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Magnetic Resonance (MR) uses many exam of medical image field. In this case report, we found an interesting case. We did not call it as patient because she did not present any symptoms, thus we call it as subject. Natural cerebral vascular deficiency was seldom to be reported due to subject does not present any obvious symptoms when subject is health or young. Hope that this case report would increase we know more about the congenital part cerebral vascular deficiency. A 36 y old female, who come to our hospital for advanced medical health examination. On the regular radiology exam, the MRI showed she has a congenital part cerebral vascular deficiency on December in 2013. In general, main cerebral artery deficiency would cause some impact on physiological, however, its seemly does not affect her in daily or intelligent working, or we still not know would it affect to human. This case report showed a young women persistent hypoglossal artery was missing. We should continuous follow the subject by regular medical health examination. For her, we can prevent further congenital caused injuries. It also added a rare case of Taiwanese in medical imaging academic field.

Balance disorders and recurring falls are the most frequent causes of medical treatment in old age. Chronic cerebral vascular insufficiency is considered to be the cause of instability in most of these cases, and its role in the development of postural instability in old age is likely to be greatly overrated. At the same time, the role of chronic peripheral vestibular disorders, by contrast, is underestimated. The emergence in recent years of sensitive, specific and, at the same time, relatively accessible methods of diagnosing peripheral vestibulopathies has led to a much more frequent diagnosis of peripheral vestibulopathies, and their role in the development of postural instability in elderly patients is being revisited. This review considers current approaches to the diagnosis and treatment of bilateral vestibulopathy.Расстройства равновесия и падения — одна из самых частых причин обращения за медицинской помощью в пожилом возрасте. Причиной неустойчивости в большинстве таких случаев считают хроническую цереброваскулярную недостаточность, роль которой в развитии постуральной неустойчивости в пожилом возрасте, вероятно, существенно переоценивается. В то же время роль хронических периферических вестибулярных расстройств, напротив, недооценивается. Появление в последние годы чувствительных, специфичных и, одновременно, сравнительно доступных методов диагностики периферических вестибулопатий привело к тому, что заболевания периферической вестибулярной системы стали диагностироваться значительно чаще, а их роль в развитии постуральной неустойчивости у пожилых пациентов пересматривается. В настоящем обзоре рассматриваются современные подходы к диагностике и лечению двусторонней вестибулопатии.

to obtain more specific information on the morphology and pathogenesis of cerebral infarctions occurring in vertebrobasilar artery (VBA) atherosclerosis.Macro- and microscopic investigations of the brain, its arterial system, and heart were conducted in 69 autopsy cases with infarctions located in the vertebrobasilar system (VBS) in atherosclerosis.69 cases were found to have 206 VBA infarctions of various extent and locations. The detected infarctions were single and multiple in 27 and 42 cases, respectively. The detected infarctions included extensive (n=7), large (n=9), medium (n=63), small deep (lacunar) (n=97), and small superficial (n=30). The brain stem showed lacunar infarctions most frequently (76% of the infarctions at this site). Medium and small infarctions were identified at the same frequency in the cerebral hemispheres and cerebellum. The occurrence of 94% of the extensive and large infarctions was ascertained to be pathogenetically associated with atherothrombotic occlusion of the intracranial arteries in the VBS. 76% of the small infarctions occurred through the mechanism of cerebral vascular insufficiency in tandem atherostenosis of VBAs in conjunction with an additional decrease in cerebral blood flow under the influence of an extracerebral factor (coronary heart disease). Medium infarctions were approximately equifrequently due to the two aforementioned causes and, in some cases, to cardiogenic thromboembolism of VBAs. Infarctions were multiple in most cases; while recent large atherothrombotic infarctions were frequently concurrent with small organized infarctions resulting from tandem atherostenosis of VBAs.This investigation could establish the relationship between the site, extent, and pathogenetic factors of infarctions in the VBA bed in atherosclerosis, as well as the prognostic value of small infarctions as predictors for severe ischemic stroke.Цель исследования - уточнение данных о морфологии и патогенезе инфарктов головного мозга, возникающих при атеросклерозе артерий вертебробазилярной системы (ВБС). Материал и методы. Проведено макро- и микроскопическое патолого-анатомическое исследование головного мозга, его артериальной системы и сердца в 69 секционных случаях с инфарктами, локализовавшимися в бассейне ВБС при атеросклерозе. Результаты. В 69 случаях выявлено 206 инфарктов различной величины и локализации в бассейне артерий ВБС. В 27 случаях инфаркты были одиночными, в 42 - множественными. Среди выявленных инфарктов 7 были обширными, 9 - большими, 63 - средними, 97 - малыми глубинными (лакунарными) и 30 - малыми поверхностными. В стволе мозга чаще всего обнаруживались лакунарные инфаркты (76% инфарктов данной локализации). В полушариях мозга и мозжечке с одинаковой частотой выявлялись средние и малые инфаркты. Установлено, что возникновение 94% обширных и больших инфарктов патогенетически связано с обтурирующим атеротромбозом интракраниальных артерий ВБС. 76% малых инфарктов возникли по механизму сосудистой мозговой недостаточности при тандемном атеростенозе артерий ВБС и дополнительном уменьшении притока крови к мозгу под влиянием экстрацеребрального фактора (ишемическая болезнь сердца). Средние инфаркты обусловливались обеими вышеуказанными причинами практически в равной степени, а также в ряде случаев кардиогенной эмболией артерий ВБС. В большинстве случаев инфаркты имели множественный характер, при этом отмечено частое сочетание крупных атеротромботических инфарктов небольшой давности с малыми организованными инфарктами, возникшими вследствие тандемного атеростеноза артерий ВБС. Заключение. Проведенное исследование позволило установить связь между локализацией, величиной и патогенетическими факторами возникновения инфарктов в бассейне артерий ВБС при атеросклерозе, а также прогностическую значимость малых инфарктов в качестве предикторов тяжелого ишемического инсульта.

