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Objective To report a cost-effective and scientifically based algorithm for the clinical assessment and treatment of patients with transient ischemic attack (TIA) or minor ischemic stroke. Design We comprehensively reviewed the literature on the epidemiologic features, assessment approaches, and treatment recommendations for ischemic cerebrovascular disease and developed an algorithm by using the available clinical and research data to support all decision-making steps. Material and Methods For patients with TIA or minor ischemic stroke, the appropriate setting for investigation (inpatient or outpatient), suggested diagnostic tests, use of anticoagulants and antiplatelet agents, and indications for surgical treatment are reviewed. Results Although stroke is a common cause of death and lost productivity in the United States, the clinical assessment of patients with TIA or minor ischemic stroke has lacked consistency. The simplified algorithm clarifies patients who may be candidates for hospitalization and possible anticoagulation therapy. Initial diagnostic studies should include computed tomography of the head without use of a contrast agent, which quickly distinguishes nonhemorrhagic from hemorrhagic cerebrovascular disease. Evolving noninvasive studies of the cerebral vasculature are providing increasingly sensitive means of detecting stenoses, yet cerebral angiography remains the "gold standard." Treatment options depend on the pathophysiologic findings on diagnostic evaluation. Conclusion The assessment of patients with ischemic cerebrovascular disease is complex. The simplified algorithmic approach reported herein necessitates entry of appropriate patients into the algorithm. Because of clinical heterogeneity, an algorithm may apply to a wide spectrum of patients but will not cover every situation; hence, evaluation must be guided by a patient's unique history and findings on examination and by the physician's clinical experience.

Nonfatal penetrating injuries to the brainstem offer a unique opportunity to assess subcortical auditory pathway function. A case study of a patient suffering a severe nailgun accident is presented. Hearing sensitivity and acoustic reflexes were normal bilaterally, but word recognition was reduced for one ear. Auditory brainstem response results indicated waves I–IV were present bilaterally, but wave V was absent bilaterally. Results of vestibular findings indicated central pathology also. Results of audiologic, vestibular, radiologic, neurologic, and physical medicine examinations are discussed.

• In the case described, electroencephalography (EEG) proved valuable for determining the nature of spells of loss of consciousness with brief clonic jerks associated with ear and throat pain. A 70-year-old woman had a history of episodic brief attacks of pain below the right ear and deep in the neck that had started three years previously. The spells became more severe and progressed to loss of awareness associated with clonic jerks of the extremities. Because of a concern that the spells represented seizures, an EEG was performed, with electrocardiographic monitoring. Multiple spells were recorded; they began with profound bradycardia followed by generalized slowwave activity and then by suppression of all EEG activity correlating with loss of consciousness and clonic jerking. The spells were thought to represent syncopal attacks associated with glossopharyngeal neuralgia.

• Brainstem auditory evoked potentials (BAEPs) were obtained in 20 patients with palatal myoclonus. The group included 14 men and six women whose ages ranged from 19 to 82 years. Six of the patients had abnormal BAEPs: two with severe head trauma and one each with a brainstem infarct, tumor, demyelination, and an indeterminate inflammatory process. The 14 patients with normal BAEPs had palatal myoclonus secondary to head trauma (five patients), brainstem infarcts (four patients), cerebellar tumors (two patients), degenerative processes (two patients), and an Arnold-Chiari malformation (one patient). Since the auditory pathways are separate from the structures associated with palatal myoclonus, it is possible to have discrete lesions producing palatal myoclonus with sparing of the auditory structures, whereas diffuse or multifocal lesions of the brainstem are more likely to be associated with abnormal BAEPs.

The natural history of postirradiation extracranial cerebrovascular disease is uncertain. Previous reported cases spanning 20 years of carotid surgery are difficult to evaluate, because patients may sometimes have unspecified symptoms, physical examinations, postoperative results, and follow-up. Also, the evolution of carotid surgery over the past two decades makes it impossible to compare earlier operative technique with the state-of-the-art technique of today. Our series of 7 patients underwent 9 carotid endarterectomies with an average follow-up period of 46 months. The number of patients is small, and although technically this is a more difficult operation, we feel the results are favorable and may be comparable with endarterectomy procedures in nonirradiated patients. These patients should be approached as if radiation changes are not a major factor when they are considered for reconstructive arterial surgery.

CHLOROQUINE PHOSPHATE may induce irreversible retinal pigmentary degeneration in humans who receive the drug in high doses over a long period of time. This report describes ocular changes seen in rabbits after the prolonged oral administration of chloroquine phosphate. Materials and Methods Four albino and four pigmented healthy rabbits were fed chloroquine phosphate mixed with their food daily for 11 months. On the basis of a usual human dose of 250 mg/day for a 60-kg human (4.2 mg/k of body weight per day), four animals (two albino and two pigmented) received an approximate daily dosage of 42 mg/day/kg of body weight (ten times the usual human dose), and four animals (two albino and two pigmented) received 21 mg/kg of body weight per day (five times the usual human dose). The dosage for this latter group was later arbitrarily increased fourfold to 84 mg/kg of body weight per day (20 times

In 29 cases of meningeal carcinomatosis reviewed, the widespread involvement of the cranial and spinal leptomeninges produced a complex neurological picture that made the diagnosis difficult. Examination of cerebrospinal fluid was the most helpful diagnostic procedure; the fluid often had decreased glucose and an increased protein content and contained malignant cells. Diffuse leptomeningeal and craniospinal nerve root infiltration was a consistent postmortem finding. The propensity of adenocarcinoma to metastasize in this fashion is reflected by the high frequency of this histologic type in this series. The two commonest primary sites were the breast and lung. In all patients there was progressive clinical deterioration; the average survival after diagnosis was only six weeks.

Thorium dioxide (Thorotrast), a radioactive substance with a very long half-life, has been used in the past as a contrast medium for various roentgenologic studies. Some of these have been followed by the delayed appearance of benign and malignant tumors, especially of the liver. Chronic arachnoiditis and myelopathy developed in three patients after myelography with thorium dioxide. Progressive involvement of the cauda equina, spinal cord, and brain stem was observed. One patient died after 26 years of illness.