Doctors often recommend these relatively new surgical procedures to patients who may not be able to withstand the stresses of major surgery, whether because of advanced age or because they have other serious medical conditions. However, these procedures are appropriate for less frail patients, too. Advantages include local or regional anesthesia instead of general anesthesia, shorter recovery time, less pain, smaller incisions, and less stress on the heart. These procedures may be used to treat aneurysms, cerebral vascular malformations, and arteries that have been occluded by plaque.
- Treatment of aneurysms: To repair an aneurysm, or a section of a vessel that has ballooned out, surgeons guide a coil (essentially, an artificial graft) into the damaged blood vessel and anchor it into place. This allows blood to flow normally again through the vessel, lowering the patient’s risk of a future hemorrhagic stroke. A long plastic tube called a catheter, which has been threaded up through a tiny incision in an artery in the thigh up to the trouble spot, is used to position the coil. X-ray imaging is used to guide the catheter.
- Treatment of cerebral vascular malformations: Endovascular surgeons may use a “superglue” substance introduced via a tiny catheter to eliminate or reduce the size of the cerebral vascular malformations. Often this facilitates further microsurgical or radiation treatment. Mechanical removal of blood clots: A new tool for treating hemorrhagic stroke is a tiny device used to physically remove blood clots that are blocking blood vessels within the brain. The Food and Drug Administration recently approved one such device, the Merci Retrieval System, which works like a corkscrew to pluck out clots. In nonbleeding (ischemic) strokes, blood clots damage the brain by depriving brain cells of the oxygen and nutrients (carried in the blood) they need to survive. But when used within the first several hours after a stroke, the device can extract clots and may reduce permanent damage.
- Angioplasty and stenting of vessels in the neck and brain: This new intervention is available at many medical centers. Cerebral angioplasty is similar to the widely used cardiology procedure, in which a tiny balloon attached to the tip of a catheter is threaded into a blocked artery and then inflated. In this case, the vessels are the carotid arteries in the neck, and a tiny tube-shaped bit of wire scaffolding, or a “stent,” is inserted into the blockage to keep it open after the balloon has been withdrawn. This procedure often is offered as an alternative to carotid endarterectomy for patients for whom the more invasive surgery is thought to be too risky, whether because of the patient’s overall health or because of the location of the blockage. Because angioplasty and stenting is fairly new, researchers are still investigating how well the stents hold up and how well the procedure reduces patients’ risk of stroke over the long term.
- Intra-Arterial Thrombolysis: For this procedure, doctors insert a small catheter into the blood vessels of the brain during cerebral angiography and deliver clot-dissolving medications directly to the blocked blood vessel.
Carotid endarterectomy
Carotid endarterectomy is a surgical procedure used to remove atherosclerotic plaque (fatty deposits associated with cardiovascular disease) from the carotid arteries. For selected patients who have had minor strokes or transient ischemic attacks (TIAs or ministrokes), carotid endarterectomy can be highly beneficial in preventing future strokes. The primary factor doctors consider when weighing this procedure for an individual patient is the extent to which plaque has narrowed the affected artery (“stenosis”). For patients with less than 50 percent stenosis, the benefits of carotid endarterectomy normally do not outweigh the risks. However, in patients with 70 to 99 percent
stenosis
who have had recent symptoms caused by the stenosis, the surgery lowers the two-year risk of stroke by about 80 percent
Stereotactic procedures
Stereotactic techniques, which involve placing markers on the patient’s head to create reference points for very precise surgeries, allow surgeons to treat vascular malformations that were previously too difficult to reach. Stereotactic surgeries employ sophisticated computer technology in combination with MRI or CT scans to pinpoint the trouble spot. Using microscope-enhanced methods and delicate instruments, the surgeons can operate without affecting normal brain tissue.
Revascularization
Revascularization is a surgical technique for treating aneurysms or blocked cerebral arteries associated with atherosclerosis or moyamoya disease (a rare disease resulting in narrow or blocked vessels to the brain and irregular blood vessels). The technique essentially provides a new route of blood to the brain by grafting a blood vessel from the surface of the face near the temple to a cerebral artery through a hole in the skull.
Hypothermia
Preliminary studies with techniques that cool the brain or body suggest that doing so may improve outcomes for stroke patients in a variety of situations. Surgeons operating on stroke patients to correct cerebral vascular malformation and aneurysms, for instance, are finding that if they first chill the patient’s brain, he or she may be less likely to suffer another stroke during the surgery. Inducing hypothermia may also give the surgeon extra time to operate.Studies of patients who are comatose after a cardiac arrest have shown that chilling their entire bodies improves their chances of a favorable neurological recovery. This has led other doctors to try cooling down stroke patients. As with stroke, brain injury in cardiac arrest patients is caused by the interruption of the blood flow to the brain. Currently, doctors are trying to determine how long and to what degree the body should be cooled, and whether the risks of cooling outweigh the benefits in stroke patients.
