Evaluation and treatment of cerebral ischemia. Carotid endarterectomy and extracranial-intracranial bypass.
Patients with cerebral ischemia comprise an extremely heterogeneous group that makes analysis of treatment extremely difficult. Given the wide range of findings in the literature, one may select specific reports to justify a predetermined viewpoint. The study of Easton and Sherman has elicited a disproportionate amount of attention. Of the thousands of reported patients in the literature, this study of 228 patients with high postoperative morbidity and mortality has regrettably been cited often as the potential representative of surgical outcome in community hospitals. Undoubtedly, surgical skill varies and may affect results. Not all studies, however, support the contention that such procedures can only be performed adequately by surgeons who frequently do such operations. Most importantly, this study should redraw our attention to the fact that the success of the individual surgeon must be evaluated for any given procedure. With proper selection of patients, both carotid endarterectomy and EC-IC bypass procedures have proved to be safe and effective. In general, technical advances have heralded surgical results that appear to be superior to medical management, or no treatment, in a wide range of patients with cerebrovascular disease. Surgical results can only be evaluated when a procedure is fully developed technically and a large number of cases are accumulated. For carotid endarterectomy, and more recently EC-IC bypass, the necessary information is becoming available. However, the classification of patients to which these procedures should be applied has lagged behind. Given the variability in patients with cerebrovascular disease, this is somewhat understandable. Properly controlled studies would necessarily be unrealistically large. However, the technology and subsequent data that should be developed throughout the next decade will provide us with important information about brain ischemia and metabolism. This new technology should allow us to more completely define the exact nature of ischemic events in the individual patient. This will lead to better classification of patients and, ultimately, will improve patient selection for any methods of treatment, either medical or surgical.
D000368:Aged; D001921:Brain / Q000098:blood supply; D002545:Brain Ischemia / Q000175:diagnosis / Q000601:surgery*; D002339:Carotid Arteries / Q000601:surgery; D002340:Carotid Artery Diseases / Q000601:surgery; D002533:Cerebral Angiography; D002539:Cerebral Arterial Diseases / Q000601:surgery; D002536:Cerebral Arteries / Q000601:surgery; D002548:Cerebral Revascularization / Q000379:methods; D003251:Constriction, Pathologic / Q000601:surgery; D004691:Endarterectomy; D006801:Humans; D002546:Ischemic Attack, Transient / Q000601:surgery; D008875:Middle Aged; D012039:Regional Blood Flow; D013699:Temporal Arteries / Q000601:surgery; D014980:Xenon Radioisotopes
D014980:Xenon Radioisotopes