±10.1 years; 46.9% males), mean CIMT was 0.74±0.12 mm, with the 75th percentile of 0.80 mm. CIMT ≥1.0 mm was identified in 13 subjects (2.4%). Plaques were detected in 79 subjects (14.7%). Compared with those without LAICOD, the 48 subjects (8.9%) with LAICOD had greater CIMTs (0.77±0.09 versus 0.73±0.12 mm; P =0.044), more with CIMT of higher quartiles ( P =0.007), and more with carotid plaques (25.0% versus 13.7%; P =0.035). However, after adjusting for confounding factors, CIMT and presence of carotid plaque were not significantly associated with LAICOD. Conclusions— The results suggest that CIMT and presence of carotid plaque probably are not independently correlated with LAICOD in Chinese community residents, which supported the existence of pathologic and pathophysiologic differences in atherogenesis of intra- and extracranial arteries.

Background and Purpose— In a pilot study we evaluated near-infrared spectroscopy as to its potential benefit in monitoring patients with steno-occlusive disease of a major cerebral artery for alterations in cortical hemodynamics. Methods— Cortical maps of time-to-peak (TTP) in 10 patients unilaterally affected by severe stenosis or occlusion of the middle cerebral artery were acquired by multichannel near-infrared spectroscopy after bolus application of indocyanine green. Hemodynamic manifestations were assessed by comparison between affected and unaffected hemisphere and evaluated for common constituents by principal component analysis. In one patient, TTP values were compared with those obtained by dynamic susceptibility contrast imaging. Results— TTP was increased on the affected hemisphere in 9 patients. Mean difference in TTP between hemispheres was 0.44 second ( P P Conclusion— Multichannel near-infrared spectroscopy might facilitate detection of disease-related hemodynamic changes as yet only accessible by tomographic imaging modalities. Being indicative for hypoperfusion and collateral flow increased values of TTP, as found to a varying extent in the present patient group, might be of clinical relevance.

Objectives: Peripheral vascular disease (PVD) is a systemic disorder, which can affect all territories of arteries. In order to maximize screening survey yield: we aimed to describe the association between positive lower extremity (LE) non-invasive flow studies in symptomatic patients and occult carotid occlusive disease (COD). Methods: A retrospective chart review was performed on 420 patients who underwent carotid duplex ultrasound and non-invasive flow studies (NIFS; aka Pulse volume recordings) for evaluation of COD and LE PVD respectively. Additional clinical variables collected included age, gender, and indication for NIFS and indication for carotid duplex. The respective studies were performed within a year of each other. Statistical analysis was performed using SPSSv20 software and SAS statistical software. Univariate analysis was performed using Mann-Whitney, student t-test and receiver operating curve (ROC). Results: 66% (266/420) of the patients were male and 43% (181/420) of patients had documented history of bruit. Patients with mild PVD (ABI between 0.81 and 1) were more likely to have clinically significant COD than patients with moderate to severe PVD (ABI < 0.8) (25% vs 16.19%, P=0.03). Therefore, severity of peripheral vascular disease did not correlate with likelihood of clinically significant COD (p>0.05). ROC analysis was performed (AUC=0.602, p=0.05). Low ABI 0.50 was found to be 92% sensitive (Se) but only 14% specific (Sp). The optimal ABI cutoff point for predicting COD was 0.95 (Se=40%,Sp 60%, Youden’s index 0.194) Conclusion: Therefore, routine screening for COD in patients with lower extremity peripheral vascular disease is unlikely to uncover clinically significant carotid stenosis. These findings do not indicate a population of patients for which a combined prospective screening is warranted.

