ABSTRACT
The importance of stroke, its risk factors, and its medical management are all expertly discussed in other chapters within this book. The goal of this chapter is to define the appropriate use of carotid endarterectomy (CEA) for symptomatic and asymptomatic patients with extracranial internal carotid artery stenosis. In this chapter the term stroke will imply an ischemic stroke and not a hemorrhagic stroke. Chiari is credited as being the first to propose that occlusive disease of the extracranial blood vessels could be responsible for neurological symptoms. In 1905 he reported that four out of seven patients in a series of 400 autopsies with thrombus superimposed on atherosclerosis near the carotid bifurcation had suffered a cerebral embolism1. However, the landmark publication describing the relationship between carotid artery disease and transient ischemic attacks (TIA) and stroke was written by Dr C. Miller Fisher in 19512. He initially described the clinical history and premortem studies and available postmortem examinations of the carotid arteries of eight patients with stroke. He later published the clinicopathologic
results of 45 more patients with occlusion or near-occlusion of the carotid arteries3. In 1954 Eastcott and colleagues were the first to publish a description of a surgical intervention on the carotid artery in a patient with neurological symptoms4. Over the ensuing years, and especially in the early 1980s, the number of carotid endarterectomies increased rather dramatically to a peak of over 100 000 operations in the United States in 19855. In the 1970s platelet antiaggregating agents such as aspirin were found to be helpful in preventing ischemic strokes. The number of operations then declined in the late 1980s and early 1990s because of reports of high complication rates and uncertainty as to which patients were most appropriate for the treatment6. A number of large, randomized and controlled clinical trials were then conducted to address the questions regarding the efficacy of CEA combined with best medical treatment, typically in comparison to best medical therapy alone. We plan to clarify the usefulness of CEA for extracranial internal carotid artery (ICA) stenosis based on the outcomes of these trials.
