A 62-year-old Caucasian man presented 1 week after an episode where he spontaneously dropped a cigarette he was holding in his right hand. He immediately noted an inability to grasp objects and numbness in his right hand. These symptoms lasted for 2 minutes and then spontaneously resolved. Currently, his right hand feels completely normal. He denies other symptoms such as amaurosis, paralysis, paresthesias, speech disturbance, or gait disturbance. His past medical history is significant for hypertension, hyper- cholesterolemia, and cramping in his calves when he walks long distances. He has a 30 pack-year history of smoking and denies use of alcohol. A carotid duplex ultrasound shows a left 70% to 99% internal carotid artery (ICA) stenosis. A surgical option was elected by the patient (Figures 21-1,21-2, and 21-3).
FIGURE 21-1
(A) Carotid endarterectomy (CEA) can be performed via a neck incision along the anterior border of the sternocleidomastoid muscle (red arrow). The inferior border of the mandible is indicated by the blue arrow. (B) The platysma is divided and the sternocleidomastoid muscle (blue arrow) and jugular vein are retracted laterally. The head end of the patient is towards the right side of the photos. Procedure is being performed on the left carotid artery.
FIGURE 21-3
(A) The intraoperative carotid clamping is tolerated without neurologic compromise by greater than 85% of patients. The plaque is noted by the green arrow as soon as the carotid bifurcation is opened. Carotid endarterectomy (CEA) may be performed with or without intraoperative shunting (dark blue arrow); if done without shunting, cerebral monitoring of some kind is indicated to detect intolerance of clamping. This can be accomplished by using regional anesthesia with direct monitoring of mental status, or with general anesthesia using electroencephalogram, somatosensory-evoked potential, or internal carotid artery (ICA) stump pressure monitoring. (B) Endarterectomy may be done longitudinally as pictured or using an eversion technique without an effect on outcome, but if longitudinal endarterectomy is performed, patch angioplasty offers better stroke and restenosis rates than primary closure (blue arrow).
Stroke ranks third among all causes of death in the United States behind heart disease and cancer, with 795,000 strokes occurring per year.1
Annually, 55,000 more women than men are affected, and over 60% of all stroke deaths occur in women. African Americans have twice the stroke risk of Caucasians. Mexican Americans also have an increased incidence of stroke compared to Caucasians.2
One-third of all strokes are related to cervical carotid disease.
Standard risk factors for coronary and systemic atherosclerosis apply to this patient population such as age, male sex, family history, smoking, hypertension, hyperlipidemia, sedentary lifestyle, and high dietary fat.
The mechanism of cervical carotid stroke is usually embolization from the carotid bifurcation plaque, but hemodynamic compromise from stenosis may also play a role. The risks of embolization and hemodynamic compromise increase with increasing ICA stenosis.3
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