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D URING the last decade the importance of atherosclerosis of the carotid and vertebral arteries in the neck as a eause of cerebral ischemia or infaretion has become recognized. This has led to revision of older views that cerebral infaretion almost invariably resulted from oeclusion of the middle cerebral or the intracranial arteries. Recent arteriographic and pathologic studies have demonstrated frequent stenosis of one or both carotid or vertebral arteries in the neck in patients with cerebrovascular symptoms.1 It is evident from routine examination of the cervical and cranial vessels in unselected cases at necropsy,j in subjects dying of stroke and by arteriography in the living, that atherosclerotic plaques occur most frequentlyin welldefined sites of the internal. carotid vessels. The commonest site for plaque formation is in the internal carotid artery witlh atherosclerotic stenosis or occlusion in the region of the carotid sinus, usually at the origin of the internal from the comnmion carotid artery or a few eentimeters distal to this point.7 Surgical removal of atheroselerotic. plaques at this site is quite feasible anid an impressive number of successful. cases have been reported.3 16 Atherosclerotic plaques of the vertebralbasilar arterial svstem are usually more diffuse. The commonest site is the basilar artery itself. Meyer, Sheehan, and Bauer17 in an arteriographic study of subjects admitted to a general hospital with From the Departments of Neurology, Wayne State TUniversity College of Medicine and Receiving THospital, Detroit, Michigan. Supported by grants from the National Heart Institute and the National Institute of Neurological Diseases and Blindness, U. S. Public Health Service, the Receiving Hospital Researeh Corporation, and the Michigan Heart Association. Dr. Gilroy is a trainee of the National Institute of Neurological Diseases and Blindness. symptomts due to vertebralbasilar disease found that the majority of cases showed diffuse atherosclerotic defects within the vertebralbasilar svstem that were not amenable to extracranial surgical reconstruction. Although isolated plaques of the proximial portion of the vertebral artery were less frequenit, such lesions are ameniable to surgerv. More satisfactory medical and surgical treatment could be provided if progressive eervicocranial atherosclerosis were diagnosed by physical exanminiation before cerebral infaretion oceurred. The present study has been designed to evaluate the usefulness of systematic aus(eutation over the cervical arteries and ehest as a diagnostie aid in a large series of cases referred to the Neurological Service at the Detroit Receiving Ilospital with symptons of cerebrovascular disease in which the diagnosis wvas later confirmed by arteriographv of all fouir cervieocerebral vessels
Auscultation of the Neck in Occlusive Cerebrovascular Disease By JOHN GTLROY, M.D., AND JOHN S MEYER, M.D symptomts due to vertebral-basilar disease found that the majority of cases showed dif- D URING the last decade the importance of atherosclerosis of the carotid and vertebral arteries in the neck as a eause of cerebral ischemia or infaretion has become recognized This has led to revision of older views that cerebral infaretion almost invariably resulted from oeclusion of the middle cerebral or the intracranial arteries Recent arteriographic and pathologic studies have demonstrated frequent stenosis of one or both carotid or vertebral arteries in the neck in Downloaded from http://ahajournals.org by on September 16, 2022 fuse atherosclerotic defects within the vertebral-basilar svstem that were not amenable to extracranial surgical reconstruction Although isolated plaques of the proximial portion of the vertebral artery were less frequenit, such lesions are ameniable to surgerv More satisfactory medical and surgical treatment could be provided if progressive eervicocranial atherosclerosis were diagnosed by physical exanminiation before cerebral infaretion oceurred The present study has been designed to evaluate the usefulness of systematic aus(eu]tation over- the cervical arteries and ehest as a diagnostie aid in a large series of cases referred to the Neurological Service at the Detroit Receiving Ilospital with symptons of cerebrovascular disease in