Cervical vascular injuries: a trauma center experience

BACKGROUND: We analyzed 76 patients with cervical vascular injuries from penetrating neck trauma (n = 528) between 1977 and 1990 at a level I trauma center to evaluate the role of angiography in diagnosis and management and to assess the course and outcome of these patients. METHODS: Patients who were hemodynamically unstable underwent immediate surgical exploration. Stable patients were subjected to diagnostic investigation. Angiography was routinely performed to diagnose vascular injury in zones I and III and zone II if the trajectory was in the vicinity of major vessels. Therapeutic embolization was performed when possible at angiography; all other vascular injuries were treated surgically. RESULTS: Thirteen patients (2.5%) died of penetrating neck trauma, in 12 of whom hemorrhage was the contributing factor (12/76; 15.8% of patients with vascular injury). In nine patients who were hemodynamically stable vascular injury was diagnosed by angiography: 5 (6.8%) of 73 in zone I and 3 (5.4%) of 56 in zone III, four of whom underwent therapeutic embolic occlusion of the injured vessel. Injuries to vertebral and subclavian arteries and subclavian and innominate veins were often multiple, causing exsanguination and death (6.8% in zone I). In three patients with no preoperative neurologic deficit, the internal carotid artery was ligated without complication; in all other patients injury to the common carotid or internal carotid artery was repaired, in six of them with polytetrafluoroethylene grafts. CONCLUSIONS: Selective management of penetrating neck trauma should include routine angiography in zones I and III. Injuries to the common and internal carotid arteries should be repaired. The internal carotid artery may be ligated in the absence of preoperative neurologic deficit. Arterial injuries in the neck can be repaired with polytetrafluoroethylene grafts.     

Ischaemic stroke from cerebral embolism in cephalic fibromuscular dysplasia

Fibromuscular dysplasia (FMD) of the internal carotid arteries and its relationship with focal cerebral ischaemia is unproven. This vasculopathy is often detected incidentally during a cerebral angiogram for non-ischaemic cerebral events. FMD affects the proximal one-third of the internal carotid artery in almost all cases and is bilateral in 60% to 85%, with middle-aged women affected in 85% of the cases. Ischaemic stroke has been postulated to result from severe stenosis or thrombotic occlusion at the FMD site. Cerebral embolism from FMD has rarely been reported. We report 3 young patients with acute ischaemic stroke who had FMD on cerebral angiography. They presented with a focal hemispheric stroke where the probable pathophysiology is embolism to the distal internal carotid artery from thrombus formed at the proximal FMD site. The patients were all males, with unilateral proximal internal carotid artery FMD lesions and occlusion of the internal carotid artery distally on the same side. All were extensively investigated and no other causes for stroke were found.     

Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass

PURPOSE: This study was undertaken to assess the natural history of carotid artery stenosis in patients undergoing cardiopulmonary bypass (CPB) at a Veterans Administration Medical Center. METHODS: Between January 1989 and August 1993, all patients undergoing CPB were offered preoperative carotid artery ultrasound screening as part of an investigative protocol. Patients were monitored in-hospital for the occurrence of perioperative neurologic deficit. RESULTS: A total of 582 patients underwent carotid artery ultrasound screening. Greater than 50% stenosis or occlusion of one or both internal carotid arteries was present in 130 patients (22%), with 80% or greater stenosis or occlusion of one or both arteries present in 70 patients (12%). In-hospital stroke or death occurred in 12 (2.1%) and 36 (6.2%) patients, respectively. Of the 12 strokes, five were global and seven were hemispheric in distribution. Of the five patients who had global events, none had evidence of carotid artery stenosis. However, of the seven patients who had hemispheric events, five had significant 50% or greater stenosis or occlusion of the internal carotid artery ipsilateral to the hemispheric stroke. Therefore the presence of carotid artery stenosis or occlusion was significantly associated with hemispheric stroke (no stenosis 0.34% vs stenosis 3.8%; p = 0.0072). Furthermore, the risk of hemispheric stroke in patients with unilateral 80% to 99% stenosis, bilateral 50% to 99% stenosis, or unilateral occlusion with contralateral 50% or greater stenosis was 5.3% (4 of 75). No strokes occurred in patients with unilateral 50% to 79% stenosis (n = 52). CONCLUSIONS: It is concluded that carotid atherosclerosis is a risk factor for hemispheric stroke in patients undergoing CPB.     