OBJECTIVE The aim of the present study was to determine whether early and late/early images on 123I-iomazenil (IMZ) single-photon emission computed tomography (SPECT) correlate with cerebral blood flow (CBF) images and oxygen extraction fraction (OEF) images on PET, respectively, in the cerebral cortex of patients with chronic unilateral middle cerebral artery or internal carotid artery occlusive disease. METHODS In 20 normal individuals and in 68 patients, CBF and OEF were assessed using 15O-PET, and brain SPECT scans were initiated immediately after (early images) and 180 min after (late images) the administration of 123I-IMZ. A region of interest was automatically placed in the middle cerebral artery territory in both cerebral hemispheres using a three-dimensional stereotaxic region of interest template, and the ratio of the value in the affected side to that in the contralateral side was calculated in each image. RESULTS Among patients, a significant positive correlation was observed between PET-CBF ratios and the SPECT-early IMZ ratios (r=0.797, P

It was not until the first half of the 19th century that the vascular nature of strokes was readily recognized and accepted. Brain "softenings" were distinguished from hemorrhagic "apoplexy," but stroke etiology remained unstudied. The terms artherosclerosis, thrombosis, embolism, and lacune were introduced to indicate etiology, but carotid occlusive disease was recognized later, in the second half of the 19th century. The development of knowledge of stroke was slow, likely corresponding to limited interest by the great early neurologists: stroke never was a field of critical interest in the Salpêtrière and Pitié Schools at the time of the local leading figures, Vulpian and Charcot. By contrast, scarce studies were due to isolated physicians, who did not contribute much to other fields, including Rochoux, Rostan, Durand-Fardel, or Dechambre; critical advances came from pathologists such as Rokitansky and Virchow. The interest in stroke among neurologists generally was clearly triggered by the development of clinical-topographic correlation studies, promoted by Déjerine and Marie, and followed by Foix, the father of modern clinical stroke research.

INTRODUCTION Aorto-iliac occlusive disease can cause disabling symptoms and Trans-Atlantic Inter-Society Consensus (TASC II) has recommended the treatment options for varying severity of the disease. In the TASC II article, an increasing interest for laparoscopic aorto-ilio-femoral surgery was noted. AIM To review the literature on the minimally invasive interventions currently used in aorto-iliac occlusive disease with a focus on laparoscopic aortic surgery. METHODS Medline search and hand search of references from relevant articles to describe the current management options for aorto-iliac occlusive disease. CONCLUSION Laparoscopic aorto-femoral surgery is a therapeutic option for most TASC C and D lesions.

Despite progressive insights into the pathologies underlying coronary, cerebral, and peripheral artery atherosclerosis, these conditions continue to cause critical tissue ischemia and disability on an epidemic scale. For the past several decades, research and therapeutic development have focused on preventing or reversing occlusive disease in conduit vessels. The ultimate failure of macrovessel-targeted therapies is never more evident than in peripheral arterial disease, in which progressive disease leads to amputation at rates that have not changed significantly in 30 years. Despite modern therapy, up to 8 million Americans with peripheral arterial disease are devastated by immobility, intractable ischemia, ulceration, impaired wound healing, or amputation,1 and the lack of additional treatment options leaves many patients with little hope for relief. Article p 58 The concept of therapeutic angiogenesis evolved from pioneering work in the 1970s by Folkman,2 who observed that the development and maintenance of an adequate microvascular supply is essential for the growth of neoplastic tissue. His hypothesis that the inhibition of “tumor angiogenic factors” would be effective against solid tumors was met with widespread skepticism, but 30 years of persistent research led to the development and approval of antiangiogenic treatments that now constitute a significant portion of the anticancer armamentarium. Soon after the identification of angiogenic growth factors, cardiovascular investigators began testing the hypothesis that stimulating angiogenesis could improve perfusion and function in ischemic tissues independent of macrovessel manipulation.3 Abundant preclinical data supported the safety and clinical potential of therapeutic angiogenesis that used growth factors or cellular-based strategies.4,5 Ac

Cerebral endovascular neurosurgery has evolved rapidly in the past decade through advances in tools and techniques and as a result of the thrust toward evidence-based medicine. More patients with diseases traditionally treated via microsurgical approaches can now be treated with techniques that focus on endoluminal reconstruction. With the introduction of intracranial clot retrievers and appropriately sized stents, stroke care is being slowly revolutionized for those patients with salvageable brain tissue at the time of admission to the hospital. In this article, the recent history, current state, and possible future of cerebral endovascular neurosurgery are reviewed for the following diseases: stroke, intracranial atherosclerotic disease, brachiocephalic occlusive disease, cerebral aneurysms, central nervous system vascular malformations, and brain tumors. New concepts and applications for endovascular treatment of epilepsy and multiple sclerosis are mentioned. The potential for nanotechnology in this field and the future endovascular suite are envisioned.