which the diagnosis wvas later confirmed by arteriographv of all fouir cervieocerebral vessels Material and Methods patients with cerebrovascular symptoms.1-' It is evident from routine examination of the cervical and cranial vessels in unselected cases at necropsy,j in subjects dying of stroke and by arteriography in the living, that atherosclerotic plaques occur most frequentlyin well-defined sites of the internal carotid vessels The commonest site for plaque formation is in the internal carotid artery witlh atherosclerotic stenosis or occlusion in the region of the carotid sinus, usually at the origin of the internal from the comnmion carotid artery or a few eentimeters distal to this point.7 Surgical removal of atheroselerotic plaques at this site is quite feasible anid an impressive number of successful cases have been reported.3' "-16 Atherosclerotic plaques of the vertebral-basilar arterial svstem are usually more diffuse The commonest site is the basilar artery itself Meyer, Sheehan, and Bauer17 in an arteriographic study of subjects admitted to a general hospital with Routine examination of all four cervical vessels by auscultation was carried out on 50 patients admitted to Detroit Receiving Ilospital during t-he last months of 1960 The admnitting diagnosis in each case was cerebral-vaseular thrombosis, carotid arterial insufficiene-, or vertebral-basilar arterial insufficieney Following the general physical and neurologic examination, arteriographic visualization of both carotid and vertebral-basilar arteries was obtained The reliability of auscultation was then correlated with arteriographic findings All arteriograms were performed under local anesthesia The vertebral-basilar arterial system was visualized by percutaneous transbrachial retrograde catheterization with the Seldinger technic.18 The iimajority of patients with cerebral-vascular thrombosis had had transient episodes or syi-mptoms suggesting vascular insufficieney prior to the major catastrophe In a few confused or dysphasic patients the history of previous syvmptoins could not always be obtained All patients with carotid oIr vertebral-basilar insufficiency had had previous From the Departments of Neurology, Wayne State TUniversity College of Medicine and Receiving THospital, Detroit, Michigan Supported by grants from the National Heart Institute and the National Institute of Neurological Diseases and Blindness, U S Public Health Service, the Receiving Hospital Researeh Corporation, and the Michigan Heart Association Dr Gilroy is a trainee of the National Institute of Neurological Diseases and Blindness 300 Circulation, Volume XXV, February 1962 301 OCCLUSIVE CEREBR()VCASCILiAR DI)SEASE Downloaded from http://ahajournals.org by on September 16, 2022 Figure I uscultation ofJ the cerebral vessels with head turning The routin' e(amination it illustratedi in A, B, aud C and was always carried out in that order Iihe povs?itior 4&oion in D iwas found to be un-reliable laIter in the studyi and(1 wca abandoned as a routine measuiire A A useiltation of the heart to exclude trlfsmnititedc (careiaC murmrtu B3 A usultation over the bifurcation of the comnmnon ca(otid (rterywt:ith head turning C A usc ultation over the origin of the vertebral aritery wcith head turning D) Auseultation over the inideeirvical position of the vertebral airter!/ with, h aed turni1ing transient symiiptomiis Somne patients witlh cet'vbrova,scular thrombosis were too ill to unddergo arteriography and were not included in this series It is also the policy at Receiving Hospital to transfer Circulation, Volume XXV, February 1962 con1scious patients, without severe synrptoins to other hospitals for treatment after e-xainination and lumbav puncture in the Enmerge,ncy Roorm It is also probable that as the neurologie residents GILROY, MEYER 302 Table Auscultatiron of the Four Cervical Vessels icith Head Turning C'arotid murmurs Suppression Caroti(l of carotid sounds sounids of poor on volunme head turning Vertebral murmurs Suppression of vertebral sounds on head turning Absence of vertebral sounds in all positions of Total the head 10 12 Results 49 abnormalities 18 becanme expert in the routine auscultation of the vessels in the neck that one or two patients witlh mnurmurs in the neck were admitted for further investigation who otherwise might