Surgical Procedures for Stroke
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The following procedures may be done to prevent further damage during a stroke:
A tiny, flexible tube (catheter) is threaded through the blood vessels until it reaches an area in the brain where a clot is lodged. Efforts are made to remove the clot through the catheter; or, clot-busting agents are administered 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 retrieve the thrombosis (blood clot). The device has corkscrew tip. It is placed in a catheter and threaded through blood vessels to the area of the blockage. Once in the proper location the tip is inserted into the clot, like a corkscrew. It is then removed from the blood vessels with the clot attached. The advantage of this procedure is that it can remove the clot in a matter of minutes, opening blood flow and decreasing the level of damage to affected tissue. Other versions of this device including one that uses ultrasound are still under investigation.
Occasionally, a large stroke can lead to significant brain swelling. When this happens and medicines are not successful in relieving the swelling, a surgical intervention may be required to prevent the pressure buildup within the skull from causing further damage to the brain. In this procedure, the surgeon may temporarily open a flap of bone overlaying the swelling in order to alleviate the pressure. If the stroke is of the hemorrhagic type (bleeding), the blood clot may also be removed to prevent further brain injury.
Other surgical procedures for ]]>stroke]]> technically falls into the prevention category.
Two conditions in the arteries in the brain or that lead to the brain can cause a risk of stroke. These can be the result of ]]>atherosclerosis]]> (fatty deposits in the arteries), which can lead to:
- Narrowing of an artery that will eventually shut off the blood supply to the brain altogether
- Ulceration of a fatty deposit (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 required to determine which lesions will benefit from surgery.
In addition, congenital (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:
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 surgeon will cut the skin over the involved artery or arteries, remove a piece of your skull if necessary, and sew a piece of tubing between a healthy artery and the diseased one. The bypass may simply 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.
Very similar to an arterial bypass (and requiring that a bypass be used temporarily during the surgery), an ]]>endarterectomy]]> simply carves out the inner lining, leaving behind the outer layers to carry the blood. There are technical reasons why one procedure is preferred over the other. Endarterectomies are performed much more commonly than arterial bypasses for atherosclerotic disease of the carotid arteries.
A tiny, flexible tube (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 stent (a mesh tube) 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 (and dangerous) than stenting, a study found that endarterectomy led to fewer deaths and repeat strokes than stenting within the first six months. ]]>*¹]]>
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.
Brain aneurysm surgery is brain surgery, with all the meticulous care and technology directed at safe, effective results. 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 (tiny tubes) 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 or other compounds. These will cause a clot to form and scars.
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. The surgeon will make small incisions in the chest. Endoscopic, keyhole or robot-assisted surgical techniques may be employed 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 performed. Catheter assisted or open surgical procedures may be necessary to remove the clot.
A newer technique called thrombus aspiration may also be employed 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 congenital (present at birth). The septums are walls separating the atria or the ventricles within the heart. In certain scenarios, 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), or “hole in the heart.” It is a very common finding, and it does not cause any problems in most people. In certain scenarios, there is concern that a PFO may predispose a person to increased risk of stroke. Using a catheter procedure through a vein in the leg, the surgeon guides the catheter to the heart and places a special device over the hole. In time, new heart tissue surrounds the implant.
New surgical procedures are undergoing extensive investigations throughout the world.
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Lutsep H. Mechanical Thrombolysis in Acute Stroke.http://emedicine.medscape.com/article/1163240-overview
A patient’s guide to heart surgery: heart valve surgery. University of Southern California Cardiothoracic Surgery website. Available at: http://www.cts.usc.edu/hpg-heartvalvesurgery.html . Accessed July 22, 2009.
Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008 Apr;39(4):1205-12.
Stroke (acute management). DynaMed website. Available at: http://www.ebscohost.com/dynamed/default.php . Updated May 2007. Accessed May 19, 2007.
Svillas T, Vlaar P, van der Horst I. Thrombus aspiration during primary percutaneous coronary intervention. NEJM . 2008;358:557-567.
¹11/20/2006 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.
Last reviewed January 2010 by ]]>Rimas Lukas, MD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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