May is stroke awareness month. Each year almost 800,000 people have a stroke. Seventy five percent of strokes are first time strokes. This is one stroke every four seconds. More than fifteen percent of these strokes result in patient deaths. These numbers are alarming. Stroke is the leading preventable cause of disability according to the American Stroke Association.
Almost ninety percent of these strokes are ischemic. Ischemic strokes occur when blood flow to the brain becomes blocked. Vascular surgeons are uniquely qualified to diagnose, prevent, and treat ischemic strokes. Many strokes are caused by carotid artery stenosis or plaque. Most patients have no symptoms of carotid stenosis until they have a stroke. Carotid stenosis is suggested by an abnormal sound or bruit (pronounced brew-ee) heard over the carotid artery with a stethoscope. However, hearing a bruit does not guarantee the patient has carotid stenosis.
Typical stroke symptoms include difficulty speaking or slurring words, an inability to use or feel one side of the body, or falling to one side of the body when standing. The American Stroke Association uses the mnemonic of FAST to help people remember the signs of a stroke and what to do. F stands for facial droop. Once side the face will often sag and the patient is often unable to smile normally. A stands for arm weakness. If a patient holds up both arms straight out in front of the body a light downward pressure will often show significant weakness on one side compared to the other. S stands for speech difficulty. The patient may have difficulty saying words or slur words. T stands for time to call 911. If you see someone with any of these symptoms, help needs to be called right away to have the best out come.
While many patients don’t have any symptoms prior to a stroke. Some patients have transient ischemic attack or TIA. Some patients refer to these events as “mini strokes”. A transient ischemic attack is characterized by stroke symptoms that last less than twenty-four hours. Unlike in a stroke, these symptoms completely resolve. They are often a sign of carotid stenosis and need to be investigated immediately. Alternatively, some patients notice what looks like a temporary shade coming down over one eye. This is called amaurosis fugax. It occurs when a piece of tissue temporarily blocks a major artery going to the eye. Again, patients with this condition need to be seen as soon as possible by a vascular surgeon.
The diagnostic test of choice is a carotid duplex ultrasound. A vascular surgeon who is a registered physician in vascular interpretation or RPVI should read this efficient, noninvasive, and painless test. This certification assures that the study is interpreted appropriately by a physician who has had sufficient training to read such studies. Although ultrasound is an excellent screening test, it does not always provide adequate details. A computed tomography angiography (CTA) shows the area of stenosis in relationship to other anatomic structures, which allows the vascular surgeon to determine the most appropriate form of treatment.
Not all patients with carotid stenosis need surgical or endovascular treatment. Those without symptoms and mild to moderate stenosis are often treated with medications. Anti-platelets help prevent strokes. Statin medications decrease cholesterol levels help stabilize the area of plaque which in turn decreased the rate of stroke. A vascular surgeon will maximize medications and operatively or endovascularly treat the area as needed.
For those patients with severe disease, and for many with less advanced disease but a history of a stroke, operative or endovascular intervention is indicated. Open repair of carotid stenosis, called a carotid endarterectomy, consists of opening the stenotic part of the carotid artery, cleaning it, and sewing a patch in place. Patch placement has been proven to decrease post-operative stroke rates and prevent recurrence.
Some patients are unable to tolerate an open surgical procedure. For these patients, stent placement is often most appropriate. However, large studies have showed that endovascular stent placement has a higher complication rate than an open procedure. A new procedure combines the best of open and endovascular intervention. A very small incision is placed in the neck and the stent is inserted through the incision. This decreases the complication rate but also avoids general anesthesia. Dr. Jenna Kazil is the only vascular surgeon in the area uniquely trained and qualified to bring this procedure to the greater Bradenton Area.