have been transferred elsewhere As far as possible, however, this series is considered to be a representative sample of routine eases of occlusive cerebrovascular disease Auscultation of the Neck Vessels The first and second heart sounds are flexed, extended, and rotated to each side Diminution or loss of the vertebral sounds and the presence of murmurs were noted Murmurs were also recorded in many patients with a Sanborn twin-beam instrument with a simultaneous electrocardiogram for time reference during phonoangiography Effects were also noted of changes in posture and of compression of the vessel proximal to the site of auscultation and of the opposite cervieal vessels trans- Downloaded from http://ahajournals.org by on September 16, 2022 nitted to the great vessels and are normally heard on auscultation over the carotid arteries or over the origin of the vertebral arteries We shall refer to these sounds as the "carotid" or "vertebral" sounds in the text Murmnurs occurring in the carotid or vertebral arteries are nearly always due to local vascular abnornmalities and are onlv oce-asionally transmitted from the heart In all eases, however, careful auseultation of the heart was made to exclude transmitted inurmurs of eardiac origin (fig la) Auscultation of the Carotid Arteries Auscultation of the carotid arteries on each side was performed with the bell of the stethoscope placed over the bifureation of the common carotid artery at the level of the upper border of the thyroid cartila-ge (fig lb) Auscultation was carried out with the head in five positions: neutral, flexed, extended, and rotated to the right and left In all positions any change in the carotid sounds or the presence of murmurs was noted If a mlurmur was heard in any position the bell was mtioved until the murmur was of maximum intensity ;nd the effects of varying pressure of the bell were recorded Auscultation of the Vertebral Arteries For auscultation of the vertebral arteries on each side, the bell of the stethoscope was placed just posterior to the sternocleidomastoid muscle inmmediately above its elavicular origin (fig le), and the head was held in the neutral position, On auscultation of the four cervical vessels with head turning, 49 abnormalities were recorded in 28 patients (table 1) Carotid murmurs were the milost frequently recorded abnormalities but murinurs were also noted over the vertebral arteries The commonest abnorinality recorded over the vertebral arteries was the disappearance of the sounids on head turning, which was infrequently elicited over the carotid vessels Arteriographic abnormualities were demonstrated in the neck vessels in 40 of the 50 patients Arteriographic abnormalities were noted 35 times in the carotid system, and 42 times in the vertebral system, and an additional 10 times in the subelavian arteries (table 2) In the remaining 10 patients, the cervical vessels appeared to be normal at arteriography except for tortuosity or plaques in the basilar artery and other intracranial vessels Correlation of Auscultatory Findings with Arteriographic Changes The Carotid System Carotid murmurs Of the 18 instances in which bruits were recorded over the carotid artery, the murmur was recorded in all positions of the head in 15 instances but was audible only on head turning in three instances In four cases, turning of the head accentuated a faint murmur heard in the neutral position In 17 instanees, murmurs occurred over an artery where abnormalities were demonstrated by arteriography In one instance of a murmur, the common, internal and external carotid arteries appeared to be normal, but the internal carotid artery on the opposite side was completely occluded, so that there was greatly increased flow at the site Circulation, Volume XXV, Februa ry 1962 303 OCCLUSIVE CEREBROVASCULAR DISEASE Table Arteriographic Abnormalities in the Neck Vessels Plaque formation at the origin of the internal carotid artery Stenosis (40 per cent or more) at the origin of the internal carotid artery Occlusion of the internal carotid artery Kinking of the internal carotid arterv Total carotid artery Plaque formation at the origin of the vertebral artery Stenosis at the origin of the vertebral artery Diffuse arteriosclerotic changes in the veTtebral artery Kinking of the vertebral artery Kinking of the vertebral