Though the human brain is only ∼2% of body mass, it represents more than 20% of total body oxygen and energy consumption,1,2 and the supply of blood to the active neurons must match their metabolic demand. Fortunately, the tight coupling between capillary endothelial cells, astrocytes, pericytes, and neurons—dubbed the neurovascular unit—ensures precise modulation of regional blood flow in response to local metabolic demand. This integration of supply and demand, termed neurovascular coupling (NVC), is critical to neurophysiologic health. Indeed, accumulating evidence shows an important role for cerebral vascular insufficiency in neurodegenerative diseases ranging from vascular cognitive impairment3 to Alzheimer disease.4 Therefore, targeting cerebral vascular pathology is a promising option for primary and secondary prevention of neurodegenerative diseases and subsequent cognitive impairments.

The efficacy of treatment with cerebrolysin was studied in 40 patients with cerebral vascular insufficiency. Cerebrolysin (20 daily i.v. infusions of 10 ml in 200 ml of physiological saline) was found to be an effective means of treating this group of patients. Courses of cerebrolysin treatment decreased the severity of memory and attention impairments, improving the overall cognitive status of the patients. Clinical observations and neuropsychological testing were supported by electrophysiological results, in terms of the P300 cognitive evoked potential. The effects of treatment at the doses used here were delayed and were seen three months after completion of treatment.

Moyamoya disease is a rare cerebral vascular disease that results in narrowing of the vessels of the circle of Willis and the formation of a network of collateral vessels at the base of the brain for compensatory perfusion. Moyamoya disease has the highest incidence during the first decade of life, and children present most frequently with transient ischemic attacks. We present two cases of Moyamoya disease in children with associated hypothalamic-pituitary dysfunction. Both children presented to the endocrinologist for decreased growth velocity. One child had hypothyroidism and both had growth hormone deficiency. A review of the literature reveals a few isolated case reports of hypothalamic-pituitary dysfunction occurring with Moyamoya disease and with other states of cerebral vascular insufficiency. We suggest that children with compromise of cerebral vascular perfusion be monitored closely for clinical signs and symptoms of hypothalamic-pituitary dysfunction.

“The eventual definition of the precise role of surgery in the management of cerebral vascular insufficiency must await the outcome of further studies, but it may be safely said at this time that surgical measures have already demonstrated their effectiveness in many patients with stroke syndromes.” 1 Jesse Thompson, a most distinguished carotid surgeon, wrote this in 1968. Nearly a quarter of a century had to pass before official accreditation was bestowed.2 During this time, rejection of surgical therapy among many physicians ranged from simple withholding of acceptance to stifling opposition. Largely because of the conviction among most vascular and neurosurgeons, based on their personal experience, that carotid endarterectomy was a beneficial and durable procedure for the prevention of carotid territory stroke, the number of operations increased each year. Approximately 17,000 were performed in 1977 and over 100,000 in 1984 in the United States alone. From 1954 to 1990 the worldwide number of carotid endarterectomies was estimated as approximately one million. Although excellent results in terms of operative morbidity and mortality as well as duration of stroke prevention were published,3–7 many reports were less salutary. This was particularly true in some series dealing with the asymptomatic carotid lesion with clearly unacceptably high rates of perioperative stroke and death.8–15 Confusion as to the proper indications for and the true utility of carotid endarterectomy increased in the medical and lay communities, and the need for controlled randomized studies became apparent.16–18

