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Stroke

Surgery

Surgery following stroke is relatively rare and only for specific cases is it helpful in treating and preventing a stroke.

Surgery following a brain haemorrhage

A few people had surgery following a brain haemorrhage (bleed in the brain). An operation is sometimes performed to remove blood from the brain and occasionally to repair the leaking blood vessel. If this happened, the operation was usually performed in an emergency, lifesaving situation and the person had not been fully conscious before surgery and had been in intensive care after so had no memory of the operation.

 

He doesn't remember his operation but understands that they cleared the blood and repaired a...

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Age at interview: 58
Sex: Male
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Was there talk about a defective artery that bled. I mean when they did the operation, did they actually tie something off or did they just mop up the blood, do you know?

My understanding is that the operation that was performed on me was pretty much to clear the blood out of my brain and then to mend the blood vessel that had burst. I don't think it extended beyond that into the arterial body, into the arterial system. I think it was simply a matter of repairing a blood vessel, however you do that, I don't know.

But anyway it was done and the blood has to be drained off because if your brain is flooded no doubt, that does account for a complete collapse in your ability to articulate and probably do a whole load of other things mentally as well. 

So I'm extremely grateful to that surgeon who, who performed what must be a pretty, a pretty terrifying operation when. Now all operations presumably are terrifying to that degree but I don't know how you get into the skull in the first place, thank goodness I wasn't awake when it happened because I'm pretty, pretty awful when blood is involved.

One woman, however, had a relatively rare condition in which a malfunction of the connections between arteries and veins in the brain caused a haemorrhage. This was identified by an angiogram (see 'Getting a diagnosis'). She underwent a special procedure using stereotactic radiotherapy to repair the connections and was awake during the procedure.

 

She had a relatively rare procedure known as stereotatic radiotherapy to repair a malfunction of...

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Age at interview: 54
Sex: Female
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I've talked about the fact they diagnosed the AVMs, have I? I can't remember. Yeah, they did. Yeah, I did earlier on. Yeah.

Yeah.

Mmm. So all the time that I was, [clears throat], excuse me, [clears throat], during the time I was in hospital and rehabilitation units, I was waiting for the blood, or should I say the neurologists were waiting for the blood to disperse from my brain, enough for me to go and have, stereotactic radiotherapy on my AVMs because I had two, I think I said I had two. One is big, was big and very deep-seated and one was smaller and near the surface, too dangerous to operate on and so, in my last rehabilitation unit the grand pilgrimage was made to [a city in the north west], which is where, you have to go, to have stereotactic radiotherapy because it's, it's only done in three countries in the world, which is America, Sweden and the UK, and in 1996, it was only done in [a city in the north west], [laughter], so I was a friend went with me actually and I went all the way up to [a city in the north west], and stayed overnight in a hospital, [laughter], and they did a, another angiogram on me and the machine broke down while they were doing it. I remember this distinctly and so I had to stay in the machine with the metal helmet that they screw on to the bone of your head screwed on my head, stuck in a machine that was broken down, [laughter] which is quite unpleasant, and the relief when they took the tube out it made me cry, and'

Was it painful?

Yes. Because the anesthetic had worn off, very painful. Yes, it was. And, yeah, and I went to, into a, another hospital, I was driven to another hospital then, where there was this enormous machine like something out of a science fiction movie, [deep breath], with a big metal circular machine that I was bolted into basically. But I, you could take music and so I'd taken the man I'd made friends with in my first rehabilitation unit, who'd really taught me to fight, had given me a tape of rock music, when I'd left and I took the rock music with me up to [a city in the north west], because it's not very pleasant actually, to be bolted into this machine and because I had quite a lot wrong with me, I had to have quite a lot of passes in and out of there. I was in there for quite a long time. So I had rock music blaring out in this, [laughter], in this room, where I was having my brain zapped basically and they took some photographs of me afterwards wearing the helmet smiling because they're about to take it off actually. But I can still feel the numb points up here where they injected me in the head and where they drilled in to my head to screw it on to my head. Yeah. 

Do you understand what they were actually doing with the radiation?

Yeah. They're firing yeah, what they're doing is firing radiotherapy at, specifically at the specific points, at the AVMs. That's what they're doing and the waiting time to find out whether that's worked is two years. So I had to wait two years, to find out whether it had been successful or not.

Carotid Endarterectomy 

Sometimes a stroke is caused by a block in one or both of the carotid arteries which carry blood to the brain through the neck. If it is suspected that this might be the cause of the stroke then a scan of the carotid arteries is performed to look at the extent of the blockage (see 'Getting a diagnosis').  

Carotid endarterectomy is usually only performed when there is a partial block and removal of the blockage will help prevent a further stroke or minor strokes. Several people had more major strokes due to a complete block in the carotid artery and were told that an operation would not help improve function or prevent another stroke.

 

He was told that an operation would not help because the blockage in his carotid artery had...

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Age at interview: 68
Sex: Male
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With the blockage in your neck did they ever discuss options for surgery?

