Surgical Approaches to Stroke Risk Reduction

Michael F. Waters, MD, PhD, FAAN, FAHA Cerebrovascular Disease p. 457-477 April 2020, Vol.26, No.2 doi: 10.1212/CON.0000000000000837
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PURPOSE OF REVIEW Surgical vascular intervention is an important tool in reducing the risk of stroke. This article examines the evidence for using the available options.

RECENT FINDINGS Carotid endarterectomy is an effective treatment option for reducing the risk of stroke in appropriately selected patients. Patients should be stratified for future stroke risk based on both the degree of stenosis and the presence of symptoms referable to the culprit lesion. Carotid stenting is also useful in reducing stroke risk, again in carefully selected patients. Because of the publication of significant data regarding both carotid endarterectomy and carotid artery stenting in the last several years, selection can be far more personalized and refined for individual patients based on demographics, sex, patient preference, and medical comorbidities. Routine extracranial-intracranial bypass surgery remains unproven as a therapeutic option for large vessel occlusion in reducing the incidence of ischemic stroke although some carefully screened patient populations remaining at high risk may benefit; procedural risks and pathology related to alterations in blood flow dynamics are challenges to overcome. Indirect revascularization remains an appropriate solution for carefully selected patients with cerebral large vessel steno-occlusive disease, and multiple variations of surgical technique are patient specific. Indirect revascularization may benefit from clinical trials with larger patient populations for validation in specific pathologies and offers the advantages of lower surgical complication rates and reduced risk of pathologic responses to altered cerebral flow dynamics.

SUMMARY Surgical solutions to reduce stroke risk provide important alternatives in appropriately selected patients and should be considered in addition to medical management and lifestyle modification for optimizing patient outcomes.

Address correspondence to Dr Michael F. Waters, Barrow Neurological Institute, 240 W Thomas Rd, Phoenix, AZ 85013, michael.waters@barrowneuro.org.

RELATIONSHIP DISCLOSURE: Dr Waters has received grant support from the Barrow Neurological Foundation and has provided medical opinion during the discovery phase of a lawsuit.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Waters reports no disclosure.

© 2020 American Academy of Neurology.