Elective carotid artery stenting in the presence of contralateral occlusion

Significant carotid stenosis in the presence of an occluded contralateral artery has a poor prognosis with medical therapy alone. Carotid cross clamping during surgical endarterectomy results in critical flow reductions in patients with inadequate collateral flow, and represents a significant risk for procedural strokes. Carotid stenting is being evaluated as an alternative to endarterectomy. We describe the immediate and late outcome of a series of 26 patients treated with carotid stenting in the presence of contralateral carotid occlusion. The mean age of the patients in this group was 65 +/- 9 years, 23 (89%) were men and 10 (39%) were symptomatic from the vessel treated. The procedural success of carotid stenting in this group of patients was 96%. The mean diameter stenosis was reduced from 76 +/- 15% to 2.8 +/- 5%. There was 1 (3.8%) minor stroke in a patient who developed air embolism during baseline angiography. At late follow-up there was no neurologic event in any patient at a mean of 16 +/- 9.5 months after the procedure. Thus, carotid stenting of lesions with contralateral occlusion can be performed successfully with a low incidence of procedural neurologic complications and late stroke.     

Symptomatic recurrent carotid stenosis and aneurysmal degeneration after endarterectomy

BACKGROUND: Aneurysmal degeneration of a carotid reconstruction was not recognized until the patient, who was known to have recurrent carotid artery stenosis, had a thromboembolic stroke. This sequelae of carotid endarterectomy is a serious complication, associated with a high morbidity and mortality rate. This review was conducted to establish the risk of transient ischemic attack and stroke for patients found to have recurrent carotid stenosis associated with aneurysmal degeneration of the carotid artery after endarterectomy. METHODS: A case is reported, and 100 literature references of aneurysmal degeneration of the carotid artery after endarterectomy were reviewed. RESULTS: False aneurysm from anastomotic disruption was the most common presentation identified in the cases reviewed. Nineteen of the patients had a significant neurologic event; however, three (50%) of six patients with aneurysm and recurrent carotid artery stenosis had a transient ischemic attack or stroke. CONCLUSIONS: The incidence of neurologic symptoms is markedly increased when recurrent carotid artery stenosis is associated with carotid aneurysm. During postoperative surveillance after endarterectomy, the identification of recurrent carotid artery stenosis requires evaluation for aneurysmal degeneration of the carotid artery with duplex scanning. These patients are at significant risk for transient ischemic attack and stroke. This rare complication merits operative repair.     

Angioplasty of the occluded internal carotid artery

PURPOSE: To review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful. METHODS: We reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed. RESULTS: All four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent. CONCLUSION: In acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Carotid endarterectomy combined with myocardial revascularization: report of 27 patients

Atherosclerosis is a systemic disease that may involve more than one territory. Myocardial infarction can occur after carotid endarterectomy and stroke is a well documented morbidity of coronary artery bypass grafting. To optimize results, we have performed concomitant carotid endarterectomy and myocardial revascularization in selected cases, with severe disease in both territories. During a 13-year period, 27 patients were submitted for this procedure, 21 (77.8%) were male and the average age was 67.6 years (range 59-81). All patients had high-grade internal carotid artery stenosis, five (18.5%) were symptomatic. Coronary artery disease symptoms were: unstable angina in 12 patients (44.4%) and effort angina in 15 (55.6%). Two patients (7.4%) required reintervention for postoperative bleeding. Two cases (7.4%) had transient renal dysfunction. One patient, with multiple organ failure, died on the 16th postoperative day (3.7%). Follow up was obtained in 26 patients (96.3%). Survival at 5 years was 80.6%, 95.7% of those patients were free of any neurologic symptom. Combined carotid and coronary surgery is a safe treatment option for atherosclerosis of multiple territories in selected patients; long term benefits are also obtained.     

