[Surgical prevention and therapy of cerebral ischemia]

Surgery for cerebral ischemias has three main purposes: (1) prevention of cerebral infarctions, (2) functional improvement in patients with chronic ischemia, and (3) reduction of morbidity and mortality after complete infarction. The preventive efficiency of carotid endarterectomy has been documented in cases of high-grade symptomatic carotid artery stenosis. Several multicentric randomized studies are still under way whose aim is to define the benefit of surgery in cases of low and medium-grade symptomatic carotid stenosis as well as asymptomatic carotid stenosis. Little data is at present available on the value of prophylactic surgery in the vertebro-basilar system. In contrast to prophylactic surgery, several procedures are used for treatment of chronic hypoperfusion syndromes. In addition to carotid endarterectomy, extra-/intracranial bypass surgery, percutaneous balloon dilatation and transposition of the vertebral artery may improve perfusion. The indication for surgery with the goal of functional improvement is based on the typical symptomatology of a fluctuating neurological deficit and on tests of cerebro-vascular reactivity. In the treatment of established infarctions, neurosurgery may help non-geriatric patients to recover to the greatest possible extent by offering the methods of monitoring and management of intracranial pressure that have been used in neurotraumatology for the last twenty years.