Clinical Neuroscience

[Forum]

SZÉL István, DÓCZI Tamás, SUBOSITS István, GÖLLESZ Viktor, NAGY Zoltán, FAZEKAS András

JULY 20, 1993

Clinical Neuroscience - 1993;46(07-08)

[Letter from Dr. Tamás Dóczi. In memory of Artúr Sarbó. Summary of the meeting of the College of Neurology held on 16 April 1993.]

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Clinical Neuroscience

Pathology of the vestibular system

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The vestibular end organ, in spite of its small size, has extremely rich interconnections with other parts of the nervous system. The vestibular system can be damaged at the end organ, along the vestibular nerve, in its brain stem representations and in its cerebellar projections. The nature of the pathological process damaging the vestibular system is manifold: neoplastic, inflammatory, vascular, nutritional and degenerative. Neural complications of AIDS may also involve the vestibular system. The lesions may be focal, multifocal and diffuse. While in the past the results of neurootological examinations could only be correlated with post mortem findings, NMI opens new horizons for neurootological and topoanatomical correlative studies.

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[In Hungary the prevalence of cerebrovascular disorders has increased so that each year vascular reconstruction surgery is needed in 2800 cases. However, only a quarter of these eligible patients are operated. After a thorough examination if all the indications for carotid surgery are met, more and more patients will end up in vascular reconstruction units. Angiography and surgery are recommended if the carotid artery stenosis is asymptomatic and is more than 90%. Also, under special conditions an asymptomatic carotid stenosis may caused by indicate surgery (before coronary by-pass operation, etc.). Another indication is a transient ischemic attack, if carotid artery lesion and the stenosis is above 70%. Ulcerated plaques also need surgery because they are a likely source of emboli. After stroke surgery may be necessary if the angiologic status is unstable and further ischemic events, that may lead to disability are expected. An acute stroke rarely calls for surgery. In contrast to this, immediate surgery is needed after repeated, TIA, or crescendo TIA because the risk of stroke is very high in these cases. Finally, sometimes surgery is indicated because of the occlusion of internal and common carotid artery. With vertebrobasilar vascular reconstruction, we do not have enough experience. Cerebrovascular syndromes due to supraaortic vascular lesions are other indications for reconstruction surgery. However, surgery is never a satisfactory substitute for pharmacological treatment.]

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[In 22 patients with subarachnoid hemorrhage secondary to ruptured intracranial aneurysms serial neurological evaluations, transcranial Doppler examinations and computer tomographic scans were performed. Transcranial Doppler flow velocities were significantly elevated for the group with vasospasm on posthemorrhage day 2. The maximum blood flow velocities were recorded between days 9 and 18, with normalization occurring within the following 3 weeks. Increase in velocity preceded clinical symptoms and could therefore be used as a prognostic factor for the management of patients with subarachnoid hemorrhage. The data also indicated that the extent and location of blood in the subarachnoid space determine the severity and location of vasospasm.]

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[Clinical details are presented of 5 patients with a giant carotid aneurysm in whom both the occlusion of the aneurysm and the parent internal carotid artery were performed with an extra-intracranial arterial bypass. In the first case ligature of the giant carotid-ophthalmic aneurysm narrowed the parent artery critically and hemiplegia developed. The bypass operation did not improve the clinical outcome. In the second case the occlusion of the aneurysm was performed after an extra-intracranial anastomosis and in spite of the severely narrowed carotid artery the postoperative course was uneventful. In three cases of giant intracavernous aneurysm the occlusion of the carotid artery on the neck and just proximal to the ophthalmic artery was performed in the presence of an arterial bypass. All of the anastomoses were patent and no ischemic event developed during the follow up period. On the basis of these experiences the authors suggest that, if the preoperative tests (TCD, EEG, SPECT) reveal impending ischemic lesion after carotid compression, surgery should be performed with the combination of extra-intracranial bypass.]

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