Correlation of cine MR velocity measurements in the internal carotid artery with collateral flow in the circle of Willis: preliminary study

The velocity-phase relationship intrinsic to phase-contrast magnetic resonance (MR) angiography permits the quantitative and qualitative assessment of blood flow. The ability to measure velocity and vessel cross-sectional area allows noninvasive assessment of volume flow rate (VFR) in the internal carotid artery (ICA). Phase-contrast techniques also demonstrate flow direction. Using two-dimensional cine phase-contrast angiography, the authors evaluated VFR in the ICA and collateral flow about the circle of Willis in 15 patients with ischemic neurologic symptoms. The VFR in each carotid artery was correlated with the degree of stenosis and presence or absence of abnormal circle of Willis collateral flow. There was a correlation between a decrease in VFR and abnormal circle of Willis collateral flow. In addition, a correlation between severe stenosis and a decrease in VFR was found. In patients with ischemic neurologic symptoms without severe stenosis (< 70% diameter stenosis), no decrease in VFR was seen. It is hoped that flow quantification and directional flow imaging with phase-contrast angiography will help further characterize carotid artery occlusive disease by enabling assessment of VFR changes associated with ischemic neurologic symptoms. This study also supports the hypothesis that two mechanisms--hemodynamic and embolic--play a role in ischemic neurologic symptoms.     

Postoperative stroke and late neurologic complications after carotid endarterectomy

From 1969 through 1973, 335 consecutive patients (mean age, 60 years) underwent 390 carotid endarterectomies using hypercarbic general anesthesia and no carotid shunting. Early neurologic complications were most common among patients with previous neurologic symptoms and among those with subtotal stenosis or occlusion of the contralateral internal carotid artery. The introduction of routine carotid shunting without hypercarbia during a subsequent series of 626 procedures from 1974 through 1978 has been associated with significantly fewer operative strokes in comparable groups of patients. Complete follow-up information during a mean interval of 8.6 years is available for 95% of 325 operative survivors. Late completed strokes have occurred in 17% of patients but have involved the cerebral hemisphere on the side of previous carotid endarterectomy in only 7%. Of 93 operative survivors who had subtotal stenosis of the contralateral internal carotid artery, 45 underwent contralateral endarterectomy as an elective procedure and 48 did not. The late contralateral stroke rates for these two groups of patients were 4% and 16%, respectively, although these differences did not attain statistical significance. Forty-nine (78%) of 63 patients with contralateral internal carotid occlusion have had no late neurologic symptoms following unilateral carotid endarterectomy.     

Surgical treatment of common carotid artery occlusion

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.     

Indication for surgery of asymptomatic carotid lesions

The incidence of cerebrovascular diseases with transient or persistent neurologic dysfunction has increased significantly. Although patients with symptomatic carotid artery stenosis clearly benefit from operative therapy, the indication to prophylactic surgery of asymptomatic carotid lesions however is still controversial. Based on data from a recently completed prospective randomized study and on analysis of the literature the indication and results of surgical treatment of asymptomatic stenoses of the carotid arteries are discussed. From 1970 to 1990 a total of 744 uni-or bilateral reconstructions of the internal carotid artery were performed in 631 patients. The perioperative morbidity (permanent neurologic deficiency) and mortality was 1.1% (n = 8) resp. 0.8% (n = 6). During the follow up period up to 18 years another 9 patients suffered from stroke (1.2%). The annual stroke incidence amounted to 0.2%. An important prerequisite for surgery is the so called critical internal carotid artery stenosis, implying reduced cerebral vasomotor reactivity or high embolic risk of an ulcerative plaque. Proper selection of patients (exclusion of multiple concomitant diseases) and an experienced team of vascular surgeons with operative morbidity and mortality below 1-2% validates surgical treatment of asymptomatic carotid artery stenoses.     

