Bilateral occlusion of the internal carotid arteries: presenting symptoms in 74 patients and a prospective study of 34 medically treated patients

The presenting characteristics of 74 patients with atherosclerotic occlusion of both internal carotid arteries are described. All had suffered either ischaemic hemisphere infarcts (80%) and/or transient ischaemic attacks (80%) involving one (78%) or both (22%) carotid territories. In addition, 10 subjects (14%) incurred recurrent vertebrobasilar or presyncopal episodes, many of which appeared secondary to haemodynamic insufficiency. The incidence of risk factors and concomitant vascular disease was high; 93% gave a history of heavy smoking. Thirty-four subjects were treated conservatively and followed prospectively for a mean of 42 months. Eighteen patients (53%) suffered further cerebrovascular events, an ischaemic event rate of 15% per patient per year. These were isolated transient ischaemic attacks (TIAs) in 7 and stroke in 11 patients. The latter suffered a total of 15 strokes during the follow-up period of 42 months; the annual stroke rate was 13% per patient year. Patients who had presented with ischaemic events involving more than one carotid territory were significantly more prone to subsequent cerebral infarction than those in whom symptoms had been confined to one territory (P less than 0.05). None of the 5 patients with haemodynamic TIAs who were managed conservatively developed a stroke during the follow-up period and their symptoms remitted spontaneously. Deaths per year amounted to 8%. Twenty-four patients (71%) survived, of whom half were either symptom-free or minimally disabled. In this group of preselected patients, which excludes those with severe deficits at presentation, bilateral occlusion of the carotid arteries may be a condition compatible with useful existence.