The significance of elongation and angulation of the carotid artery: a negative view.

Many authors have postulated that angulation of the carotid artery is a cause of stroke and recommend corrective operation. Symptoms attributed to such lesions are often nebulous and unrelieved by the operation, and proof is lacking that unselected patients who have this condition have a risk of stroke exceeding operative risk. A review of 282 cerebral angiograms showed an incidence of elongation and potential angulation of 43 percent in children and 20 percent in adults. Acutal angulation was not found in children, however, and no child was suspected of having cerebral ischemia. Of 47 adults with potential angulation, 17 were suspected of having cerebral ischemia, the remainder having a variety of other lesions, such as tumors, aneurysm, and intracranial hemorrhage. Of the 17 having suspected cerebral ischemia, all had alternative explanations for their symptoms (hypertension, intracranial atherosclerosis), except one whose symptoms were completely inappropriate to the carotid distribution. A single patient had a completed stroke, demonstrable angulation, and only mild hypertension. Elongation and potential angulation of the carotid artery is common but usually coexists with other lesions. If the finding is postulated as the cause for neurologic morbidity the surgeon must be assured that symptoms are clearly neurologic, that no other cause exists, that angulation reduces the carotid lumen significantly and reproduces symptoms, and that the risk of operation is less than the expected risk of stroke in untreated patients.

Massive intracerebral hemorrhage following carotid endarterectomy.

To our knowledge, a particularly lethal complication of carotid endarterectomy, intracerebral hemorrhage, has not been given due consideration in the literature concerning carotid surgery. In the Atlanta area, massive intracranial hemorrhage developed in ten patients following routine carotid endarterectomies performed during a recent ten-year period. All ten of the patients in this series died despite a variety of therapeutic interventions. Risk factors may include the following: extreme arterial stenosis with resultant postoperative hyperperfusion, involvement of multiple extracranial cerebral vessels, postoperative systemic hypertension, and administration of anticoagulant or antiplatelet medications. Unfortunately, identification of the subset of patients potentially at risk for this complication is difficult, and, to date, therapy has been generally ineffective.