DURING THE PAST decade, endovascular techniques and clinical experience have matured to the point that all or a significant part of the treatment of acute ischemic stroke, cerebral aneurysms, brachiocephalic occlusive disease, and arteriovenous fistulae or malformations is performed in angiography suites by neuroradiologists, vascular surgeons, peripheral interventionists, cardiologists, neurologists, and neurosurgeons worldwide. With improvements in technology and lower morbidity rates, the scope of endovascular techniques will only increase. Currently, in the United States alone, this amounts to a volume of more than 500,000 patients annually. Neurosurgeons currently provide only a small portion of the care of these patients. The workforce needs for endovascular surgeons in neurosurgery will be determined by the patients, the willingness of neurosurgeons to embrace endovascular techniques, and the broad scope of cerebrovascular disorders that can be treated.

The purpose of this study was to evaluate the efficacy of a pain-free treadmill walking program in intellectually disabled (ID) adults with arterial occlusive disease. Fourteen participants with mild ID participated in the walking program. Six patients showed stable intermittent claudication. A control (nontreadmill, n = 12) group consisted of 4 individuals with intermittent claudication. Noninvasive determinations of lower-limb hemodynamics included photoplethysmography and ankle-brachial pressure. Pain levels were measured according to a pain pathophysiology index. The treadmill program consisted of individually prescribed low-endurance walking at a 0% incline done at a comfortable speed 3 times per week. All participants completed the 15-week walking program and showed significant improvements (p < 0.05) in walking speed, distance, and duration. Pain levels were reduced in individuals suffering from intermittent claudication. Blood hemodynamic parameters also showed significant improvements. In conclusion, low-intensity treadmill walking significantly improved the functional capacities of adult individuals with mild ID with vascular occlusion and reduced pain levels.

Background and Purpose—We sought to determine the incidence of recurrent stenosis after carotid endarterectomy.Methods—One thousand consecutive carotid endarterectomy patients were followed prospectively. The surgery was performed in a standard fashion. Cerebral protection was provided with intraoperative electroencephalographic monitoring and selective shunting. All arteriotomies were repaired with a patch graft. Each patient was seen 3 months after surgery and then yearly, with a duplex ultrasound obtained at each visit. Evidence for new ischemic events or recurrent stenosis of ≥70% was recorded.Results—The 30-day combined minor and major stroke and death rate was 1.9%. At 7.1-year follow-up, 0.1% of patients had recurrent stenosis ≥70%, the majority of which were asymptomatic.Conclusions—Carotid endarterectomy is a low-risk procedure for the treatment of carotid occlusive disease, with excellent long-term durability. Although less invasive, carotid angioplasty must demonstrate equal robustness in long-term follow-up before it is considered a routine alternative to surgery.

Improved surgical techniques for carotid endarterectomy (CEA) surgical patients have resulted in improved postoperative hemodynamic stability of patients and reduced lengths of hospitalization. The purpose of this pilot project was to determine CEA patient outcomes after a rapid recovery hospitalization program. Thirty-nine patients were enrolled in the study and contacted at 1 month after CEA surgery to examine carotid occlusive disease clinical symptoms, functional status, atherosclerotic disease risk-factor reduction, and patient satisfaction. Findings of the pilot study demonstrated that CEA surgical patients were able to resume physical and psychosocial functioning by 1 month after surgery at levels comparable to preoperative functioning. Subjects reported relief of carotid artery occlusive disease symptoms and reported high levels of independent functioning and satisfaction with CEA surgery. Men in the study had significantly higher levels of reported independence in functioning compared with the women, using a "0" to "10" scale to rate level of functioning independence. Findings from the pilot study will be used to develop an early recovery and atherosclerotic disease risk-factor modification program for CEA surgical patients.

Occlusions of the retinal arterial and venous circulations are common causes of severe visual decline and can affect all age groups. Acute retinal arterial obstruction is often associated with critical cerebrovascular and cardiovascular disease that may require systemic treatment. Retinal venous obstruction may be the presentation of significant systemic hypertension, diabetes mellitus, and a greater risk for cardiovascular morbidity. Additional metabolic and hematologic abnormalities have been identified in patients with retinal occlusive disease. The authors review recent advances in the study of systemic conditions associated with retinal vascular occlusions and offer guidelines for appropriate medical evaluation of patients with retinal occlusive disease.

