role of vascular surgeon in stroke done at anuradhapura

1. Joel Arudchelvam
Consultant Vascular and Transplant
Surgeon

2.  In
 Carotid artery disease
 Vertebral artery disease
 Brachio-cephalic artery disease

3.  Brain is supplied by 2
carotid and 2
vertebral arteries.
 carotid artery divides
in carotid triangle into
 Internal carotid artery
(ICA)
 External carotid artery
(ECA)
at the upper border of
thyroid cartilage
 No branches to ICA in
the neck

4.  Formed by branches
of bilateral carotid
and basilar artery
 Basilar artery - union
of vertebral arteries
 Allows collateral
flow

5.  TIA - focal neurological deficit lasting <24
hours
 Stroke - symptoms continue for >24 hours
 Nondisabling stroke - a residual deficit associated
with a score ≤2 according to the Modified Rankin
Scale.

6.  0 - No symptoms
 1 - able to carry out all usual activities
 2 - unable to carry out all previous activities, but able to look after without
assistance
 3 - Moderate disability; requiring some help, able to walk without
assistance
 4 - Moderately severe disability; unable to walk without assistance and
unable to attend to own bodily needs without assistance
 5 - Severe disability; bedridden, incontinent and requiring constant nursing
care
 6 - Dead

10.  The degree of
stenosis - velocity
criteria
 higher the velocity
the - greater the
stenosis

11.  Normal: PSV < 125 cm/s , no
plaque is visible.
 < 50% stenosis: PSV < 125 cm/s
and plaque is visible.
 50-69% stenosis: PSV is 125-230
cm/s and plaque is visible.
 >70% stenosis to near occlusion:
ICA PSV >230 cm/s and visible
plaque
 Total occlusion: No flow seen

12. Interobserver agreement =
higher

13. • 70 - 99% - CE (Level A).
• 50-69% - CE may be considered (Level B) (at least a five year life expectancy )
• <50% stenosis - CE not be considered (Level A). Medical management (Level
A).
• Total occlusion – no need of revascularisation
• Non disabling ischemic stroke or transient ischemic attacks (within 6 months)
• Fit for surgery

14.  NICE guidelines – within 2 weeks
 No place of emergency surgery in patients with
unstable presentation
 Due to haemorrhagic transformation and unprepared
patient high (allow stabilisation of infarction)

15.  Stop Smoking
 Blood pressure control (less than 140/90
mmHg)
 Antiplatelet agents
 Cholesterol lowering drugs / diet ( LDL less
than 100 mg/dL)
 Lifestyle advice

16.  Modes
 Local infiltration
 Cervical plexus block
 GA
 Aim
 Maintain cerebral perfusion
 Reduce cardiac workload
 Allow smooth recovery to assess neurological status

17.  Invasive arterial blood pressure monitoring/stump
pressure (70mmHg)
 maintain blood pressure
 Maintain CO2 tension –avoid hyper / hypo
 Agents –
 Induction
 Thiopentone - protect against focal ischaemia
 Propofol – rapid awakening
 etomidate CV stability
 Maintenance with volatile agent –
 Isoflurane
 Neurological monitoring
 EEG, transcranial Doppler

19. •Nerves to preserve –
•Hypoglossal
•Vagus
•Marginal
mandibular

22.  Perioperative stroke – 7.4% (2/27)*
 Haematoma
 Hyper perfusion syndrome
 Nerve injury -7.4% (2/27)*
 Hypoglossal
 Vagus
 Infection
JD Arudchelvam , et.al. carotid endarterectomy: experience in a single vascular unit.presented as an abstract at annual academic sessions of the college of
surgeons, Sri Lanka , Aug 2012.

23.  Keep propped up, O2
 Control blood pressure (surgical disturbance of
baro receptors) -Use short acting anti-
hypertensive agents such as labetolol
 Especially within 48 hours
 hyperperfusion syndrome, haematoma
 Check document neurological status
 CT scan

24.  In high grade stenosis
 Results in cerebral oedema, haemorrhage
 Unilateral headache, seizures

25.  Carotid stenting
 Difficult surgical access
 radiation, previous neck surgeries
 Medically not fit for surgery

26.  Stroke / TIA
 Early imaging
 Optimization / best medical treatment
 Vascular referral

27. Thank you