artery on head turning Occlusion of the vertebral artery Indentation of the vertebral artery by cervical spondylosis Total vertebral artery Diffuse arteriosclerotic changes in the subelavian artery Total subelavian artery Total Downloaded from http://ahajournals.org by on September 16, 2022 of the murmur There was therefore a "functional steniosis " in physiologic terms Murinurs occurred over three arteries showing severe stenosis (40 per cent or more reduction of lumen) (fig 2) and in three arteries with mnurmurs, plaque formation was only of moderate degree (less than 40 per cent) (fig 3) In one instance a murmur was heard where there was complete occlusion of the internal carotid artery and stenosis at the origin of the external carotid artery Suppression of carotid sounds on head turning In the two instances in which the varotid sounds were found to be suppressed by head turning, the vessels appeared to be niormal on arteriography This finding may r esult from movement of the artery away fromn the stethoscope or under the sternoelei(lomastoid muscle Carotid sounds of poor volume Carotid sounds were recorded as being of poor volume in all positions of the head in comparison to the opposite side in three instances and in each case significant atherosclerotic changes were demonstrated in the vessel so described Comment Auscultation of the carotid artceries was thought to be abnormal in 23 in-stances and in 20 instances this impression was confirmed by arteriography (accuracy of 87 per cent) A further 15 vessels were, howCirculation, Volume XXV, February 1962 27 35 18 3 42 10 10 87 shown to be abnormal but did not show abnormal signs on auscultation Thus, auseultation of the cervieal carotid arteries detected about 57 per cent of significant atherosclerotic plaques The presence of a carotid murmur appears to be a reliable indication of plaque formation or stenosis at or jllst beyond the origin of the internal carotid artery Murmurs, however, may be heard over the contralateral vessel in complete occlusion of an internal carotid artery Auscultation may detect relatively small plaques Such plaques may give rise to symptomas by thronaboembolism of fibrin and platelet thrombi deposited upon them.23 ever, The Vertebral System Vertebral murmurs Murmurs were recorded over the vertebral arteries in 10 instances Subsequent arteriography showed stenosis at the origin of the vertebral artery in two instances and in another two instances diffuse atherosclerotic plaques were present (accuracy of 40 per cent) (fig 4) In four instances, however, the vertebral arteries appeared to be normal but there were marked atherosclerotic changes with plaque formationi and irregularity of the lumen of the subelavian artery Presumably the subelavian murmurs artery transmitted to the vertebral two instances both subelavian and were In GILIROY IM1]YEJI 304 Downloaded from http://ahajournals.org by on September 16, 2022 Figure Patient writh /i/n p0lo/s of' tros a'4cnt cerebral isehenila had a lou(/I s/stol//C mrfmur/ll r' the bifurea;ioni of the right / /1o ce//otild orterrJ in a ll posit ions of tie/ he/d A/'teriogrophy/ shows a secre stenosis oj t/e rilght inet(eratl carotid arte/!t/ just above ti/e origiii, oof ti/e rs5s(l1 (-I/ic to a localcl1 arterioscleroitic pl/qyic verltebr'al atrt/Ties apl)pl(/ati(I to be niormiial ai(Il the cause C/f thie ntiurniiur was unexplained- Disappearance of IlC VC trtabral so0i tds on htead tutrniily I)isappeararice of vertebral sounds on bleau1 ttirning( aVsl; r ecordled in 12 instances and subse(Cnenl arteriography vert ebral atshowed ani abnormalityM ill t tery in seveni iistalnees (acc!uracy of 58 ple cent) In the remaining five instances the vertebral artery appeared to lIe niormal, bhut inl two instanees ther e wvere marked atheroseirotic chang,es ini the subelaviatn arteri-es Ahbscncc of vcricbral sonntis 0i/ all posifito//s af tlte hcad FaiSlure to hear sound,s; over' the vertebral arterv occurred ini four instances In three inistances poor filling, of the vessels wvith terminationi of filliing in the mildceervi(/al region occurred (accuracy of 75 per cent') (fig 5) Ini the foulrtlh inistanice, thfe vertebral Figure 1Ptntiei? /lit/i ton ,st/wI/d/1y Syp/tl/po/s o/ f c erebroraseular in/su flceuacy had a loud systolic mrimuti (ccev/tuated b/j 1I/t/d turning o1n