RATIONALE AND OBJECTIVES Phosphorus-31 (31p) magnetic resonance spectroscopy (MRS) is used to assess the influence of sex and age on quadriceps muscle metabolism before and after exercise. METHODS Fifty-four healthy volunteers and 56 patients with an arterial occlusive disease were examined by dynamic 31p MRS. In the magnet, the quadriceps muscle was stressed by an isometric and an isotonic form of exercise until exhaustion. RESULTS Older subjects showed a significantly larger ratio of inorganic phosphate (P(i)) to phosphocreatine (PCr) than younger subjects (r = 0.52, P = 8 x 10(-9)). With subjects' increasing age, the ratio of adenosine triphosphate (beta-ATP) to total phosphate decreased (r = -0.36, P = 5 x 10(-5)). The ratio of phosphomonoester to beta-ATP and phosphodiester (PDE) to beta-ATP showed a strong age dependence (r = 0.71 and 0.69, P = 3 x 10(-17) and 4 x 10(-15), respectively). The pH was the only one of the evaluated spectroscopic parameters that showed a sex dependence. Female subjects had a significantly lower pH (7.03+/-0.02) than male subjects (7.05+/-0.03) (P = 6 x 10(-4)). With increasing age, the maxima of P(i) to PCr were less extreme during both of the exercises (r = -0.51, P = 3 x 10(-16)). Likewise, the exercise-induced acidosis was less severe with increasing age (r = -0.51, P = 7 x 10(-16)). After the exercises ended, the times of half recovery of P(i) to PCr and the pH neither correlated with the subjects' age nor with sex or the cross-sectional area of the quadriceps muscle. CONCLUSIONS The sex and age of volunteers or patients may affect spectroscopic results in a significant way. This influence has to be considered in the interpretation of spectroscopic studies. According to the recovery rates of P(i) to PCr and the pH, an age-related deterioration of muscular metabolism seems to be avoidable by appropriate physical activity.

Abstract —Although each of the major lipoprotein fractions is composed of various subclasses that may differ in atherogenicity, the importance of this heterogeneity has been difficult to ascertain owing to the labor-intensive nature of subclass measurement methods. We have recently developed a procedure, using proton nuclear magnetic resonance (NMR) spectroscopy, to simultaneously quantify levels of subclasses of very low density (VLDL), low density (LDL), and high density (HDL) lipoproteins; subclass distributions determined with this method agree well with those derived by gradient gel electrophoresis. The objective of the current study of 158 men was to examine whether NMR-derived lipoprotein subclass levels improve the prediction of arteriographically documented coronary artery disease (CAD) when levels of lipids and lipoproteins are known. We found that a global measure of CAD severity was positively associated with levels of large VLDL and small HDL particles and inversely associated with intermediate size HDL particles; these associations were independent of age and standard lipid measurements. At comparable lipid and lipoprotein levels, for example, men with relatively high (higher than the median) levels of either small HDL or large VLDL particles were three to four times more likely to have extensive CAD than were the other men; the 27 men with high levels of both large VLDL and small HDL were 15 times more likely to have extensive CAD than were men with low levels. In contrast, adjustment for levels of triglycerides or HDL cholesterol greatly reduced the relation of small LDL particles to CAD. These findings suggest that large VLDL and small HDL particles may play important roles in the development of occlusive disease and that their measurement, which is not possible with routine lipid testing, may lead to more accurate risk assessment.

