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tion of seizures, has been seen, rarely and with no explanation, in migraineurs, including two cases with which we are familiar For intracranial internal carotid stenosis or for thrombi that extend into the siphon and stem of the middle cerebral artery, a transcranial (super cial temporal middle cerebral) anastomosis had in the past been employed Though this operation is technically feasible, its therapeutic value has been discounted by the careful multicenter study of Barnett and collaborators, who found that it did not produce a reduction in TIAs, strokes, or deaths There may still be particular circumstances that justify its use Carotid angioplasty and stenting has been alluded to several times earlier Its role in clinical practice is still being determined, but it offers an alternative to surgery if the patient is too ill to undergo an endarterectomy Direct comparisons are being made to surgery in several organized studies In one randomized trial reported by the CAVATAS investigators, the incidence of minor (nonstroke) complications was lower in patients who had angioplasty and stenting This has not been our experience, where sizable groin hematomas have been common Also, a higher proportion of these patients than those who had undergone endarterectomy had restenosis Otherwise, the recurrent stroke rates were similar, 10 percent for both groups Asymptomatic Carotid Stenosis Finally, there is the problem of the asymptomatic carotid bruit or incidentally discovered stenosis The population study by Heyman and associates has shed some light on this They found, not surprisingly, that cervical bruits in men constituted a risk for death from ischemic heart disease They also noted that the presence of asymptomatic bruits in men (but not in women) did carry a slightly increased risk of stroke but, more importantly, that the subsequent stroke often did not coincide in its angioanatomic locus and laterality with the cervical bruit Similar ndings have been reported by Ford and coworkers and by Chambers and Norris On the other hand, Wiebers and colleagues found that patients with asymptomatic carotid bruits who were followed for 5 years were approximately three times more likely to have ischemic strokes than an age- and sex-matched population sample without carotid bruits In an attempt to clarify the role of surgery for asymptomatic carotid stenosis, the Asymptomatic Carotid Atherosclerotic Study (ACAS), as reported by their Executive Committee, has suggested that the frequency of strokes can be reduced from 11 to 5 percent over 5 years by removing the plaque in asymptomatic patients in whom there is a stenosis greater than 60 percent (diameter) These ndings have been tempered by a reanalysis of the ACAS data, pointing out that almost half of the strokes in these patients were lacunar or cardioembolic in origin (Inzitari et al) Data from a recent European trial, encompassing 3120 patients, obtained similar results [MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group] The latter study has indicated that asymptomatic carotid stenosis of over 70 percent carries only a 2 percent annual risk of stroke over a 5-year period and that the risk is reduced to 1 percent with endarterectomy It was concluded that endarterectomy may be justi ed for asymptomatic carotid stenosis of this degree, but the authors emphasized that an audited surgical risk below 3 percent is required to obtain favorable results From the results of several trials, it can be concluded that endarterectomy does not reduce strokes in patients who have asymptomatic carotid stenosis with luminal narrowing that is less than 70 percent of normal diameter All these comments probably apply to patients who are about to undergo major surgery such as cardiac bypass.

grafting, but adequate studies of this circumstance have not been carried out The bene ts of surgery for asymptomatic carotid stenosis seem to us to be marginal and we counsel caution until more definite data on this matter have been obtained Also, as already noted, the neurologist s advice should be tempered by the documented surgical risk in his particular institution Our practice with asymptomatic cases has been to re-evaluate the lumen of the internal carotid artery (by ultrasound) at 6- to 12-month intervals Only if the lumen is decreasing in size and becomes narrowed to 15 mm or less or if there is an event that could be construed as a TIA referable to the stenotic side is surgery considered In the case of an asymptomatic but progressive stenosis larger than 15 mm, there is still considerable controversy about treatment; anticoagulation or antiplatelet agents are reasonable alternatives to surgery We generally agree with the guidelines for carotid endarterectomy set down by the American Heart Association as reported by Moore and colleagues, but there must be a careful evaluation of the circumstances in each patient

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Physical Therapy and Rehabilitation In all but the most seriously ill patients, beginning within a few days of the stroke, the paralyzed limbs should ideally be carried through a full range of passive movement several times a day The purpose is to avoid contracture (and periarthritis), especially at the shoulder, elbow, hip, and ankle Soreness and aching in the paralyzed limbs should not be allowed to interfere with exercises Patients should be moved from bed to chair as soon as the stroke is completed and blood pressure is stable Prophylaxis for deep venous thrombosis is appropriate if the patient cannot be mobilized An assessment for swallowing dif culty should be made early during recovery and dietary adjustments made if there is a risk of aspiration Nearly all hemiplegics regain the ability to walk to some extent, usually within a 3- to 6-month period, and this should be a primary aim in rehabilitation The presence of deep sensory loss or anosognosia in addition to hemiplegia is the main limiting factor A short or long leg brace is often required By teaching patients with cerebellar ataxia new strategies, balance and gait disorders can be made less disabling As motor function improves and if mentality is preserved, instruction in the activities of daily living and the use of various special devices can help the patient to become at least partly independent in the home What little research is available on the effectiveness of stroke rehabilitation suggests that a greater intensity of physical therapy does indeed achieve better scores on some measures of walking ability and dexterity In a randomized trial, Kwakkel and colleagues achieved these results by applying an additional 30 min per day beyond conventional physical therapy of focused treatments to the leg or arm, 5 days per week, for 20 weeks Other studies have demonstrated clearly the now well-known undesirable effects of immobilizing a limb in a splint after a stroke The neural substrates of improvement after stroke are just beginning to be studied A wealth of clinical experience and physiologic and radiographic data have demonstrated that the injured brain has some degree of plasticity; remodeling of brain tissue and reorganization of neural function continue for months after even large motor de cits Experimental work in monkeys and limited data from patients suggest that improvement can be obtained by restraining the normal limb and forcing use of the sound limb This may re ect functional expansion of the cortical motor representation into adjacent undamaged cortical areas, indicating the potential.

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