auss(/ultatio/ orer ti/c6 bifurcation of ti/e le ft Co/nm?oiO/ (c/rotid7 artcry A rt rioyrapl/y sh5ow/ed s//tll atl/erosclerotie plaques and an area of dilatation just atiove the origi// of the left internal carotidI arteryf There is a(lditiol/al er'idc//ee of difftise atherosclerosis il ti/e extraeraxial a//d intraero/ol.d v-essels artery, aippeared to be ic/rinal (o1i arteriography Co!anmt n t Abnorriinaities were recorded Cve'r the vertel)ral vessels by auseultation in 26 instainees, anid in 17 instances an abnorrnalitv was found on arteriography in either t he vertebra or subelaviain arte vies (accuraey of 60 per ceLlent) 11howevTer, arteriography showed somne abnornality in the vertebral vessels in 42 instances and in the subelavian vessels in 10 instalnces Thus auseultationl of the cervical vertebra:,l arteries detected abouit Circulation, Volutme XXV, Febratary 1962 305 OCCLJUSIVE CEREBROVASCIILAR DISEASE Figure Patient with rerteb ral-basilar insufficiency A systolicw murmur w;as heard over the origin of the Downloaded from http://ahajournals.org by on September 16, 2022 left qrertebaltarter'y which was altered in iWtensity by head turninig Arteriograiphy demnonstrated a pioorly filled lef't c rtebral arterJy with dliffuse at/ueroscierotic changes producing nmmerous areas of narrowling of the lumen 45 per ceint of significant, athieroselerotic plaques Auscultatiou over the origin of the vertebral arteries is therefore less reliable thanl over the carotid vessel Phonoangiography The phonioeardiogram proved to be useful for obtaininig a graphic record of murmnurs from any of the four cervicocrantial arteries In addition to lead turning a number of other manieuvers affected the volumie and quality of murmurs over the carotid or vertebral arteries (figs and 7) A change from recumnbent to sitting position decreased the volume Proximal compression of the vessel led to obliteration of the murmur; compression of other eervicocranial vessels occasionally increased the murmur Discussion Carotid and basilar-arterial inisufficiency is a recurrent disturbaniee of hemodynamics (hemodynamic crisis) in which unusual physCirculation, Volume XXV, February 1962 Figure Patient with symptoms of vertebral-basilar insufficiency Sounds were absenit ocer the origin of the right vertebral artery on all positions of the head Arteriograpky revealed a poorly filled right vertebral artery iwith narrowing and bending due to diffuse atherosclerosis The vessel did ntot fill beyond the fourth cervical vertebra There is a well developed collateral circulation via the anterior spinal artery iolocric stress may give rise to symptoms, the pattern of which is determined by the distribution of the vessel affected.'7 1923 Mleyer23 has stressed the importance of fibrin and platelet embolism from mural plaques of the MEYER ~~~~~~~~~~~GTLROY, 306 306 ® RECUMBENT PROXIMA.L.COM.PRESS:ION i )ON,", ol 00:: ooo: o!o:- oo ::;.:-.A A loo Ooo-7- :.:: 0, 00 © ©k) H.E.A.D EnE.N ATED RIGHT HEAD -~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SITN SITTING ©.HEA ROATDLET T.VETBRL.OPRSSO - it~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -~ - Figure right.interna carti arteryon.a atien with30.pe.c over Phonoangiograms the~~~~ plaque The effects~~~~~~~~~~~~~~~ origin of the vessel due to a localized atherosclerotic stenosis atthe of~~~~~~O chne nha trigadiceaei lo7lw ihrgtvreba opeso areshown~~~~~~~ Downloaded from http://ahajournals.org by on September 16, 2022 arteries in the neck as a cause of symptoms Other types of hemodyiiamic crises may oc- cur resnlitiug fromt factors suchi as tranisienit lowxeringy of blood pressuire anid chianges iii the viscosity or c.oagulability of the bloodl Transienlt, partially reversible or permianlent symptoms occur depending on the duration and severity of the local cerebral hypoxemia anid acidemia iniduced in vulnerable arleas of braini anid brain Stem1.24 In ani arteriographic study of 71 cases of patients with cerebrovaseular disease, Bauer et al.5 noted tortuosity and kinkingr of the cervical arteries, which they attributed to hypertensioni, atherosclerosis, or comipression by osteophytes in cervical spouidylosis Tortuosity and kinking, occurred in at least one major cervical vessel and was accenatuated during, rotationi of the head in approximately quarter of the