Background and Objectives: Early neurological improvement (ENI) at 2-hours post thrombolysis has recently been proposed to most accurately predict recanalization when repeat vascular imaging is not available. However, these studies analyzed recanalization at a delayed time point (≥24 hours). The Argatroban tPA Stroke Study (ARTSS-1), is a recently completed NIH sponsored, Phase IIa, prospective, open-label, safety and activity study of Argatroban and rtPA in patients with ischemic stroke ( NCT00268762 ). We hypothesized 2-hour recanalization correlates with ENI (NIHSS improvement of 20% or greater from baseline). Methods: A total of 65 patients with intracranial large vessel occlusive disease were given standard dose (0.9mg/kg) tPA and a 100 μg/kg bolus of argatroban followed by infusion of 1 μg/kg per minute for 48 hours adjusted to a PTT of 1.75 times baseline. Pre-tPA vessel imaging using TCD or CTA confirmed intracranial occlusions. A multivariate logistic regression tested whether recanalization at 2 hours was associated with ENI after controlling for age, NIHSS, clot location (ICA, MCA or vertebrobasilar). We analyzed whether patients with ENI had statistically significant greater odds of an excellent mRS (0 or 1) at day 7. Results: Recanalization data was available for 47 patients at 2-hours. ENI occurred at 2-hours in 46% patients. Patients with any recanalization (complete or partial) at 2-hours were more likely to experience ENI (OR 3.4; 95% CI 0.71-16.6, p=0.124). This association strengthened when 2-hour complete recanalization was analyzed (OR 5.4; 95% CI 0.98-29.2, p=0.053). In an unadjusted analysis, patients with ENI at 2-hours were five times more likely to have excellent mRS outcomes at day 7 (OR 4.7; 95% CI 1.4-15.6, p=0.01). In the adjusted model, the association remained significant (OR 3.8; 95%CI 1.1-13.4, p=0.041). Conclusion: Two-hour recanalization is predictive of early neurological improvement and better early clinical outcomes in patients treated with combination Argatroban and tPA. A randomized, controlled clinical trial of this promising adjunctive therapy is warranted and ongoing (ARTSS-2 trial, NCT01464788 ).

Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.

Xu et al.1 should be commended for their study that assesses the importance of middle cerebral artery (MCA) “deep tiny flow voids” (DTFV) on high-resolution MRI in patients with steno-occlusive disease. The incidence of DTFV increased with the degree of MCA stenosis and was more common in asymptomatic patients. Obvious flow voids in the basal ganglia region were observed in 57% of patients with moyamoya disease but no patients with DTFV.

Recent studies documenting the efficacy of carotid endarterectomy (CEA) in selected patients provide further impetus for developing noninvasive techniques to evaluate carotid occlusive disease. Eliminating the morbidity due to preoperative angiography would further refine the treatment of this condition. Recent improvements and greater experience with magnetic resonance angiography (MRA) of extracranial vessels have increased the accuracy of this technique. We present our experience using MRA in combination with duplex ultrasonography as the primary mode of preoperative evaluation for CEA. Fifty-two patients referred for CEA underwent these two studies. In 47 patients (90%), significant stenosis (70%) was unambiguously identified on both ultrasound and MRA. Forty-one of these patients underwent CEA on the basis of these studies alone, without conventional angiography. In all of these cases, significant stenosis was identified at the time of surgery (100%), and CEA was performed without difficulty or complications. In five cases (9.6%), the MRA and ultrasound findings did not concur exactly. In three of these cases, the interpretation of the two studies differed with respect to the severity of stenosis; in the others, one of the studies was indeterminate. These patients underwent conventional angiography before surgery. Our experience suggests that the combined use of MRA and ultrasonography affords an accurate noninvasive evaluation of carotid occlusive disease sufficient for surgical planning in most cases.

Territorial cerebellar infarcts have mainly a thromboembolic mechanism. Cerebellar infarcts less than 2 cm in diameter have recently been reported as nonterritorial infarcts, but it is not clear whether they are low-flow or embolic infarcts. The aim of the present study was to compare the characteristics and causes of territorial and nonterritorial infarcts in a prospective series of 115 patients. We collected data from 115 consecutive patients with cerebellar infarcts (79 territorial and 36 nonterritorial [ie, less than 2 cm]), using magnetic resonance imaging (88 patients) and computed tomography. Patients with territorial infarcts and those with nonterritorial infarcts had similar vascular risk factors and clinical presentations and an equal frequency of cardiac source of embolism (32% versus 42%; P = NS) and of large artery occlusive disease (23% versus 19%; P = NS). Occlusive lesions of large arteries at angiography occurred at the level of one cerebellar artery (5% versus 0%; P = NS) and proximal to the ostia of the cerebellar arteries (18% versus 19%; P = NS). Infarcts distal to occlusive lesions were subdivided into unilateral vertebral artery occlusive disease (presumed artery-to-artery embolic mechanism; 18% versus 5%; P = NS) and low-flow state distal to bilateral vertebral or basilar artery occlusion (presumed hemodynamic mechanism; 0% versus 14%; P = .004). Patients with nonterritorial infarcts had more frequent hypercoagulable state (17% versus 1.25%; odds ratio, 15.6 [95% confidence interval, 1.8 to 135]). For the remaining patients, the mechanism of the infarct was unknown (34% versus 22%; P = NS). Cerebellar infarcts less than 2 cm in diameter (ie, nonterritorial) have the same high rate of embolic mechanism as territorial infarcts (47% versus 49%; P = NS), have more frequent hypercoagulable state, and sometimes have a hemodynamic mechanism.

