Presidential address: stroke--a perspective

A vascular surgeon must recognize that strokes may be caused by embolism from or obstruction of the extracranial afferent arteries to the brain. Furthermore, embolic disease and the hypoperfusion syndrome may occur in the same patient. A transient ischemia attack (TIA) is diagnostic of localized cerebral ischemia. A bruit has little significance other than as an indication for further study. The most practical noninvasive method of studying patients for cerebrovascular disease in our laboratory has been oculopneumoplethysmography and B-mode scanning. Interobserver variations in interpretation of arteriography make measurement of the percentage of stenosis an unacceptable standard for judging the accuracy of other diagnostic techniques. Endarterectomy with local or general anesthesia with the routine use of a shunt or EEG monitoring is satisfactory and useful. In my opinion the most important elements are wide exposure, minimal preclamping handling of the carotid artery, meticulous and unhurried technique for endarterectomy, and postoperative control of blood pressure. Since 1970 I and my associates have performed 882 carotid endarterectomies. The operative mortality rate has been 1%, permanent neurologic deficit 0.96%, and transient neurologic deficit 2.1%.