Neurologic complications of cerebral angiography

PURPOSE: To examine the incidence of neurologic complications associated with modern cerebral angiography and to assess patient characteristics associated with an increased risk of complications. METHODS: One thousand consecutive cerebral angiographic procedures were evaluated prospectively. Examinations were performed using transfemoral catheterization and film-screen methods. For purposes of this trial, a neurologic complication was defined as any new focal neurologic deficit or change in mental status occurring during the angiogram or within the following 24 hours. Patients were evaluated during and at the completion of angiography. Follow-up evaluations were performed on the day of and the day after angiography. RESULTS: There were a total of 10 neurologic complications within 24 hours of angiography, 5 of which were persistent. Onset of 5 of the deficits occurred during angiography, the other 5 (3 persistent) were delayed. All complications occurred in patients being evaluated for stroke/transient ischemic attack or (in one case) asymptomatic bruit. A higher average age, longer average procedure time, and greater volume of radiographic contrast was noted in these patients than in the study population. CONCLUSION: Cerebral angiography was associated with a 1% overall incidence of neurologic deficit and a 0.5% incidence of persistent deficit. All complications occurred in patients presenting with a history of stroke/transient ischemic accident or carotid bruit, which may reflect the difficulty of performing angiography in this population at risk for atherosclerotic changes.     

Tribute to 50 years and a look forward

OBJECTIVES: Carotid angiography is associated with a 2% risk of stroke and, since the advent of colour-duplex ultrasound, its role in the assessment of patients with carotid disease has been the subject of debate. The aim of this study was to evaluate a policy of adopting routine duplex supplemented by selective angiography on operative outcome over a 5-year period. METHODS: A prospective audit of the results of carotid endarterectomy without routine angiography from January 1992 to December 1996. Angiography was performed only if the ultrasonography was concerned about the distal or proximal extent of disease or to assess subocclusion. RESULTS: During the study period, 494 carotid endarterectomies were performed but only 35 patients underwent carotid angiography. The indications for angiography were subocclusion/string sign in 22 patients, to assess the limits of proximal or distal disease in 12 and abnormal anatomy in one. During the 5-year study period the overall perioperative death and/or stroke rate was 4.2%. By 1997, the perioperative stroke rate had fallen to 1.3%. In no case in this series was the operation abandoned due to unexpected findings. CONCLUSION: Although concerns exist about the precise duplex criteria for diagnosing a severe stenosis, this study has shown that a policy of selective angiography does not compromise patient safety or operability and avoids the unnecessary mortality, morbidity and costs associated with routine angiography.     

Microemboli during carotid angiography. Association with stroke risk factors or subsequent magnetic resonance imaging changes?

BACKGROUND AND PURPOSE: Carotid angiography is associated with a 1% risk of major stroke. Recently, transcranial Doppler ultrasonography (TCD) has shown cerebral microemboli during carotid angiography. To determine their significance, we correlated the number of microemboli during angiography with clinical characteristics, angiography findings, and preangiography and postangiography cerebral magnetic resonance imaging (MRI). METHODS: One middle cerebral artery was monitored with TCD in 24 patients during angiography for carotid territory ischemia. The number of microemboli was correlated with angiographic and clinical characteristics. T2-weighted cerebral MRI was performed before and < or = 48 hours after angiography, and the number of new ischemic lesions was determined in a blinded review. RESULTS: Microemboli were seen in all patients, with an average of 51 per procedure (range, 12 to 154). The majority of microemboli had signal characteristics typical of air. Sixteen of the 24 patients had both preangiography and postangiography MRI. One of 24 patients had an angiographic stroke, with a single new thalamic lesion on MRI. No other patient had a new lesion. The microembolus count correlated with the angiographic contrast volume (P < .001) but not with any other radiological or clinical characteristic. CONCLUSIONS: This study confirmed the presence of numerous cerebral microemboli during carotid angiography. The microembolic signal characteristics and the correlation with contrast volume indicate that introduced air is the cause. These microemboli are usually clinically silent and do not lead to new changes on cerebral MRI.     

