Carotid surgery

Anatomy:

The brain is vascularized by 4 arteries:

2 which lie ahead in the neck: the carotid arteries.

2 who are back in the neck: the vertebral arteries.

These arteries can provide the oxygen and nutrients needed for the proper functioning of the brain.

These 4 arteries communicate with each other in the brain via an “arterial polygon” called the polygon of Willis. What explains that when 1 of the 4 arteries get blocked, there is often no effect on cerebral Vascularity since the other 3 take the relay.

Carotid stenosis: 

Favored by the cardiovascular risk factors, these arteries can “gum up” by of the atheroma, particularly at the level of the bifurcation of the carotid artery.

These deposits cause strictures that result:

  • When the plate grows, it may become unstable and present on the surface of the “cracks” that send small clots (“embols”) in the brain. These embols cause pain to the brain either transient (less than 24 hours), we speak in this case of transient ischemic accident (T.I.A.), or final suffering, we speak in this case of stroke (A.V.C.).
  • Stenosis can also gradually “clog” completely causing a blockage of the carotid artery. In most cases, when only one of the 4 arteries is occluded, it has no effect on the brain, since the other 3 take the relay. More rarely this occlusion can cause unlike a stroke when the other arteries cannot take over properly.

What are the possible manifestations?

When the symptoms last less than 24 hours, called transient ischemic accident (T.I.A.) and when it takes more than 24 hours called cerebral vascular accident (A.V.C.)

When the embol hand in the carotid system, it will cause suffering to the earlier and middle part of the brain that control sight, movements and the sensitivity of the face, the upper limb and lower limb.

Note that the right brain controls: the sight of his right eye, sensitivity and mobility of half of the face, the upper and lower left.

The most common symptoms are:

-a simple black veil on the eye that lasts from a few seconds to several minutes. This corresponds to an embol in the retina. One speaks of amaurosis.

-paralysis of half of the face, of half of the face and the arms, or half of the face and half of the body. One speaks of hemiplegia or hemiparesis.

-a loss of sensitivity on the hand, arm, half of the front.

The intensity of the symptoms depends on the extent and the area affected by the clot.

When the embol leaves in the spinal artery, it causes pain in the posterior part of the brain and the cerebellum, which control including: balance, part of the view.

What are the ways of screening?

In consultation with your doctor, the appearance of a cervical auscultation breath can evoke a carotid stenosis.

The best screening tool is the arterial doppler echo of supra-aortiques trunks. This review made by one angiologist or vascular doctor helps to identify stenosis, describe his character stenosant (degree of stenosis: 30%, 50%, 70%…), the appearance of the plate (stable smooth so little dangerous or unstable because ulcerated).

In the event of significant stenosis (> 70% in screening) this echo-doppler must still be confirmed by a second review:

  • either an another echo-doppler arterial directed by another doctor vascular supra-aortiques trunks.
  • either an angio scan supra-aortiques trunks.
  • evening a trunks supra-aortiques MRI angio.

What are the treatments?

When the plate is Beginner:

The first of them, is prevention, by limiting or avoiding cardiovascular risk factors: not smoking, keep a regular physical activity, combat overweight, combat cholesterol, particularly LDL cholesterol, diabetes, high blood pressure limit.

It takes in general add to these measures medical treatment that limits the atheromateuse disease and stabilizes the plate, it consists in general of an antiplatelet, a Statin, and a conversion enzyme inhibitor.

When the plate becomes too large:

It’s called a carotid endarterectomy consider surgery by removing the plate.

When should he remove the plate?

Two cases:

  • You made a STROKE or a TIA: you’re carrying a carotid plaque at more than 50%, and the balance of your STROKE or didn’t find causes (heart…) other than at the level of the carotid plaque. One speaks then of symptomatic carotid plaque. In this case, it is permissible for a surgical treatment from 50% of degree of stenosis to prevent a STROKE or a TIA more severe.
  • You have no symptoms (plate carotid asymptopatique), you had an echo-doppler screening who finds a carotid plaque. It is lawful for a surgical treatment from a level of 70% to avoid a new STROKE or a TIA.

Why not operate before carotid plaques?

Carotid surgery is not without risk. While you will be surgery of the carotid artery to prevent a STROKE, the risk of surgery is to cause a STROKE. It therefore expected that the carotid plaque presents a risk of STROKE, which is higher than the statistical risk of STROKE when carotid surgery. However, this risk is very low (between 1 and 2% for trained teams).

Can you treat carotid stenosis by ‘stent’?

Description recent treatment by method Endovascular carotid stenosis. Currently, the health authority authorizes the implementation of stent for carotid stenosis in some very specific cases: a single carotid, inoperable, patient patient patient with radiation therapy on the neck, patient who had surgery of the carotid artery.
Indeed, for the usual indications, treatment with stent showed no superior to the conventional surgical technique. The technique by stent should thus be reserved only in very rare cases after a multidisciplinary assessment (neurologist, surgeon, radiologist…).