I N THE more than 25 yr since the first report of successful carotid artery reconstruction for symptoms of cerebral vascular insufficiency,’ the role of extracranial arterial surgery in the management of these disorders has become established. Carotid artery bifurcation endarterectomj is now an accepted form of therapy for selected patients with monocular or cerebral hemispheric transient ischemic attacks.*” Conversely, it is generally agreed that arteriography and carotid artery surgery should be avoided in patients with progressing and acute severe stroke, because of the risk of exacerbating the neurologic deficit.6.m9 However, a small percentage of patients have thromboembolic cerebral ischemia manifested by unstable neurologic deficits of only mild to moderate degree. There is no consensus on the indications for and timing of surgery in these patients, but most neurologists and vascular surgeons have treated them as acute strokes and withheld angiography and surgery. Because several such patients in whom this approach was followed progressed to a severe, fixed neurologic deficit, we adopted a more aggressive plan of management. This approach and the results of its use are described in this report.

Patients with ccrebral vascular insufficiency can frequently be treatcd and benefitted by carotid endarterectomy. Approximately 60 to 70 per cent of patients with cerebral vascular insufficiency have stenotic, ulcerative, or occlusive lesions in the extracranial portion of one or more of the four major arteries that supply the brain.

SummaryThis retrospective study concerning 102 patients was undertaken to study the therapeutic decisions in these patients when they presented with symptoms of cerebral vascular insufficiency, mostly from the territory of the carotid artery, either transient or accompanied by a deficit. The current literature on the subject is also mentioned. The clinical outcome with regard to the quality of life, seems to have been better in patients who were subjected to carotid endar terectomies than in those who received medical treatment.

One hundred and eight patients were studied with fluid-filled oculoplethysmography and carotid phonoangiography (OPG-CPA) and by arteriography. Thirty-two patients also had "Doppler evaluation" of supraorbital arterial flow. The OPG-CPA correctly predicted the degree of occlusion in 76% of the involved vessels, including the degree of occlusion of each carotid for each patient (63%). The OPG-CPA identified at least one obstructing carotid lesion in 51 of the 56 (91%) patients with obstructing lesions demonstrated by arteriography. On a per patient basis, which requires that both carotids be correctly assessed, the OPG-CPA had a false negative rate of 9.6% and false positive rate of 50%. The supraorbital artery "Doppler evaluation" had an accuracy rate of 66%, a per patient false negative rate of 50%, and a per patient false positive rate of 12%. The OPG-CPA and supraorbital artery "Doppler evaluation" are adjunctive tests for evaluating patients with cerebral vascular insufficiency and should not, at present, replace arteriography in symptomatic patients or in certain asymptomatic patients.

Collateral circulation is of most concern in the pathologic process of the brain, particularly in the occlusive disease of the cervical and cerebral arteries. The collateral circulation to the brain exists in three main areas (Kaplan)1): (1) through extracranial arterial connections; (2) through developmental extracranial to intracranial persisting arteries; and (3) through intracranial cerebral arterial anastomoses. The author directed efforts toward an analysis of collateral circulation to the brain of the aged subjects with some degree of atherosclerosis in the cervical as well as in the cerebral arteries. The present study consists of three parts: (1) a study on atherosclerosis of the major cervical and cerebral arteries; (2) a demonstration of the collateral circulation between the internal carotid, external carotid, and vertebral arteries; as to the intracranial anastomoses, emphasis was laid on the variations of the basal cerebral arteries, including the circle of Willis; and (3) a clinical consideration of cases with severe stenosis of the cervical arteries, with regard to cerebral vascular insufficiency due to a drop of the systemic blood pressure.

