Carotid Endarterectomy to Prevent Ischemic Stroke
Carotid endarterectomy is a surgical procedure used to clean out and open up the narrowed carotid artery. It is used to prevent thrombotic (large-artery) strokes caused by blockage in the internal carotid artery, which is responsible for about 9% of ischemic strokes.

Procedure Description. The procedure generally is as follows:

 
• The patient is usually given general anesthesia, although it has been reported that using local anesthetic is just as safe and reduces the cost of the procedure.  
• A by-pass tube is put in place to transport blood around the blocked area during the procedure.  
• The surgeon scrapes away the plaque on the arterial wall.  
• The artery is sewn back together and blood flow is restored.  
• The patient generally stays in the hospital for about two days. There is often a slight aching in the neck for about two weeks, and the patient should refrain as much as possible from turning the head during this period.

Patients who have this procedure after a Stroke  are usually advised to wait six weeks. Studies are reporting however, that having the procedure earlier does not pose greater risks.

Appropriate Candidates In general, any patients with severe stenosis and symptoms of Stroke can benefit from endarectomy. Severe stenosis is defined as over 70% obstruction of the carotid artery. It has not been clear whether the benefits of the procedure outweighs the risk in elderly patients who meet the criteria, although a 2001 study suggested it may be even more advantageous for people over 75 than for young patients. .

And, anyone with mild stenosis (less than 50%), even with symptoms, would do better with medications.

The benefits of endarectomy for people with symptoms and stenosis between 50% to 70% are somewhat unclear, however. The best candidates for preventive corotid enderactomy in such cases iinclude those with all of the following conditions:

 
• Patients with symptoms that indicate blockage in the brain.  
• Male patients. The benefits of this procedure for women are uncertain.  
• A history of a stroke that occurred three months earlier or less.  
• The medical centers have major complications rates after endarterectomy of less than 3%.

Carotid endarterectomy in patients with stenosis of over 60% but who have no symptoms has been a subject of much controversy. In general, surgery is recommended in asymptomatic patients who have have the following characteristis:

 
• Are under 79 years old  
• Stenosis is at least 60%  
• The risks of surgical complications are less than 3%.

An important 2000 study reported that over half of the Strokes that occurred in patients with asymptomatic stenosis were caused by embolisms (traveling clots) or lacunar infarcts (very tiny, ischemic strokes). Only 3.5% of the strokes were due to blockage in the carotid arteries, which is the only condition that is benefited by carotid endarterectomy. Given these results, the experts in the study could not recommend the procedure for even asymptomatic patients with severe stenosis (narrowing of 70% to 99%) of carotid arteries until more studies define which patients would benefit. (Other experts disagree and still believe that many asymptomatic patients with severe stenosis are good candidates, regardless of whether they have symptoms or not.)

Benefits after a Stroke. The long-term benefits of surgery include improvements in vision, speech, swallowing, functioning of arms and legs, and general quality of life. It should be noted that the studies showing such high benefit of surgery versus drug therapy were done in institutions whose surgeons are experienced with such operations.

Complications. There is a risk of a heart attack or even stroke from the procedure. Studies have reported, in fact, that strokes occur during or immediately after the operation in up to 9% of these operations. The other overall risk of death from postoperative stroke was 2.8%. Women appear to have a significantly higher risk for postoperative stroke than men have. Doctors are researching the utility of an emergency procedure that places a stent (a circular wire mesh) to open the carotid artery in the event of such a stroke.

A 2000 study reported that older surgeons had a worse record than younger ones, possibly because they relied on residents or were less likely to adopt new procedures. Patients should be sure the surgeon has recent experience in the procedure and has a history of complication rates of no more than 4%.

Carotid Angioplasty
Carotid angioplasty is being investigated as an alternative to carotid endarterectomy. It is based on the same principles as angiography done for heart disease.

 
• An extremely thin catheter tube is inserted into an artery in the groin.  
• It is threaded through the circulatory system until it reaches the blocked area in the brain carotid artery.  
• The physician either breaks up the clot or inflates a tiny balloon against the blood vessel walls (Angioplasty ). Or, after temporarily inflating the balloon, the doctor may leave a circular wire mesh (stent) inside the vessel to keep it open.

This procedure carries a risk for an embolic stroke. In fact, recent studies report very high complications, and in one study, results with Angioplasty  were worse compared to carotid endarterectomy. At this time, angioplasty is not recommended except for highly selected patients. More experience with the procedure may improve results.

Extracranial-Intracranial Bypass
Extracranial-Intracranial (EC-IC) bypass has been under investigation for decades for ischemic stroke, but has had very mixed results, some extremely negative. With this procedure a healthy artery in the scalp is rerouted to an area of the brain that was deprived of blood because of a blocked artery. This procedure is now sometimes used for patients with aneurysms. Some experts hope, however, that, in specific cases chosen via careful imaging and using the latest surgical techniques, EC-IC may prove to be helpful for some stroke patients.

Surgery for Preventing and Treating Hemorrhagic stroke
Surgical Intervention of Unruptured Aneurysms. If an unruptured aneurysm is detected, patients should discuss all options with their physician, including surgical repair. Unruptured aneurysms occur in between 1% and 6% of the general population, however, and controversy exists over when to operate and on which patients. In general, the decision rests on the size of the aneurysm, but uncertainty still exists:

 
• One study reported that in patients with aneurysms smaller than 10 mm the risk for rupture was only .05% per year (which is far greater than the risks from surgery). Even people with a history of subarachnoid hemorrhage had only a 0.5% annual risk for recurrence when aneurysms were that small.  
• For aneurysms between 10 and 25 mm, the risk of rupture was still quite low, slightly less than 1 percent per year for both groups.  
• Aneurysms over 25 mm had a 6% chance of rupturing within a year.

Aneurysms can often cause symptoms, however, even if they do not rupture. Patients should discuss their particular risk factors carefully with their physicians. Individuals with Arteriovenous malformation, a condition caused by abnormal associations between arteries and veins, should be monitored for the development of aneurysm.

Clipping the Aneurysm. If is it possible, the standard surgical procedure for treating a ruptured aneurysm is to place a clip across the neck of the aneurysm, which blocks off bleeding. It is usually performed within the first three days. Getting to the aneurysm is often extremely difficult. Deep cooling of the body to stop circulation may be used to allow more time for the operation. Procedures that remove large portions of the bone in the skull are being developed to allow fast access. One long-term 2001 study indicated that there is a relatively high risk for newly formed aneurysms, particularly after nine years. Patients may want to discuss follow-up angiography to detect any new aneurysms nine or ten years after the procedure.

Transcatheter Embolization for Sealing off the Aneurysm. In a technique called transcatheter embolization, surgeons thread a thin tube through the artery leading to the aneurysm through which materials are passed to plug or obstruct the aneurysm. In one version of this procedure, the following occurs:

 
• A tiny platinum coil is inserted through the tube and positioned into the aneurysm.  
• An electric charge is passed through the coil to form blood clots.  
• In this case, blood clots benefit the patient by using the coil as a scaffold and sealing off the aneurysm.  
• In small trials using the coil, only 3.7% of patients suffered a second stroke after seven months compared to the usual re-rupture rate of 30% to 40%.

Clipping the aneurysm appears to produce better results, but embolization is less invasive and may be suitable for selected patients. More comparative studies are needed.

Emergency Surgery for Hemorrhagic stroke. Emergency surgery for a Hemorrhagic stroke usually involves locating and removing large blood clots. In the past, such procedures had little effect on survival. Advances, however, are improving outcome when surgery is performed very early.