Thirty-seven patients with various coverage problems and with lower extremity occlusive disease underwent free transfer of the greater omentum into the defect with a favorable clinical success rate. There are a number of advantages of this technique for such reconstructive problems.

After amputation for arterial occlusive disease of the lower limbs, healing and local adaptation to a prosthesis depend on the oxygen ratio in the tissue. Transcutaneous oxygen tension (TcPO2) is a noninvasive microcirculatory exploration. Forty six below-knee stumps were selected without any prosthetic problem excepting vascular, with a follow-up mean duration of 23 months. They were classified into different prosthetic categories. The first was the worst because it required further amputation on the thigh and the fourth the best, which displayed complete adaptation to a socket contact. These groups were related to their TcPO2 values on the anterior and exterior face of the stumps in both reclined and seated positions. It seems that it is impossible to achieve healing when the TcPO2 value is lower than 15 mm Hg in lying position. However, healing is possible above 20 mm Hg but socket contact is not possible when TcPO2 values are under 40 mm Hg. When TcPO2 values are above 40 mm Hg, a good prosthesis fitting is possible when no problems are encountered other than vascular ones.

Cardiovascular disease continues to be a major cause of death in the United States. Although the number of deaths has decreased in the past several years, disability from the disease remains significant because of its systemic nature. As the population continues to age, peripheral vascular disease (PVD) will become increasingly prevalent in society as a result of the process of atherosclerosis. This article focuses on the care of patients with PVD. Risk factors, presenting signs and symptoms, and diagnostic and therapeutic modalities associated with chronic arterial occlusive disease, as well as nursing responsibilities and interventions, are discussed.

To determine the presence, location and pattern of arterial occlusive disease within the hypogastric-cavernous arterial bed in impotent men following blunt perineal and pelvic trauma, we reviewed the selective internal pudendal arteriograms of 20 patients with a history of blunt perineal and 7 with blunt pelvic trauma who had immediate development of impotence. Arteriographic studies of 104 other impotent patients also were reviewed and compared. Patients with persistent impotence immediately after blunt pelvic and perineal trauma had significantly different patterns of arteriographically demonstrated occlusive disease within the distal hypogastric-cavernous arterial bed consistent with the site of the traumatic injury. Those who sustained blunt pelvic trauma and complained of immediate impotence revealed arterial occlusive lesions mainly in the internal pudendal, common penile, cavernous and dorsal arteries. The incidence of arterial lesions in the distal internal pudendal or common penile artery was significantly higher (p less than 0.01) in patients with blunt pelvic trauma (92%) than in those with blunt perineal trauma (35%). Patients who sustained blunt perineal trauma and complained of immediate impotence demonstrated a more focal pattern of pathological arterial occlusion primarily in the cavernous and dorsal arteries. The incidence of a solitary arterial lesion in the cavernous artery without proximal disease was significantly higher (p less than 0.05) in patients with blunt perineal trauma (48%) than in those with blunt pelvic trauma (8%). It is hypothesized that blunt trauma without immediate impotence may be a potential risk factor for later development of arterial vasculogenic impotence, and that unrecognized or seemingly innocuous trauma may be a factor in cases of idiopathic impotence. Patients without trauma and with vascular risk factors have a more diffuse pattern of arteriographically demonstrated arterial lesions.