Risk factors for stroke after cardiac surgery: Buffalo Cardiac-Cerebral Study Group

PURPOSE: The purpose of this study was to identify risk factors for stroke in patients undergoing heart surgery. METHODS: A retrospective chart review of patients who underwent cardiac surgery in three hospitals of the State University of New York at Buffalo system over a 36-month period was completed. Demographics and risk factors were recorded, and stroke and death were determined by chart review. Carotid artery stenosis was determined by duplex examination. Data were analyzed by chi-squared and multiple logistic regression. RESULTS: One thousand one hundred seventy-nine cases were analyzed, with a mortality rate of 2.3%, stroke rate of 1.6%, and combined stroke/death rate of 3.1%. Four variables were found to be associated with an increased risk of stroke: carotid artery stenosis greater than 50%, redo heart surgery, valve surgery, and prior stroke. Five variables were associated with increased mortality rates:; carotid artery stenosis greater than 50%, redo surgery, peripheral vascular disease, longer pump time, and hypercholesterolemia. Carotid artery stenosis greater than 50% was present in 14.7% of cases. Carotid artery stenosis greater than 75% was not itself associated with increased stroke risk. Most strokes occurred more than 24 hours after surgery. Stroke distribution did not correlate with site of carotid artery stenosis greater than 50%. CONCLUSIONS: Most neurologic events after heart surgery occur in a subset of patients who can be defined before operation. Whereas carotid artery stenosis greater than 50% is a strong risk factor, the role of prophylactic endarterectomy is unclear. Future studies should focus on this high-risk subgroup. A prospective study of prophylactic carotid endarterectomy in patients undergoing coronary artery bypass grafting is needed.     

Correlation of neurologic complications and pressure measurements during carotid endarterectomy

There was no significant difference between the mean occluded internal carotid artery pressure in asymptomatic, transient ischemic attack or prior stroke patients. The stump pressure was not consistently elevated at the second operation in those having undergone bilateral procedures. Estimate of back bleeding from the internal carotid artery operation did not necessarily correlate with the stump pressure. Adequate back bleeding was recorded in patients with a low stump pressure, and reduced bleeding was noted in individuals with a high stump pressure. The pressure gradient across the stenosis of the bifurcation of the carotid artery was helpful in assessing the degree of stenosis present. The occluded internal carotid artery pressure seemed to be a helpful aid in indicating those patients with poor collateral flow and, therefore, at high risk of ischemic brain damage. The use of an inlying shunt in those individuals having a low stump pressure may be expected to reduce the over-all neurologic complication rate in patients undergoing carotid endarterectomy.     

Asymptomatic angiographic occlusion of the internal carotid artery: an indication for emergency endarterectomy

A 56-year-old man had retinal artery embolization from a carotid artery atheroma. Complete occlusion of the internal carotid artery occurred during cerebral angiography, but the patient developed no acute symptoms of cerebral ischemia. The patient immediately underwent emergency carotid endarterectomy which he tolerated well, and follow-up angiography nine days later demonstrated continued patency. The patient has remained neurologically unchanged.     

Race and sex differences in the distribution of cerebral atherosclerosis

BACKGROUND AND PURPOSE: The purpose of this study was to assess the influence of race, sex, and other risk factors on the location of atherosclerotic occlusive lesions in cerebral vessels. Previous angiographic studies of patients with stroke or transient ischemic attack (TIA) suggest that extracranial atherosclerosis is more common in whites and intracranial disease is more common in blacks. Noninvasive techniques such as duplex ultrasound, transcranial Doppler (TCD), and magnetic resonance angiography (MRA) allow vascular assessment of a more representative proportion of patients than does conventional angiography alone. METHODS: Consecutive patients evaluated at a community hospital for stroke or TIA over a 2-year period were reviewed. Lesions were defined as a 50% or greater atherosclerotic stenosis by angiography, duplex ultrasound, or TCD, or a moderate stenosis by MRA. RESULTS: Whites were more likely than blacks to have extracranial carotid artery lesions (33% versus 15%, P = .001), but the proportion of patients with intracranial lesions was similar (24% versus 22%). Men were more likely to have intracranial lesions than women (29% versus 14%, P = .03). When multivariate logistic regression analysis was used, white race was the only predictor for extracranial carotid artery lesions, and male sex was the only predictor for intracranial lesions. The cause of stroke/TIA was extracranial carotid artery disease in 8% and intracranial disease in 8% of all patients in the study. CONCLUSIONS: The distribution of cerebral atherosclerosis is influenced by race and sex but not by other vascular risk factors. In our patient population, intracranial disease is as common a cause of cerebral ischemia as extracranial carotid disease.     

