stroke and vascular surgeon

1
Role of vascular surgeon in stroke

• Joel Arudchelvam
• Consultant Vascular and Transplant Surgeon

2
Role of surgeon

• In
• Carotid artery disease
• Vertebral artery disease
• Brachio-cephalic artery disease

3
Anatomy Carotid Arteriesand Vertebral arteries

• Brain is supplied by 2 carotid and 2 vertebral
  arteries.
• carotid artery divides in carotid triangle into
• Internal carotid artery (ICA)
• External carotid artery (ECA)
• at the upper border of thyroid cartilage
• No branches to ICA in the neck

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The Circle of Willis

• Formed by branches of bilateral carotid and
  basilar artery
• Basilar artery - union of vertebral arteries
• Allows collateral flow

5
Transient Ischemic Attacks (TIA) and Strokes

• TIA - focal neurological deficit lasting lt24
  hours
• Stroke - symptoms continue for gt24 hours
• Nondisabling stroke - a residual deficit
  associated with a score 2 according to the
  Modified Rankin Scale.

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MODIFIED RANKIN SCALE

• 0 - No symptoms
• 1 - able to carry out all usual activities
• 2 - unable to carry out all previous activities,
  but able to look after without assistance
• 3 - Moderate disability requiring some help,
  able to walk without assistance
• 4 - Moderately severe disability unable to walk
  without assistance and unable to attend to own
  bodily needs without assistance
• 5 - Severe disability bedridden, incontinent and
  requiring constant nursing care
• 6 - Dead

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Location of stroke
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Location of stroke
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Location of stroke
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Carotid Duplex

• The degree of stenosis - velocity criteria
• higher the velocity the - greater the stenosis

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Carotid Duplex

• Normal PSV lt 125 cm/s , no plaque is visible.
• lt 50 stenosis PSV lt 125 cm/s and plaque is
  visible.
• 50-69 stenosis PSV is 125-230 cm/s and plaque
  is visible.
• gt70 stenosis to near occlusion ICA PSV gt230
  cm/s and visible plaque
• Total occlusion No flow seen

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CT Angioram

• Interobserver agreement higher

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Management of symptomatic carotid stenosis
(American Academy of Neurology (AAN)
evidence-based guideline)

• 70 - 99 - CE (Level A).
• 50-69 - CE may be considered (Level B) (at
  least a five year life expectancy )
• lt50 stenosis - CE not be considered (Level A).
  Medical management (Level A).
• Total occlusion no need of revascularisation
• Non disabling ischemic stroke or transient
  ischemic attacks (within 6 months)
• Fit for surgery

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Timing of Surgery

• NICE guidelines within 2 weeks
• No place of emergency surgery in patients with
  unstable presentation
• Due to haemorrhagic transformation and unprepared
  patient high (allow stabilisation of infarction)

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Best medical treatment

• Stop Smoking
• Blood pressure control (less than 140/90 mmHg)
• Antiplatelet agents
• Cholesterol lowering drugs / diet ( LDL less
  than 100 mg/dL)
• Lifestyle advice

16
CEA Intra Op anaesthesia

• Modes
• Local infiltration
• Cervical plexus block
• GA
• Aim
• Maintain cerebral perfusion
• Reduce cardiac workload
• Allow smooth recovery to assess neurological
  status

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CEA intra op anaesthesia

• Invasive arterial blood pressure monitoring/stump
  pressure (70mmHg)
• maintain blood pressure
• Maintain CO2 tension avoid hyper / hypo
• Agents
• Induction
• Thiopentone - protect against focal ischaemia
• Propofol rapid awakening
• etomidate CV stability
• Maintenance with volatile agent
• Isoflurane
• Neurological monitoring
• EEG, transcranial Doppler

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Carotid Endarterectomy
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Carotid Endarterectomy

• Nerves to preserve
• Hypoglossal
• Vagus
• Marginal mandibular

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Carotid Endarterectomy
21
Carotid Endarterectomy
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Complications of CEA

• Perioperative stroke 7.4 (2/27)
• Haematoma
• Hyper perfusion syndrome
• Nerve injury -7.4 (2/27)
• Hypoglossal
• Vagus
• Infection

JD Arudchelvam , et.al. carotid endarterectomy
experience in a single vascular unit.presented as
an abstract at annual academic sessions of the
college of surgeons, Sri Lanka , Aug 2012.
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Post operative care

• Keep propped up, O2
• Control blood pressure (surgical disturbance of
  baro receptors) -Use short acting
  anti-hypertensive agents such as labetolol
• Especially within 48 hours
• hyperperfusion syndrome, haematoma
• Check document neurological status
• CT scan

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Hyperperfusion Syndrome

• In high grade stenosis
• Results in cerebral oedema, haemorrhage
• Unilateral headache, seizures

25
Carotid Stenosis Treatment

• Carotid stenting
• Difficult surgical access
• radiation, previous neck surgeries
• Medically not fit for surgery

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Summary

• Stroke / TIA
• Early imaging
• Optimization / best medical treatment
• Vascular referral

27

• Thank you