The surgical management of chronic atherosclerotic renal artery occlusion (RA-OCC) was studied.From January 1987 through December 1996, 397 consecutive patients were treated for atherosclerotic renal artery disease. Ninety-five hypertensive patients (mean blood pressure, 204 +/- 31/106 +/- 20 mm Hg; mean medications, 3.0 +/- 1.1 drugs) were treated for 100 RA-OCCs. Eighty-four (88%) patients had renal dysfunction, defined by serum creatinine levels/=1.3 mg/dL (mean serum creatinine level, 2.8 +/- 2.0 mg/dL). Demographic characteristics, operative morbidity and mortality, blood pressure/renal function response, and postoperative decline in renal function were examined and compared with that of 302 patients treated for renal artery stenosis (RAS).After operation, there were 5 perioperative deaths (5.2%), 2 (2.8%) after revascularization and 3 (12%) after nephrectomy (P =.11), compared with 12 (4.0%) perioperative deaths in the RAS group (P =.59). After controlling for important covariates, estimated survival and blood pressure benefits did not differ between RA-OCC patients treated by nephrectomy or revascularization (P =.13; 87% vs 92%, P =.54). Excretory renal function was considered improved in 49% of 79 RA-OCC patients with renal dysfunction, including 9 patients removed from dialysis-dependence. Among patients treated for unilateral disease, revascularization for RA-OCC was associated with significant improvement in renal function (P.01); however, nephrectomy alone did not increase renal function significantly. Improved renal function after operation was associated with a significant and independent increase in survival (P.01) and dialysis-free survival (P.01) among patients treated for RA-OCC. In addition, blood pressure benefit, renal function response, and estimated survival did not differ significantly after reconstruction for RA-OCC or RAS.Among hypertensive patients treated for RA-OCC, equivalent beneficial blood pressure response was observed after both revascularization and nephrectomy. In patients who underwent bilateral renal artery revascularization, the change in excretory renal function attributable to repair of RA-OCC cannot be defined. In patients treated for unilateral disease, however, improvement in function was observed only after revascularization. Moreover, improved renal function demonstrated a significant and independent association with improved survival. This experience supports renal revascularization in preference to nephrectomy for RA-OCC in select hypertensive patients when a normal distal artery is demonstrated at operation.

OBJECTIVE: There has been a resurgence of interest in selective extracranial-intracranial bypass for revascularization of cerebrovascular occlusive disease. We evaluated the usefulness of intraoperative blood flow measurements in predicting graft success after extracranial-intracranial bypass. METHODS: A retrospective review of 51 cases of extracranial-intracranial bypass for purposes of flow augmentation in the setting of cerebrovascular occlusive disease was performed. In all cases, free flow from the cut end of the donor vessel, termed cut flow, was measured. The cut flow index (CFI) (bypass flow [ml/min] / cut flow [ml/min]) was derived and correlated with bypass patency, postoperative bypass flow, cerebrovascular reserve testing, and clinical outcome. RESULTS: The CFI was a significant predictor of bypass patency (P = 0.002). Using a CFI of 0.5 as a threshold, the bypass patency rate was 92% in cases with a CFI greater than 0.5 compared with 50% in cases with a CFI less than 0.5. Intraoperative bypass flow correlated well with postoperative measurements obtained from quantitative phase-contrast magnetic resonance imaging. An analysis of cases with a poor CFI indicated that a logical interpretation of bypass function can be performed during surgery. CONCLUSION: A poor CFI can alert surgeons to potential difficulties with the donor vessel, anastomosis, or recipient vessel during surgery. Furthermore, a CFI closely approximating 1.0 provides physiological confirmation of impaired cerebrovascular reserve in the recipient bed.

To the Editor: In a recently published editorial, Caplan propounded a question for new therapy strategy in ischemic stroke patients.1 He pointed out 3 main factors that are responsible for progression and worsening of neurological deficits in patients with noncardioembolic stroke. According to Steinke and Ley,2 one of these factors concerns reduced blood flow in the ischemic zone following occlusive disease of the supplying arteries. In respect of discussed facts, Caplan concluded that the only efficient therapy for worsening in stroke patients is an augmentation, ie, improvement in cerebral blood supply. In addition to his proposal about either pharmacological or surgical management (eg, by established carotid endarterectomy),3,4⇓ there …