Continuing Controversies Surgery for Acute Stroke: Current Status

ABSTRACT Although investigations regarding surgery for acute ischemic stroke span 4 decades, the topic remains controversial. This review considers emergency carotid surgery for acute stroke from four perspectives: an operation attempting to reverse an acute neurological deficit, an operation soon after acute stroke to prevent further neurologic deficit, reoperative surgery for acute neurological deficit early after carotid endarterectomy (CEA), and management of severe carotid stenosis after successful thrombolytic therapy for acute ischemic stroke. The available clinical data are absent or incomplete for each of these unusual aspects of carotid surgery. In the absence of a badly needed ran-domized trial, case selection is important and should be accompanied by a proven record of successful, low-morbidity, elective carotid surgery before undertaking more controversial indications. Delaying CEA for 4 to 6 weeks after stroke has repeatedly been shown to be unnecessary and to increase risk of interval new stroke. Finally, the impact of new thrombolytic treatment upon reoperative surgery for complications of CEA and for planning semielective reconstructive surgery needs to be considered