CAROTID Flashcards
determination of timing for her carotid endarterectomy with stroke
highest risk of operation within the first month of stroke
Operating to early risks a reperfusion injury
A large infarction on CT scan and hypertension cannot be controlled risk is high
If CT scan is normal with nondisabling acute stroke may proceed with carotid endarterectomy Within 2 weeks of primary stroke
Large stroke on CT scan were depressed level of consciousness during stroke operation should be delayed for-6 weeks once recovery begins to plateau
Asymptomatic carotid atherosclerosis study
ACAS asymptomatic carotid stenosis 60-99% Aspirin or aspirin plus CEA reduction of stroke: from 11% to 5% CEA no benefit for women!
overall one of the carotid artery endarterectomy indicated in asymptomatic patient regarding percent stenosis
60-99%
North American symptomatic carotid endarterectomy trial
carotid endarterectomy is beneficial for: SYMPTOMATIC stenosis: 70-99% symptoms defined as: Nondisabling stroke Transient ischemic attack Amaurosis fugax
Exclusions:
Severe neurologic deficit
No prognosis of meaningful recovery
Marked alteration in consciousness
Aspirin alone group human the risks of ipsilateral stroke 2 years:
26%
CEA Group Cumulative risk ipsilateral stroke 2 years:
9%
stenosis: Less than 50%
no advantage of CEA
stenosis: 50-69%
five-year risk of ipsilateral stroke:
ASA: 22.2%
CEA 15% significant improvement
WOMEN ( higher perioperative mortality) only benefited if one additional risk factor: H. greater than 70 Severe hypertension History of myocardial infarction In the hemispheric event
complete occlusion of carotid artery managed with
observed
There is thought to be no further embolic risks with completely occluded vessel
causes and treatment of the new neurologic deficits the present within the first 12 hours after carotid endarterectomy
these all need heparinization and immediate reexploration without confirmatory test
Causes:
Thromboembolic phenomenon from carotid endarterectomy site
Thrombus on endarterectomy arterial surface
Residual intimal flap leading to occlusion
Residual flap and external carotid artery being 2 external carotid thromboses and a retrograde embolization into internal carotid
Cause and management of deficits occurring 12-24 hours after carotid endarterectomy
prompt CT scan and arteriography
Usually due to thromboembolic phenomenon stemming from carotid endarterectomy site but may also because by postoperative hyperperfusion syndrome
Postoperative hyperperfusion syndrome may be worsened by immediate heparinization and reexploration!
Advantages of patch closure for CEA
Decreased rate of early postoperative ICA occlusion
Decreased 30 day perioperative stroke rate
Decrease rate of restenosis in the first year
ICA patch material
most common, background or PTFE
vein associated with rupture, false aneurysm, thromboembolism-if used take from the thigh
Morse, and
cerebral hyperperfusion syndrome after carotid endarterectomy - pathophysiology and Risks
impaired autoregulation Risk factors: Recent stroke High percentage stenosis Concomitant contralateral ICA occlusion Evidence of a lateral hypoperfusion Poorly controlled preoperative and postoperative hypertension
cerebral hyperperfusion syndrome after carotid endarterectomy symptoms and treatment
as lateral frontal headache most commonly fifth postoperative day
Possible focal motor seizure difficult to control
Treatment:
Beta blocker
Anti-seizure medication
Possible diuretics
surgical maneuvers to gain better exposure carotid artery
division of posterior belly of the digastric
Division of the omohyoid
Subluxation of the mandible
Division of the descendens hypoglossi ( branch of the ansa cervicalis to send carotid sheath) - no significant clinical disability
carotid body tumor
malignant 6-12.5% origin femur receptor at carotid bifurcation CT angiogram MRI or duplex Widening of carotid bifurcation NO biopsy Preoperative embolization only for tumors greater than 4 cm removed in pre-adventitial plane cranial nerve injury and as many as 20%
fibromuscular dysplasia of the internal carotid artery
most common non-atherosclerotic disease of ICA
25% association intracranial aneurysm
65% bilateral
Most common:
MEDIAL fibrodysplasia
String of beads
White woman
Surgery for symptomatic patients
The distal angioplasty with antiplatelet
temporal arteritis
“giant cell arteritis” Elderly female averaged 69 years Vasculitis of medium and large arteries The aortic arch and branches ICA, ECA sudden blindness Jaw claudication Diagnosis: Temporal artery biopsy the least 2 cm segment Duplex scanning and diagnosis - clear halo around artery
treatment:
Rapid high-dose steroid