l)atients Arteriogranms mnade during hiead rotationi demionstrated stenosis of the cerxvical vessels due to comipression of the vertebrald or initernial carotid artery ag,ainst the atla.s, kinking of a tortni ous initernal carotid or vertebral artery, anid comipression of the vertebral arter-y by osteophiytes Many patienits witht miarked arter-iosclerotic chiangces in the cervical arte-ries are asymyptoinatie presumably becauise of effective collateral circulation Othiers have recurrent sylinp toinis with transien't lowering~of the blood pressure, head turniniig, hypog-lycemia, embolism from cervical arterial plaques, anid other ca-uses If these, warninrg symnptoms are igniored, the patient may suffer cerebral infarcone tion at a later date Most of our patients with severe cerebral thrombosis due to cervical Circulation, Volume XXV, February 196,2 OCCLUSIVE CEREBROVASCULAR DISEASE Downloaded from http://ahajournals.org by on September 16, 2022 artery disease gave a history of transient cerebral isehemic episodes prior to the maljor catastrophe Ilntermittent attaeks of Internal carotid insufficiency result in tranisienlt uinilateral motor or sensory impairmnent, transient aphasia or dysplasit, and ipsilateral impairment of vision Focal seizures are rare Vertebral-basilar insufficiency gives rise to transienit diminuless of vision or blinldness often associated witht unsteadiniess of gait, clouding of cVlosciouslness, Confusion, sudden syneope, sudden loss of tone in the legs with collapse but no loss of consciousniess (tlhe '"drop attack') ,18 dvsartlhria, ptosis, aind bilateral motor or senisory phen-tomena It shoulld be emnphasized thcat attacks occur abruptly and may be of only a few seconds' durationi This may aecounlt for the tendency in the past to ascribe these episodes to ''hypertension " or " vasospasmn.77 A common diagnostic error in subjeets with vertebral-basilar arterial insufficieney where unsteadiness or verticro are niajor coinlplaints is to consider them due to ''Meniere's disease."' In patients with symptoms of possible cerebrovaseular disease, palpation of the carotid arteries in the neck or in the wall of the pbarynx has been unreliable in our hands Compression of the unaffected carotid artery is a useful diagynostic test buit is not without hazards.26 Muirmuirs in the cervical vessels in the presence of stenosis have been frequently menltioned3 13, 27-33 buLt systematic auseultation of the cervical vessels has not been reported and nio correlation has been madle witlh arteriographie findings, particularlv in relation to head turning In this series auscul tation of the earotid aiteries with head turninlg was positive and accurate in tlhe localizationi of an abnornialit-v in the ipsilateral vessel in mnore thani 50 per cent of the v-essels subsequlently showni to be abniormal by arteriography A earotid miiurmnur is therefore considered to be a relicable inidicationi of athleroselerotic chance in the earotid artery but rarely ''false positive"' signis occur Such apparently misleading signs mnay be helpful, however The murmLur bieard over the inltact carotid artery due to complete occlusion of the contralateral vessel, Circulation, Volume XX V, February 1962 307 L Vertebral, 50 % stenosis at origin A B I :R.Vertebral, minimol stenosis at origin ,L,.jL.-A l. -j7* -T-" I", " A.''; - 1M Figure Phonoawgiograms over verteb rat arteries There was a loud systolic murmur oa the left anld a systolic murmur of moderate volume oa the right side Suibsequent arteriography firmdl the stenosis in these ressels althougyh iiaccurate in localizing thle lesion, jumstifies arter iographic visunl ization of both carotid arteries We lhave also recorded a murmur over tile carotid artery oni onie occasioaI in a patienit not included in thiis series where there wvas proximal occlusion of the, vertebral artery anid a well-(leveloped collateral circulation fr omn the ascen(linr cervical branches of the subelavian artery to the upper part of the vertebral artery Vertebral sounids higher in the neck were often iniauidible a]thoug(,h they were present proxim-ially, so the procedure of vertebral auscultation high in the neck was abandoned as a routine In obese patients considerable tissue separates the bell of the stethoscope from the Cartery so that licad turning regularly causes nmarked