People who have already had a stroke or warning signs of a stroke ("mini stroke" or "TIA") are at a higher risk of having another, perhaps major, stroke. All patients with an increased risk of stroke are given medical treatment and advice to reduce this risk. This includes:
- treatment of high blood pressure,
- management of diabetes,
- drugs to reduce cholesterol levels
- stopping smoking.
- aspirin (or other similar drug)
In a small number of patients, stroke or mini stroke may be related to a partially blocked or diseased artery in the neck (carotid artery). In these circumstances, a small piece of clot may break off from the narrowed segment and travel up into the brain causing stroke or TIA. It is important to realise that the left side of the brain looks after the right arm and leg and the right side of the brain looks after the left arm and leg.
We know from research that, if this happen once, it may happen again. Medication (such as aspirin) may be effective in reducing the risk of recurrent stroke to about 25% over three years. However, in patients who are fit for surgery, an operation (carotid endarterectomy) to clear the clear the blocked segment is about twice as effective as medication alone in patients who are suitable for surgery.
Carotid surgery is usually only recommended after your individual case has been discussed, and your test results reviewed, by surgeons, neurologists and stoke physicians in our regular multi-disciplinary conference.
Before the operation.
Narrowing in the carotid artery is usually identified on an ultrasound scan performed in the vascular laboratory. There is no need to fast for this test and it only takes a few minutes. During the test, some jelly is applied to the neck and an ultrasound probe is pressed against the neck to image the carotid arteries. This test is not uncomfortable.
Some patients will also require further imaging including CT (CAT) scanning or Magnetic Resonance (MRI) scans, tests on your heart (echocardiography, holter recordings) and routine blood tests. Some patients will be invited to participate in a research study and this may involve other tests.
If you have not already been admitted to hospital as an emergency, carotid endarterectomy surgery involves admission to hospital for between three and five five days. You can review some information to assist in planning your admission on the TUH website. Before the operation you will be seen by the anaesthesiologist who will examine you. You will also have an opportunity to ask the medical and surgical team any further questions you may have. Your primary physician or a member of the surgical team would be happy to speak with a family member with you, if you wish, to explain the procedure and answer any questions that you might have. Your nurse will also explain the ward routines.
You will have a number of pre-operative tests including blood tests, a cardiogram and a chest x-ray. You may require other tests depending on your medical history and these will be explained to you. You will be asked to eat or drink absolutely nothing for 6 to 12 hours before the operation.
The operation is performed in the operating theatre, usually under general anaesthetic (i.e you will be asleep). Once you have been anaesthetised (general anaesthesia), a cut (between 5 and 10 cm long) is made in the skin of the neck over the carotid artery on the appropriate side. The artery is then temporarily clamped off and the diseased lining removed. The artery is then closed. Stitches (which may be absorbable) will be used to close the skin and there may be a drainage tube placed which will be taken out after 24 or 48 hours.
After the operation.
When you wake up, you will find that your arm is connected to one or two plastic tubes to provide you with fluids and to monitor your blood pressure. There will usually be a drainage tube (catheter) in the bladder also. You will be monitored in the recovery area for up to four hours or occasionally overnight to allow close monitoring of heart and blood pressure.
After this you will be returned to your own ward or to a specialised area where you can be monitored more closely. You will be allowed to drink after you have woken up completely from the anaesthetic. The operation itself is not particularly painful but you will be given some painkillers, if required.
On the day after surger,y you will be allowed to get out of bed and to eat normally. In many cases, you may be allowed home on the third or fourth post-operative day. Arrangements will be made to remove the skin sutures, if absorbable skin sutures have not been used.
Are there any risks?
Some minor bruising around the wound is common after the operation and a blood transfusion is occasionally necessary. Bruising of the neck may take several weeks to settle down. There is usually a numb area on the side of the neck that may take several months to settle down but this may be permanent. This is usually due to the injury of some nerves in the skin rather than a stroke. Most patients who get permanent numbness get used to it over time and it does not trouble them particularly.
Temporary weakness of the side of the mouth, tongue or voice is possible. This is usually due to pressure or stretching of nerves rather than a stroke and this will usually recover after a period of time.
There is a small (but definite) risk of developing a stroke or a heart attack during the operation combined with a very small risk of death. While this may be a minor stroke with complete recovery, more severe strokes may also occur. This combined "operative" stroke and death risk is less than 5%. However, you are more likely to avoid a major stroke in the long run, if you undergo surgery rather than relying on medications.
You are welcome to discuss these risks with your surgeon or your primary physician in more detail before the operation.
What about afterwards?
You will usually be seen in the outpatient clinic about one month after surgery. An ultrasound scan similar to the one that was performed before your operation may be arranged on some occasions but routine scans are not usually performed postoperatively. You will usually be on Aspirin tablets (or something similar) and a cholesterol lowering tablet. You can also help by improving your general health by taking regular exercise, stopping smoking and reducing the amount of fat in your diet.
You will find further information on the Society for Vascular Surgeons website