Surgery for stroke

Studies on the natural history of cerebrovascular disease have shown that patients with symptomatic tightly stenosed and occlusive disease of the internal carotid artery are at high risk of subsequent stroke. However, carotid endarterectomy is still unpredictable in its outcome and morbidity and mortality levels do not support surgery in asymptomatic mild or moderate stenosis. The prime indications for surgery are transient ischaemic attacks (TIAs) and transient stroke with focal lesions of the origin of the internal carotid artery. Combined severe stroke morbidity and mortality should be less than 4%. Extra-intracranial bypass is indicated when cerebral symptoms are associated with low cerebral perfusion. Symptomatic smooth tight stenoses of the origin of the aortic arch branches are effectively treated with angioplasty and occlusion of these origins with bypass surgery. More research is required into the prevention of atheroma, methods of reducing thrombo-embolism and means of undertaking safe surgery. With this must be linked the study and management of acute ischaemia and post-stroke rehabilitation.