Carotid Artery Disease: Contemporary Treatment

Carotid artery disease is one of the most common yet controversial causes for treatable stroke. The care for these patients rests upon cerebrovascular specialists who are ultimately interested in preventing disabling strokes, whether by scalpel or catheter. Improvements in neuroimaging, endovascular techniques, and surgical outcomes have “raised the bar” in terms of expected outcomes from interventions rather than medical therapy. I have been fortunate to work with an incredible array of surgeons, radiologists, and neurologists whose efforts are detailed in this issue of Seminars in Neurosurgery. I thank them for their conscientious contributions. Compiled in this issue is a summary of their major work in the area of carotid artery disease.

The first article (Dr. DeGraba) evaluates the pathophysiology of the vunerable plaque in an attempt to identify those patients at highest risk for a stroke related to their carotid stenosis. Advances and the appropriate algorithm for imaging patients with carotid artery disease are then discussed (Drs. Bell, Armonda, and Noonan).

Once high-risk patients have been identified, based on a combination of clinical and radiographic data, the next chapter (Drs. Cooper and McInerney) discusses the techniques and complications associated with surgical interventions. Subsequent chapters then deal with those patients who are the best candidates for endovascular therapies followed by both chemical and mechanical protection from thromboemboli, currently the major risk involved in endovascular stenting (Drs. Lopes and Snell; Drs. Armonda, Benitz, and Rossenwasser; Drs. Hanel, Xavier, and Siddiqui et al).

Drs. Martin and Armonda examine the most common cause of stroke in younger patients-carotid dissection. Diagnosis, imaging, and treatment modalities are discussed.

Lastly, Drs. Krishnan, Armonda, and Rothstein review complications and avoidance during carotid endarterectomy.

The goal of this issue of Seminars in Neurosurgery is to provide the active clinician with a summary of the major recent developments in avoiding complications in the treatment of patients with carotid artery disease. Patients who will most benefit from intervention are identified; lesions are correctly identified; meticulous surgical or endovascular techniques to effectively treat the patient are described.

The ability to foresee potential complications may allow the clinician to avoid such pitfalls. Ultimately, clinical trials and time will identify those patients best served by surgery or endovascular therapies. Until then, higher risk patients for surgical treatment are selected for endovascular treatment. These concepts have been clearly elucidated and should serve as a practical working guideline.