An attempt has been made to emphasize the importance of a neurologic complication of minor surgery. In the later decades of life the decreased adaptability and the presence of arteriosclerosis may be well tolerated until the patient is faced with the need of adjusting to a group of factors, each tending to contribute some degree of transient cerebral anoxia. The effect of these various stresses is cumulative and their sum total is capable of resulting in acute cerebral vascular insufficiency. Based on the physiologic changes involved, certain measures are suggested which would seem to lessen the risk of anoxic damage to the brain. As new drugs and technics steadily increase the human life span, physicians have a vital responsibility to try to keep the added years as free as possible of disabling neurologic symptoms. State hospitals filled with elderly patients who are psychotic due to cerebral vascular damage cannot be considered a tribute to medical progress. Until the problem of preventing the development of arteriosclerosis and hypertension is solved, no practical clinical means of postponing their effects even temporarily should be overlooked.

The surgeon's interest in cerebral vascular disease began in the last century with the concern for hemorrhagic collections on the surface of the brain-the epidural and subdural hematomas. In this century, with the development and use of cerebral angiography since the thirties, cerebral aneurysms and their intracranial complications have gained increasing attention. Of more than academic interest, many aneurysms are now amenable to surgical treatment. More recently, patients having a socalled “cerebral vascular accident,” or “stroke syndrome,” have been referred to the neurosurgeon for evaluation. By collaboration, the radiologist also is involved in seeking a physiologic explanation for the dysfunction associated with cerebral vascular insufficiency and/or failure. Such collaboration is based mainly upon the application of the radiologic technic of angiography. This revealing premortem pathophysiologic roentgen procedure is disclosing new and important information concerning the dynamics of cerebral blood...

Surgery to relieve extracranial obstruction to cerebral flow has proved to be a valid treatment for cerebral vascular insufficiency. This is particularly true of isolated stenosis of the carotid bifurcation producing transient ischemic attacks.

• Of 358 patients referred for evaluation of cerebral vascular insufficiency over a ten-year period (January 1971 to April 1981), 32 were isolated who had experienced hemispheric transient ischemic attacks (TIAs), and lacking other identifiable abnormality were found angiographically to be free of suspicious extracranial occlusive or ulcerated lesions. These patients were studied retrospectively to evaluate their prognosis in terms of cerebral infarction and recurrent neurologic symptoms. In a mean follow-up of 16 months, ranging from three months to four years, no patient suffered a cerebral infarction. Six had further symptoms; however, three were due to other abnormalities found subsequently. Three patients continued to be symptomatic; however, only one patient had recurrent hemispheric symptoms, the others being global and vague in description. Severe hypertension was associated with an increased risk of further attacks. The data indicate that the prognosis for patients with normal angiograms and hemispheric TIAs, lacking other identifiable abnormality, is good. ( Arch Surg 1981;116:1587-1591)

1. Direct surgical denervation of the carotid sinus would appear to offer the best long-term results for carotid sinus syncope. 2. Carotid sinus denervation should be done under temporary cardiac pacing for safety and for completeness of denervation. 3. Arteriography is indicated to eliminate those cases of cerebral vascular insufficiency that might mimic carotid sinus syndrome. Credit must be given to Dr. R. Hughes, Clearfield, Pa., who recognized this diagnosis and referred the patient for therapy.

Elongation with kinking of the internal carotid artery is not an uncommon finding. Cerebral vascular insufficiency has been reported secondary to this abnormality. Although arteriosclerosis is a frequent cause in adults, the etiology in children has never been explained. Three children with significant kinking of the internal carotid artery are reported here. Each underwent surgical correction by excision and reconstruction. Histological review showed the elastic tissue to be disrupted, diminished in amount, and unevenly distributed. Retrospective examination of this elastic tissue dysplasia showed it to be localized, there being normal morphology both proximally and distal to the involved area. There was recurrence of elongation and kinking in one patient due to incomplete excision. Correction was accomplished after re-excision of the involved tissue with a vein graft interposition. From this study, it can be concluded that elongation and kinking of the internal carotid artery in children is secondary to elastic tissue dysplasia. It is imperative that the entire involved area be removed in order to prevent recurrence. The excised specimen should be studied histologically with elastic tissue stains. Such stains cannot be performed as frozen section. Should permanent studies show the margins of resection not to be beyond the dysplastic tissue, careful followup of these children is essential to recognize recurrence.

Six years ago we began using a dense vascular suture method for bypass operations in our hospital. Having standardized the microvascular suture procedure, we tried to reduce the duration of the operation and the amount of suture material employed. In 50 patients with cerebral vascular insufficiency of various degrees, we partially glued the vessels at the anastomosis (1, 3). We preferred a small osteoplastic flap and an intracutaneous suture to minimize ischemia of the tissues.

