Deanna M. Neff, MPH
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The following procedures may be done to prevent further damage during a
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 doctor 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.
This is a procedure used to treat acute strokes. 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 devices have either a corkscrew tip or a special ring used to remove the clots. They are placed in a catheter and threaded through blood vessels to the area of the blockage. Once in the proper location these devices are used to remove the clot blocking the blood vessel. The advantage of these devices is that they can remove the clot in a matter of minutes, opening blood flow and decreasing the level of damage to affected tissue. Other versions of these devices are still under investigation.
Other surgical procedures for
technically fall into the prevention category.
Two conditions in the arteries in the brain or the arteries that lead to the brain can cause a risk of stroke. These can be the result of
(fatty deposits in the arteries), which can lead to:
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
. The doctor 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
simply carves out the inner lining of the carotid artery, leaving behind the outer layers to carry the blood. There are technical reasons why one procedure is preferred over the other. CEA is performed much more commonly than arterial bypass 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, it may be preferred over angioplasty for some patients. Angioplasty may be an option for patients who are have a high risk of complications from CEA.
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.
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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 scar.
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 doctor 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.
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.
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.
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 doctor guides the catheter to the heart and places a special device over the hole. In time, new heart tissue surrounds the implant.
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