Radiation exposure of the population by roentgen diagnosis. II. The collective effective dosage of the population in former East Germany caused by 1987/1988 roentgen diagnosis

OBJECTIVES: To examine the relations between the development of neurologic events and the following variables: degree of stenosis of the contralateral carotid artery, prior neurologic symptoms and stump pressure of the ipsilateral internal carotid artery in patients undergoing carotid endarterectomy under regional anesthesia. PATIENTS AND METHODS: We undertook a prospective study of 92 patients undergoing carotid endarterectomy with a blockade of the superficial and deep cervical plexus. Neurological integrity was assessed and internal carotid artery stump pressure was monitored. Contralateral carotid artery stenosis and neurologic disease present before surgery were studied. RESULTS: Neurologic events developed when the carotid artery was clamped in 9.7% of patients. Mean stump pressure was significantly lower in symptomatic patients (43 +/- 11 mmHg) than in asymptomatic patients (74.6 +/- 24 mmHg) (p < 0.001). Neurologic symptoms developed during clamping of the carotid in 27.2% of the patients with stump pressure less than or equal to 50 mmHg, but in only 4.2% of those with stump pressure surpassing 50 mmHg. Stump pressure was significantly lower in patients with contralateral carotid stenosis. The incidence of neurologic events during clamping was unrelated to contralateral carotid condition, however. Likewise, neurologic symptoms before surgery was also unrelated. In six of the nine patients with neurologic events, internal carotid stump pressure was less than or equal to 50 mmHg, indicating that the sensitivity of this parameter to the development of neurologic events in our series was 66%. CONCLUSIONS: Although internal carotid artery stump pressure identifies a subset of patients likely to have a higher incidence of neurologic events during carotid artery clamping, it can not be considered the only criterion for placement of an intraluminal shunt to prevent such events. The state of the contralateral carotid artery and preexisting neurologic symptoms are not objective screening criteria for identifying patients at high risk of neurologic events during carotid clamping.     

Immunoaffinity column as cleanup tool for a direct competitive enzyme-linked immunosorbent assay of cyclopiazonic acid in corn, peanuts, and mixed feed

PURPOSE: Atherothrombotic occlusion of the cervical internal carotid artery (ICA) without collateral flow is one of the most critical forms of acute ischemia. We report the results of urgent thrombolytic treatment of patients with major stroke in this clinical category. METHODS: Clinical findings and outcome in 33 patients were investigated. All patients had suffered a major stroke, with a score of 24 or higher on the NIH Stroke Scale on admission. Ischemic abnormalities were not detected on initial CT studies. Diagnoses were made at angiography, and patients were treated by intravenous or intraarterial local thrombolysis within 6 hours of stroke onset. RESULTS: Recanalization was accomplished in eight patients with intraarterial local thrombolysis; four of these patients had a good clinical outcome. Two factors characteristic of those whose treatment was successful were dramatic improvement of symptoms after partial recanalization achieved within 3 hours of onset and stabilized improvement after subsequent percutaneous transluminal angioplasty or carotid endarterectomy for residual atherosclerotic stenosis at the ICA origin. CONCLUSION: The results of this study suggest that urgent intraarterial local thrombolysis may be a successful treatment method for some patients in this critical clinical category if the treatment can be accomplished within 3 hours of ictus and followed by either angioplasty or endarterectomy for residual stenosis.