reduction in the volume of sountids Auscultation inust be very carefully donie in a quiet room, otherwise obliteration of the vertebrlaCl sounds on head turninigwrill ofteni be reportedl erroneously Auseultation over the origin of the vertebral artery is unquestionably wortl while A murmur is a valuable diagnostic sign of atherosclerotic disease of the vertebral- GILROY, MEYER 308 Figure Downloaded from http://ahajournals.org by on September 16, 2022 Patient with recur-ent hemiplegia Auseultation revealed murmurs over the origin of both internal carotid arteries, both murmurs of sea-gull type Arteriography showcs marked sfenzosis of both vessels basilar arter ial system; head turning is of further value because it nmay accentuate or uncover a murmur In proximal stenosis of the brachiocephalic trunk (iilnominate arterv) and of the left subelavialn and left common carotid artery at their origin from the aorta (aortic arch syndrome), muirmurs arising from stenosis at the origin of the brachiocephalie trunk may be mistaken for carotid or vertebral murmurs Stenosis at this site may give rise to cerebral symptoms The following considerationis are helpful in differentiating occlusive disease of the aortic arch: There may be a palpable difference between the radial pulses, the pulse on the side of the stenosis being of dierotic or plateau type The blood pressure is usually different in the two arms (lower on the side of stenosis of the subelavian or brachiocephalic trunk) The murmur is transmitted below as well as above the clavicle in stenosis of the braehio- eelhlalie trunk but is imaximal above tire clavicle anld is not of car-diae origin On the right side it may be audible in the right carotid, subelcavian, arid vertebral arteries but the intensity of the murlmur rapidly diminishes from the point of maximiial intensity immediately above the clavicle The murmur in steniosis of the brachiocephalic trunk or of the left subelavian artery may be audible in the axillary artery and heard by plaeing the stethoscope bell in the apex of the axilla over the axillary artery Murmurs of brachiocephalic origin are not altered by head turning Murmurs present over onie or both eyes but not present in the iieck may iii(lieate atherosclerosis of the internal carotid artery in the sipholn or intracranial portion adjacenit to the sella tureica.33 Arteriovenious malformations, aneurysms, severe anemia, anld functional murmurs in children of no clinical significance miay also grive rise to indisting,uishable inltracranial bruits Venous hums may be difCirculation Volumne XXV, February 1962 309 OCCLUSIVE CEREBROVASCULAR DISEASE Downloaded from http://ahajournals.org by on September 16, 2022 ferentiated, since they disappear with light pressure on the neck In adults, particularly those with transient neurologic symptoms, murmurs over the cervical vessels that are not tranismitted from the heart are presumptive evidence of atherosclerotic disease of the neck and mediastinal arteries Murmurs are occasionally heard over the carotid artery supplying a large cerebral arteriovenous vascular malformation These lesions are known to act as an arteriovenous shunt and carotid flow is greatly increased as occurs with occlusion of one carotid artery Such greatly increased carotid flow results in relative "physiologic" stenosis and a bruit may result In hyperthyroidism, murmurs may be present in the neck, arising from increased blood flow in the thyrocervical trunk, but the signs of thyrotoxicosis usually make recognition of the condition simple A murmur in any cervical or cranial vessel that is present in both systole and diastole (to-and-fro murmur) indicates a severe degree of stenosis.33 Very rarely a high-pitched "sea-gull" murmur may be heard in systole and diastole The pitch, although high in both, is different in systole and diastole This type of murmur usually indicates a pin-point lumen A case prior to this study was examined in which high-pitched but different "seagull " murmurs were present over both carotid arteries in a patient with recurrent hemiplegia Bilateral severe stenosis of the internal carotid arteries in the neck was confirmed by arteriography, and its atherosclerotic nature was confirmed by surgical exploration (fig 8) Another cause of a systolic murmur in the neck is the thoracic outlet syndrome