Clinical Considerations in the Surgical Management of Strokes

Abstract

Four hundred carotid endarterectomies were performed on 320 private patients with cerebrovascular insufficiency during an eight-year period. Patients are classified into four groups: frank stroke (135 patients), transient cerebral ischemia (151 patients), chronic cerebral ischemia (13 patients), and asymptomatic bruit (21 patients). Over-all operative procedure mortality was 3.5%. In frank strokes it was 7.4%; in transient ischemia, 1.02%; and in the other two groups was zero. As a safety factor during operation, the routine use of an inlying bypass shunt is advocated. Of 60 long-term deaths, six (10%) were due to strokes. Among frank stroke survivors, 42.8% are normal, and 48.4% are improved. One patient had a mild subsequent stroke. In transient ischemia survivors, 88.4% are normal, and 7% are improved. Three patients had strokes due to unoperated lesions. Surgery appears to have lowered the incidence of strokes in these groups. There were no strokes in the other two groups. Indications for and timing of operative procedures are suggested on the basis of the clinical results. Transient ischemia, chronic ischemia, and asymptomatic bruit patients may be operated upon electively unless an imminent total occlusion demands emergency operation. Acute and rapidly progressing strokes should not be operated upon as an emergency, but allowed to stabilize and be considered for surgery at a delayed time. The concept of total cerebral blood flow is discussed in relation to its therapeutic implications and the reversibility of neurological deficits. Carotid endarterectomy is a safe, definitive therapy in selected patients with cerebrovascular insufficiency.