Surgery

Carotid Angioplasty and Stenting

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 carotid artery.
• The doctor either breaks up the clot or inflates a tiny balloon against the blood vessel walls (angioplasty).
• After temporarily inflating the balloon, the doctor typically leaves a circular wire mesh (stent) inside the vessel to keep it open.

This procedure carries a risk for an embolic stroke and other complications. At this time, it is being used in some centers as an alternative to endarterectomy in patients who cannot undergo endarterectomy, especially for patients with severe stenosis (blockage greater than 70%.). A 2002 study reported that complications from stents were equal to or less than those of endarterectomy.

Hemicraniectomy

Hemicraniectomy is surgical removal of a bone patch from the skull to relieve pressure. The bone is stored under sterile conditions and reimplanted a few months latter. It may have be a life-saving option for some patients with severe stroke that has resulted in swelling and injury to a large area in the brain. Studies are showing some benefits for high-risk patients, but more information is needed to determine specific conditions that will respond to this treatment. (In one study, for example, patients with subarachnoid hemorrhage had a poor outlook after this procedure.)

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 Strokes

Surgical Intervention of the Ruptured Aneurysms. In patients with subarachnoid hemorrhagic stroke, surgery to block off the aneurysm is usually recommended within a few days of the stroke. The standard procedure is to clip the aneurysm and stop bleeding. Alternative approaches are promising.

Surgical Intervention of Unruptured Aneurysms. If an unruptured aneurysm is detected, patients should discuss all options with their doctor, including surgical repair. Unruptured aneurysms occur in between 1 - 8% of the general population, however, and controversy exists over when to operate and on which patients.