Carotid artery stenosis
Prevalent site】 Mostly occurs in the bifurcation of the carotid arteries bilaterally.
Clinical symptoms] Mostly caused by microscopic thrombus dislodged into the cerebral vessels, resulting in ischemia in the related blood supply area. Most of the symptoms are mild paralysis, weakness, numbness, pins and needles, aphasia, blurred vision or blindness in one eye, dizziness, headache, impaired consciousness and other transient cerebral ischemic symptoms in one limb or one limb. Jin Yongjian, Department of Neurosurgery, Aviation General Hospital of China Medical University
【Diagnosis】.
1. symptoms of transient anterior circulation cerebral ischemia.
2. Vascular murmurs can be heard in the carotid vessels.
3. CTA, cervical ultrasound, MRA, DSA and other imaging diagnoses.
[Indications for neurosurgical treatment].
– Symptomatic TIA with carotid artery stenosis greater than 70%.
– Symptomatic TIA with carotid artery stenosis of 50-69% for which medical treatment is ineffective.
– Atherosclerotic plaques with non-severe ulcerative plaques.
【Treatment method】.
Carotid endarterectomy (CEA), intracranial and extracranial vascular bypass surgery, and carotid stenting can be performed. The purpose of surgery is to prevent thrombus dislodgement and reestablish paracrine blood flow.
1. Carotid endarterectomy
Indications for surgery
– Symptomatic TIA with carotid artery stenosis greater than 70%.
– As long as the surgical risk is low, the degree of carotid stenosis is 50-69% symptomatic TIA.
– In asymptomatic patients with carotid stenosis greater than 60%, carotid endarterectomy is also beneficial to the patient.
– Atherosclerotic plaques are non-severe ulcerative plaques.
– No severe cerebral infarction or no severe stroke attack within 3 weeks.
【Surgical method】.
The operation is performed under a microscope, and a 10-15 cm incision is made in the surgical neck. After confirming the carotid artery, the distal and proximal ends of the carotid artery are temporarily clamped, and then the carotid artery is incised and the diseased intimal plaque is peeled off and removed, so that the inner wall of the carotid artery is smooth and the inner diameter is restored to normal size, and if necessary, a patch is used to form a repair. The operation takes only 2-3 hours, and the patient can resume normal life 1-2 days after the operation.
[Evaluation of surgical results
According to a study conducted in 1998 in more than 80 hospitals in 14 European countries with the UK as the center, 576 patients with high stenosis were randomly treated with CEA or medication and then prospectively followed up for 6.1 years, resulting in a 3-year stroke risk of 6.8% with CEA and 20.6% with medication. This is a good indication that carotid endarterectomy has significant efficacy in preventing the occurrence of stroke, although there are some risks. Complications were less than 6%, and the overall efficiency of the procedure was 98 %.
Another study showed that patients with ischemic cerebral infarction due to carotid stenosis had a 60% chance of recurrence within two years after the first attack, and 50% of these recurrences resulted in death. If the first stroke is treated with carotid endarterectomy, the 1-year recurrence rate of the disease can be reduced from 5 to 20 % to 2 %.
2. Carotid artery stenting
Indications for surgery
– Stenosis of more than 70%.
– The vessel is less flexed and the catheter can pass through the stenosis.
– Patients of advanced age.
– Patients with many systemic underlying diseases and poor general condition.
– Patients with high stenosis or occlusion of the contralateral carotid artery.
– High-grade lesions above C2.
– Patients with unremarkable results of internal anticoagulation therapy.
– Restenosis after CEA or radiation therapy.
– Advantages and disadvantages of carotid artery stent placement.
– Clamped aneurysm.
[Contraindications to surgery].
– Patients with severe vascular tortuosity that prevents the introduction of the interventional catheter into the cranium.
– Patients with soft plaque in the stenosis and who are prone to cerebral embolism at the distal end of the stenosis.
Surgical method]
Under a special umbrella that prevents the dislodged thrombus from entering the intracranial vessels, a microcatheter with a balloon is introduced into the stenosis (carotid stenosis) and dilated, and then a special metal stent is introduced and placed into the stenosis and dilated, thus achieving the purpose of rebuilding the blood flow in a cis-directed manner. Since the procedure is performed under local anesthesia, the patient can remain conscious during the procedure.
Advantages and disadvantages of carotid artery stenting
Advantages.
– The procedure can be performed under local anesthesia, with an incision of about 2 mm in the femoral artery at the root of the thigh.
– The operation time is short.
– The patient suffers less pain and is hospitalized for fewer days.
– The normal blood vessels and nerve tissues around the carotid artery are not damaged, which can reduce the complications of the operation.
– Intraoperative blood flow is not blocked, and ischemic complications are low.
Disadvantages
– Interventional catheter cannot be introduced into the skull in severe vascular tortuosity.
– The risk of intraoperative plaque dislodgement from the stenosis to the distal end to form an embolism.
– High cost of treatment.
[Evaluation of treatment effect
In 1989, stentoplasty was introduced for the treatment of carotid artery stenosis. Compared with carotid endarterectomy, carotid stenting has a wide range of indications, and many patients who cannot receive surgical treatment can be treated with carotid stenting, thus effectively preventing the occurrence of stroke. Arterial stenting is less invasive and has fewer surgical complications than open surgery, and can be performed under local anesthesia, resulting in less pain and fewer days in the hospital. Stenting is highly effective and has few comorbidities.
Chief of Department 010-59520364(Jin Yongjian)
Department head: 010-59520364(Jin Yongjian) Department: 01059520282
Cerebrovascular disease personal website:URL; http://www.hk-neurosurgery.com http://www.hkpiantoutong.com
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