According to the statistics of the World Health Organization (1970), cerebrovascular disorders rank among the top three categories of disease leading to mortality in the industrialized countries. A better understanding of cerebral vascular insufficiency, its detection and localization, may be gained through a quantitative characterization of the complete circulatory system of the brain in terms of the vascular morphology and the pressure and blood flow wave forms. Furthermore, various control mechanisms appear to condition blood flow in the brain, possibly by modifying the cross-sectional areas of certain blood vessels.

Sermion (nicergoline) is an ergoline derivative clinically active in chronic cerebral vascular insufficiency [1] and in patients with senile dementia [2].

Thirty-nine patients (mean age: 33 years) with Takayasu's disease were observed over the past 8 years. Among these patients, 33 had surgical intervention with a mean follow-up of 4 years. Lesions of the aortic arch were the most common (29 patients, 69 lesions) and frequently were associated with lesions in another site as well. However, in this group of patients, the infrequent presence of signs of cerebral vascular insufficiency limited the number of suitable surgical candidates to 14 patients. Lesions of the renal arteries were noted in 25 patients (37 lesions) and were associated with coarctation of the thoracoabdominal aorta in 12 patients. In contrast to lesions of the aortic arch, the presence of severe hypertension was a frequent indication for surgery in Takayasu's disease. Twenty-one patients had operation. Twenty of 21 patients were considered cured or improved of hypertension. The one patient who received no benefit was the only operative death of the study. In conclusion, although Takayasu's disease is progressive and the life expectancy is foreshortened, hypertension secondary to aortic and renal artery lesions is a frequent and important indication for aggressive operative treatment.

Excerpt The clinical syndrome of carotid artery occlusion with resultant cerebral vascular insufficiency is well recognized, having been emphasized as long ago as 1914 by Hunt1and more recently rev...

Excerpt Transient cerebral vascular disturbances are of common occurrence and have been observed by most clinicians. When such episodes result from widespread cerebral ischemia, they are ordinarily...

Acute cerebral vascular insufficiency may be defined physiologically as a deficiency of cerebral arterial blood flow resulting from an inadequate systemic arterial blood pressure or impairment of the cardiac output.1This condition is often transient and correctible, although the resulting deleterious effect upon the brain may or may not be permanent. The deficit in cerebral blood flow may involve the whole brain, or it may be localized. When it is generalized, the well-known symptoms of syncope, generalized grand mal seizures, etc. may occur. It has not been clearly recognized, however, that focal cerebral manifestations, such as hemiplegia, hemisensory disturbances, and Jacksonian seizures, are not uncommonly the result of localized cerebral vascular insufficiency. In the past, such disorders when permanent have been attributed to cerebral hemorrhage, thrombosis, or embolism. When focal cerebral signs have been transient, they have usually been considered a result of localized cerebral vascular spasm. It is

The natural history of 500 patients was studied prospectively over a mean period of 4.6 years (S.D. 2.8). One hundred and fifty-one patients presented with cerebral vascular insufficiency and of these 94 developed a stroke later in the history. Three hundred and forty-nine patients presented with a stroke and of these 164 had no further stroke episode. One hundred and eighty-five had further stroke episodes and in 76.8 per cent this occurred within three years of the onset of the disease. The worst prognosis was associated with recurrent stroke episodes as indicated by the survival rates. The survival rates for transient vascular insufficiency uncomplicated by stroke were similar to those of the normal population.

The commonest cause of cerebral vascular insufficiency is arteriosclerotic involvement of the caroticovertebral system. Although the significance of these lesions in patients with cerebral arterial insufficiency was recognized by Chiari1and Hunt6decades ago, the segmental nature of arteriosclerosis and recognition of early clinical manifestations of carotid and vertebral artery occlusion were not described until recent years.5,7 Early attempts in the treatment of these occlusive lesions, such as procaine (Novocain) block of the cervical sympathetic ganglion, denervation of contralateral carotid sinus, and establishment of caroticojugular fistula, proved ineffective. Renewed effort was urged for direct arterial surgery. The accumulated experience with other segmental arterial lesions and development of carotid angiography9led to the application of operative procedures which had proved effective in surgery of aortoiliac and femoropopliteal occlusions. Satisfactory results following endarterectomy,2excisional treatment,4,8and grafting procedures3of the involved arteries introduced a new