In these patients the subelavian artery is compressed by a cervical rib, a fibrous band or an unusually high first rib (the scalenus anticus syndrome) Subjects suffering from this condition are usually young women and show Raynaud 's phenomenon, ischemic neuropathy, compression of the lower cords of the brachial plexus, and, in some cases, recurrent embolization of the hands and fingers In the last few months we have seen two such cases in which a systolic murmur became audible over the subelavian artery on abducting the arm Circulation, Volume XXV, February 1962 on the same side to a right angle and rotating the head toward the opposite shoulder In both cases the murmurs were present bilaterally, and symptoms and signs were improved by section of the anterior scalene muscles Summary and Conclusions Atherosclerosis of the carotid and vertebral arteries, an important cause of transient cerebral ischemia amid infaretion, is now amenable to medical anid surgical treatment There is, however, a need for greater accuracy in diagnosis of cervicocranial atherosclerosis by routine physical examination before cerebral infaretion occurs A group of 50 patients admitted with the diagnosis of cerebrovascular disease were studied by auscultation of the four major vessels in the neck with head turning Results were then compared with arteriographic findings Carotid murmurs were the most frequent abnormality and were found to be a reliable indication of atherosclerotic plaques Carotid sounds having low intensity in all positions of the head when compared to the opposite side were an accurate indication of atherosclerotic change Auscultation of the cervical carotid arteries led to the detection of 57 per cent of atherosclerotic plaques In the vertebral system, murmurs recorded over the origin of the vertebral arteries were associated with atherosclerotic changes in the vertebral arteries in 40 per cent of cases In a further 40 per cent, the murmurs were evidently transmitted from plaques in the subelavian arteries but it is quite possible that some of these plaques involved the origin of the vertebral arteries Disappearance of the vertebral sounds on head turning was less reliable as an indication of atherosclerotic change Absence of vertebral sounds in all positions of the head was associated with disease of the vertebral arteries in a high percentage of cases Auscultation of the cervical vertebral arteries led to the detection of about 45 per cent of atherosclerotic plaques demonstrated by arteriography of all four cervicocranial vessels References HUTCHINSON, E C., AND YATES, P 0.: Caroticovertebral stenosis Lancet 1: 2, 1957 310 Downloaded from http://ahajournals.org by on September 16, 2022 LoFSTRoM, J E., WEBSTER, J E., AND GURDJIAN, E S.: Occlusive disease of the cerebral vessels Mississippi Doctor 35: 7, 1957 MURPHEY, F., AND MILLER, J H.: Carotid insufficiency-diagnosis and surgical treatment A report of twenty-o-ne cases J Neurosurg 16: 1, 1959 GuRDJIAN, E S., LINDNER, WV D., HA&RDY, W G., AND WEBSTER, J E.: Cerebrovascular disease an analysis of 600 cases Neurology 10: 372, 1960 MEYER, J S., WALTZ, A G., THESS, J W., AND ZAK, B.: Serum lipid and cholesterol levels in cerebrovascular disease Arch Neurol 1: 303, 1959 SAMUEL, K C.: Atherosclerosis and occlusion of the internal carotid artery J Path & Bact 71: 391, 1956 PETERSON, R E., LIVINGSTON, K E., AND ESCOBAR, A.: Development and distribution of gross atherosclerotic lesions at cervical carotid biftureation Neurology 10: ll, 955, 1960 EASTCOTT, H H G., PICKERING, G W., AND ROB, C G.: Reconstruction of the internal carotid artery in a patient with intermittent attacks of hemiplegia Lancet 2: 944, 1954 LiM, P M., JAVID, M., AND DOYLE, E J.: Partial internal carotid artery occlusion treated by primary resection and vein graft Report of a case J Neurosurg 13: 650, 1956 10 EDWARDS, C., AND ROB, C G.: Relief of neurosurgical symptoms and signs by reconstruction of a stenosed internal carotid artery Brit MA J 2: 1266, 1956 11 GASS, H H., AND SMATHERS, H M.: Carotid artery insufficiency corrected by internal carotid thrombectomy Neurology 7: 6570, 1957 12 ROB, C G., AND WHEELER, E B.: Thrombosis of internal carotid artery treated by arterial surgery Brit M J 2: 264, 1957 13 FIELDS, 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