Carotid Endarterectomy

A stroke is what happens when a small area of the brain is damaged. It can affect strength or feeling in a limb, or particular actions such as speech or swallowing. Although significant improvement can occur, there is often some permanent effect. Some people will recover fully, but this may take some days or longer.

The same symptoms can occur if part of the brain is temporarily injured but recovers in less than 24 hours; this is known as a ministroke or Transient Ischaemic Attack (TIA). The symptoms always get better completely, usually in under an hour.

There are many causes of stroke but they amount to blockage of small arteries in the brain or by bleeding into the brain. The treatemnt of these is very different, and it is essential to know which sort of stroke has occurred. Blocked arteries can be due to a piece of clot that has travelled to the brain from elsewhere, or that has formed in the brain artery itself. It is important to tell these apart in order to reduce the risk of a further stroke.

A CT scan of the brain will show whether the stroke was due to a blockage or a bleed. If an artery has blocked then an ultrasound (Duplex) scan of the arteries in the neck and of the heart will identify possible sources. There will be other tests for other potential causes such as blood pressure, blood clotting problems or diabetes.

For about 1 stroke patient in 6, there is a significant narrowing of the arteries in the neck that feed the brain. This is a well recognised cause of further strokes and many patients will be recommended to have an operation to clear out the artery (carotid endarterectomy). If this is the case, then the stroke team will refer you to a Vascular Surgeon.

The main risk is of causing a stroke during or immediately after surgery. This risk is about 2%, which is much less than the chance of a stroke without surgery. There are also a couple of large nerves that affect the tongue and voice, which can be bruised or very occasionally damaged, particularly if the anatomy is a bit unusual. The symptoms of this are the tongue pointing to one side a little, or a hoarse voice. The risk is about 1% but most of these recover completely. There are also all the risks of any operation such as the anaesthetic, infection, bruising or numbness around the scar.

As soon as possible. The highest risk of a second stroke is in the first few days, and reduces steadily thereafter. This means the earlier you have the operation the less likely you are to have another stroke. We would like to operate within 2 days of a stroke but this is rarely possible. We aim to operate within 2 weeks of a stroke, but surgery is still beneficial up to about 12 weeks.

It is possible to stretch the narrowing with a balloon, similar to heart or leg arteries. However the risk of dislodging more clot and causing another stroke is much higher than with surgery, so this is reserved for high-risk patients.

You should be on a mild blood-thinning medication such as aspirin forever, and initially there may be more than one. You will also need to have a check kept on your blood pressure, cholesterol and any tendency to diabetes. You should never smoke again.

This is an interesting question, but as much a philosophical one as medical. The large international studies have shown no really clear benefit for surgery before a stroke. However, there is some evidence that patients under 70 years old, and particularly men, may get a slight reduction in their risk of stroke in later years. This is something that you should discuss with a Vascular Surgeon.