Role of vascular surgeon in stroke
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Transcript of Role of vascular surgeon in stroke
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Joel ArudchelvamConsultant Vascular and
Transplant Surgeon
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In Carotid artery disease Vertebral artery disease Brachio-cephalic artery disease
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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
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Formed by branches of bilateral carotid and basilar artery
Basilar artery - union of vertebral arteries
Allows collateral flow
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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.
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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
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The degree of stenosis - velocity criteria
higher the velocity the - greater the stenosis
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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
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Interobserver agreement = higher
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• 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
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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)
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Stop Smoking Blood pressure control (less than 140/90
mmHg) Antiplatelet agents Cholesterol lowering drugs / diet ( LDL
less than 100 mg/dL) Lifestyle advice
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Modes Local infiltration Cervical plexus block GA
Aim Maintain cerebral perfusion Reduce cardiac workload Allow smooth recovery to assess neurological
status
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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
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•Nerves to preserve –•Hypoglossal•Vagus•Marginal mandibular
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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.
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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
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In high grade stenosis
Results in cerebral oedema,
haemorrhage
Unilateral headache, seizures
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Carotid stenting
Difficult surgical access radiation, previous neck surgeries
Medically not fit for surgery
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Stroke / TIA
Early imaging
Optimization / best medical treatment
Vascular referral
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Thank you