Patients with clinical evidence of cerebral vascular insufficiency frequently relate that a particular head position may precipitate their symptoms. Usually, extension of the head, as in looking upward, or lateral rotation, as in looking over the shoulder, is mentioned. In a previous study1we found that many such patients tolerated compression of a carotid artery when their heads were face forward but quickly developed signs and symptoms of insufficiency when carotid compression was repeated after the head had been turned to one side. In the past, those2,3who have recognized this influence which head position can have upon response to carotid compression have usually attributed it to stimulation of a carotid sinus reflex mechanism or to local anatomical factors which permit more effective compression of the sinus when the head is rotated. In this paper we suggest that a more important factor may be change in blood flow

RECENT literature suggests that pacemaker tachycardia or "runaway" has become a rare problem. The phenomenon still occurs, however, and may be transient and difficult to document. Report of a Case An 85-year-old woman was brought to the emergency room after collapsing at home. She had had a Stanicor model 143 E7 ventricular inhibited pacer inserted transvenously at another hospital 261 days earlier for complete heart block with a slow ventricular rate. Her symptoms prior to the insertion were fatigue, lethargy, and syncope, as well as an episode of cerebral vascular insufficiency with transient left-sided weakness and dysarthria. She subsequently did well until the morning of admission, when she suddenly collapsed. In the emergency room the patient was unresponsive and apneic, and her blood pressure was unobtainable. An electrocardiogram demonstrated the pacemaker artifact at a variable rate between 300 to 375 beats per minute (Figure). There was no sign of ventricular

ACUTE cerebral disturbances are usually considered to be the result of cerebral - hemorrhage, thrombosis, embolism, or spasm. 1 Yet in 60 of 100 cases of fatal cerebral infarction Hicks and Warren 2 were unable to find evidence of mechanical occlusion of cerebral vessels by thrombosis, embolism, or arteriosclerosis. In other words, cerebral infarction without occlusion of the cerebral arteries may occur. For many years the finding of cerebral infarction without cerebral arterial occlusion and the transiency and reversibility of various acute manifestations of cerebral dysfunction 3 have been explained on the basis of cerebral vascular spasm. At present there appears to be considerable doubt concerning the role of spasm of the cerebral arteries in the production of focal cerebral disorders. 4 The present study is not concerned with the problem of whether spasm of cerebral arteries may bring about cerebral disorders. Rather, it is desired to call attention to another

RECONSTRUCTION of the carotid bifurcation to alleviate cerebral vascular insufficiency is a proven procedure but the selection of patients for operation, the technical conduct of the operation, and the results achieved are areas in which there is a lack of agreement. In an effort to clarify these areas we are presenting our experience with the use of thromboendarterectomy in arteriosclerotic occlusive disease of the carotid artery bifurcation. Occlusive disease of the aortic arch and the innominate, subclavian, and vertebral arteries is not included. The clinical picture related by the patient with carotid artery insufficiency may be extremely variable, encompassing symptoms from mild "wooziness" to hemiplegia, coma, and death. There is no consistent pattern, probably explained by multiple areas of arterial involvement, anatomical differences producing a variable collateral potential, the happenstance destination of small emboli, and the individual patient's variation in brain area tolerances to hypoxia. However, contralateral hemiparesis, and paresthesias

A femoral-axillary bypass graft was done for complicated brachiocephalic obstruction with cerebral vascular insufficiency. It appears to be an effective method for managing problems of cerebrovascular insufficiency, which enables one to avoid thoracotomy when a source of blood flow in the neck is not available.

The Seventh Princeton Conference on Cerebral Vascular Diseases, held in January 1970, included discussions of spinal cord vascular diseases, cerebral edema and cerebral vascular disease, techniques for diagnosis of obstructive vascular disease, cerebral blood flow and metabolism, acceleration, weightlessness, and the cerebral circulation, cerebral vascular insufficiency, and intracranial arterial aneurysms. The papers presented are of reasonable length, generally of high caliber, and many will hold significant interest for the internist. The discussion of clinical aspects of vascular disease of the spinal cord is very well done, and two brief papers on transient ischemic attacks give a valuable perspective on natural history and prognosis. Of particular importance is the report of the cooperative study on surgery for transient ischemic attacks which fails to indicate any major benefit from operation. The volume includes generous sections of discussion. It is highly recommended for those who have responsibility for patients with cerebrovascular disease.