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The American Heart Association carotid endarterectomy (CE) guidelines endorse CE for asymptomatic carotid stenosis if the procedure can be performed with low morbidity. However, the Canadian Stroke Consortium has published a consensus against CE for asymptomatic stenosis. The views of practicing neurologists in the two countries on this subject are unclear.
A survey was undertaken of 270 neurologists from either Florida or Indiana and 180 neurologists from either Ontario or Quebec.
The survey was returned by 36% of neurologists. Both Florida (65%) and Indiana neurologists (35%) were significantly more likely than Canadian neurologists (11%) to sometimes/often refer patients for surgery(p<0.001). Neurologists from Florida relied more on noninvasive methods of carotid stenosis assessment (36%) than Canadian neurologists (12%, p=0.003), who preferred angiography. Neurologists from Florida more often cited medicolegal concerns as a reason for referring patients for surgery (27%), compared to Canadian neurologists (3%, p=0.0001).
Practices pertaining to carotid stenosis evaluation and management differ both regionally and by country. Canadian neurologists refer fewer asymptomatic patients for CE and rely more on angiography as a preoperative diagnostic tool. The potential of medicolegal liability is a greater force in clinical decision-making for certain U.S. neurologists, compared to their Canadian counterparts. These differences may partly explain the variations in CE utilization in the two countries.
The most common locations for cerebellar infarcts are the posterior inferior cerebellar artery (PICA) and superior cerebellar artery (SCA) territories and they are about equally involved. Cerebellar infarcts are often characterized by associated non-specific symptoms, transposing into clinical conditions difficult to diagnose. The clinical presentation of ischemia in the territories of the various cerebellar arteries depends on whether the ischemia affects only the cerebellum, only the brainstem, or a combination of brainstem and cerebellum. The most common symptoms are vertigo or dizziness, vomiting, abnormal gait, headache, and dysarthria. The SCA infarcts often provoke edema with brainstem compression and herniation of the cerebellar tonsils. Cerebellovestibular signs are prominent in patients with partial occlusion of the SCA territory. Dysarthria is a characteristic symptom of SCA territory infarction. Pseudotumoral infarcts are responsible for the development of increased pressure within the posterior fossa and intracranially and may mimick posterior fossa tumors.