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Surgical Procedures for Stroke

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Treatment

The following procedures may be done to prevent further damage during a stroke :

Decompressive Craniotomy

Occasionally, a large stroke can lead to significant brain swelling. When this happens and medications do not help relieve the swelling, a surgical intervention may be needed to prevent the pressure buildup within the skull from causing further damage to the brain. In this procedure, a flap of bone overlaying the swelling may be temporarily opened in order to relieve the pressure. If the stroke is of the hemorrhagic type, the blood clot may also be removed to prevent further brain injury.

Catheter Embolectomy

This is a procedure used to treat acute strokes. A tiny, flexible tube called a catheter is threaded through the blood vessels until it reaches the area in the brain where the clot is lodged. Efforts are made to remove the clot through the catheter; or, clot-busting agents are given through the catheter to the location of the actual clot.

Mechanical devices may be used to remove a clot. New devices have been approved by the FDA that may provide a quick way to remove the blood clot. The devices have either a corkscrew tip or a special ring used to remove the clots. They are placed in a catheter and threaded through blood vessels to the area of the blockage. When the device is in the proper location, it is used to remove the clot blocking the blood vessel. The advantage of these devices is that they can remove the clot in minutes, opening blood flow and decreasing the level of damage to affected tissue.

Prevention

Other surgical procedures for stroke fall into the prevention category.

Two conditions in the arteries in the brain or the arteries that lead to the brain can cause a risk of stroke. These can be the result of atherosclerosis, which are fatty deposits in the arteries. This can lead to:

  • Narrowing of an artery that will eventually shut off the blood supply to the brain
  • Ulceration of a fatty deposit known as plaque that makes it likely to break off and obstruct the artery further down stream

Surgery attempts to correct either or both events. Very careful evaluation is need to determine which lesions will benefit from surgery.

In addition, conditions at birth, post-surgical, or other heart or valve conditions can lead to stroke. Surgical interventions may be necessary to help decrease the risk of stroke. The following surgical interventions may be necessary to manage or prevent stroke:

Arterial Bypass

A narrow area of your artery, usually the carotid artery, can be bypassed by sewing in a replacement tube above and below the obstruction.

This surgery is nearly always done on the carotid arteries, which lie on either side of your windpipe. It may also be done between a scalp artery and a vessel inside your skull.

After attaching you to monitoring devices in the surgical suite, you will be under general anesthesia . The skin over the involved artery or arteries will be cut. A piece of your skull will be removed, if necessary. A piece of tubing will be sewn between a healthy artery and the diseased one. The bypass may go around a short narrowed segment of a carotid artery, or it may connect an artery inside the skull with one from outside the skull.

Carotid Artery Endarterectomy (CEA)

Very similar to an arterial bypass and requiring that a bypass be used temporarily during the surgery, an endarterectomy carves out the inner lining of the carotid artery. It leaves behind the outer layers to carry the blood. There are technical reasons why one procedure is preferred over the other. CEA is performed much more commonly than arterial bypass for atherosclerotic disease of the carotid arteries.

Angioplasty

A catheter is threaded through the blood vessels and into the carotid artery or, less commonly, another artery in the brain. A balloon is introduced through the catheter and inflated within the blood vessel, in an effort to widen the blood vessel and improve blood flow through it. A mesh tube called a stent is often left within the artery to keep it as open as possible. A mesh screen may be placed within the artery to catch any bits of plaque or clots that might otherwise flow upward into the brain.

Even though endarterectomy is more invasive, it may be preferred over angioplasty for some patients. Angioplasty may be an option for patients who are have a high risk of complications from CEA.

Aneurysm Repair

Aneurysms are weak spots in arteries that balloon out and may rupture, allowing blood at high pressure to pump into neighboring tissues. It is sometimes possible to repair an aneurysm before it causes a major hemorrhagic stroke. An enlarging aneurysm may produce pressure in the brain before it ruptures. Or, it may leak slowly enough to allow detection and repair before the major bleeding begins.

Cerebral Aneurysm
IMAGE
Copyright © Nucleus Medical Media, Inc.

Brain aneurysm surgery is brain surgery. The goal is removal or clipping of a small weak spot on a blood vessel. Once visualized, the standard procedure is to clamp a small metal clip around the base of the aneurysm.

There are alternatives that can be accomplished without surgically entering the skull. Aneurysms are connected to the circulation and can be approached through blood vessels by threading long, thin catheters into them. It may then be possible to block the aneurysm from inside, perhaps by inserting metal coils or squirting them full of tiny beads or other compounds. These will cause a clot to form and scar.

Cardiac Valvular Surgery

Four heart valves open and close to allow blood to flow properly through the heart. Surgery may be necessary if one or more of the valves does not function as it should. Problems with heart valves can significantly increase the risk of strokes. The valve may be repaired or replaced with a prosthetic valve during open or minimally invasive surgery.

Minimally invasive surgery is becoming more common. Small incisions will be made in the chest. Endoscopic, keyhole, or robot-assisted surgical techniques may be used to reach the heart for surgery. The heart is stopped temporarily during surgery; breathing and blood flow is done by a heart and lung machine. An incision is made in the heart or aorta to reach the valve. The valve is repaired or replaced, and the incision areas are stitched. The heart is started again.

Cardiac Thrombosis Surgery

A blood clot can form on the valves or in the chambers of the heart. This can also happen with a prosthetic heart or valve. If the blood clot is not reduced with medication, surgery may be done. Catheter assisted or open surgical procedures may be necessary to remove the clot.

A newer technique called thrombus aspiration may also be used to remove the blood clot in or around the heart. This technique uses a small vacuum to suction the clot during surgery.

Cardiac Septal Defect Surgery

Ventricular and atrial septum defects are present at birth. The septums are walls separating the atria or the ventricles within the heart. In certain cases, there is concern that these defects can be associated with increased risk of strokes. These are commonly repaired during surgery using sutures or a tissue patch.

Patent Foramen Ovale Closure

When the atrial septum does not close properly after birth, it is called a patent foramen ovale (PFO), also known as a hole in the heart. It is a common finding, and it does not cause any problems in most people. In certain scenarios, there is concern that a PFO may increase the risk of stroke. A catheter may be guided through a vein in the leg until it reaches the heart. A special device is placed over the hole. In time, new heart tissue surrounds the implant.

Revision Information

  • Reviewer: Rimas Lukas, MD
  • Review Date: 11/2013 -
  • Update Date: 11/20/2013 -
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  • 11/20/2006 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1726-1729.