Yes. Well, no. Because they all said you couldn't do anything about it. They all say that and several and [the hospital at home] said the same. They said, 'No, you can't do anything about it now because it's dangerous if they open it' I believe I was told if you do it very quickly after the stroke, the they can, as I said, medication sort of drug, I don't know, but they can do it, but I don't, they can I, I nobody's ever told me they can, they can do it. Everybody's said the same thing, once it's blocked, it's gone, you know, you've lost it, it's gone. And I assume that, you know, because basically when it's blocked I think it means all those blood, blood vessels are dead, you know, sort of like my eye. You know, they will never move again. They said, 'We can't do anything about it' because those, those vessels are gone, you know, they've just been dead not dead but whatever the word is not dead its' So all, so I don't know but nobody's ever told me they can do anything about it, no. No.

A few people had been experiencing Transient Ischaemic Attacks (TIAs) or minor strokes as a result of a partial block in the carotid artery and were offered surgery to clear the blockage.The main treatment options for severe blockages in the carotid artery are carotid endarterectomy, and carotid angioplasty or stenting.

Carotid endarterectomy is an operation to clear the blockages in an artery. The surgeon will make a small incision (cut) in the side of the neck so they can see the carotid artery, which will then be clamped shut. The surgeon will then open up the artery and remove the inner lining along with any debris. It is likely that a graft will then be sewn onto the artery to widen it - most surgeons believe this lowers the risk of a repeat stroke. A graft is a piece of tissue that may be taken from a vein in the thigh, or it may be man-made. When the surgeon is finished the artery will be stitched up, the blood supply restored, and the small cut in the neck sewn up (Description of surgery from Stroke Association April 2012)
 
Carotid angioplasty is carried out under local anaesthetic. A small flexible tube is passed into the carotid artery through an artery in the groin. The tube has a small balloon at the end of it. When the tube reaches the narrowed area, the balloon is inflated. This expands the artery, allowing the blood to flow through it again. The balloon is then removed.
 
Carotid stenting involves the same procedure at first, but once the balloon is inflated, a small wire mesh cylinder called a stent is then inserted to keep the artery open, improving blood flow. The stent will stay there permanently.

Surgery is most successful when the arteries are between 70 and 99% narrower than they should be. It is most effective when carried out within two weeks of a stroke. NICE- National Institute for Health Care Excellence recommends surgery within 2 weeks (CG68 March 2017)  “In people who have previously had a stroke or a TIA, their risk of having another stroke or TIA within the next three years is reduced by a third after surgery.” NHS choices 2015.

Those who were offered a carotid endarterectomy had been told that it was 95% successful but that there was a risk of having a stroke during the surgery. One woman was quite nervous about the operation and initially decided to put it off, however, when she continued to get TIAs she decided to go ahead with the surgery. She chose to have the surgery under general anaesthetic because she was quite nervous.
 

At first she decided not to have the carotid endarterectomy because of the risk but when she kept...

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Age at interview: 67
Sex: Female
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And then the result from the vascular scan I was shocked, I was told that the right artery, or carotid artery was furred up between 65 and 70% and that was a shock to my system. So of course also immediately I was seen by a specialist, a vascular surgeon, consultant, the out, the out-patients appointment was made almost immediately and he talked, he explained to me a lot what could happen although I was put also on two aspirin actually, one is 75mgs, it's a tiny white one and then another one, I can't pronounce the name, Clavix, 75mgs and also the Simvastatin 

Is that once a day?

Yeah once a day and the Simvastatin, which you take at night and that is to keep the cholesterol level down and that was 4, 40mgs. Then I was seen by a, a vascular neurosurgeon, consultant and he explained to me he said, 'Although, if you are on medication it does not mean that you are safe from having TIAs or mini-strokes or that you are safe from having a major stroke. There is an operation, a surgery we can perform, and it's quite safe, it's about 95% it is safe but although with each operation there is always a risk, yes? But it is quite a safe operation, it is safer to have the operation and you have a lesser, risk, chance in getting a stroke, than being just on the medication although you may never have a major stroke while on medication but you see it's the uncertainty. Then I decided, alright after I saw the consultant I decided not to go ahead with the surgery, because he also explained there is a possibility that I might have a stroke under surgery and end up in a wheelchair, but it's a very, very small risk. And I wasn't pushed, I wasn't pushed in any way, just take your time, think it over and that's it and I left. 

Then Easter Sunday I went to church and I was there for about twenty minutes and I was saying to the person next door, we were supposed to stand up for the Bible reading and I said 'Oh I don't feel well, I don't feel good.' And again vision went and I felt like passing out, I felt really dreadful. So they took me outside into a cooler place and there again it was speech went, again slurred speech and difficulties with walking and my left arm again very heavy. So those kind people brought me home by car and phoned the emergency doctor, she came straight away, almost immediately and she said 'Well there's not much I can do about your medication you know, I think we ought to transfer you to the hospital yes?' Phoned the ambulance, ambulance came, blood pressure high again and I was seen again by a registrar and he discussed again the type of surgery. And he did say to me, 'You've had quite a few of those mini-strokes now and the ones you've felt of late they've been more severe than they were the first ones.' He said, 'Well if it was me I would go ahead with that surgery because it is very successful now and you're going to have a good quality of life.' And that made me thinking because you know the fear, am I going to have a major stroke in town, walking up the road, is it going to happen in the shop, is it going to happen in the bus, is it going to happen in my garden? I'm on my own, I'm a widow, what is going to happen, am I going to have any more of those mini-strokes anywhere you know and what is going to happen? And I also thought alright I'll think about it. And the consultant he did say to me, or registrar, I beg your pardon registrar, he did say to me, 'I'm going to make another out, out-patients appointment with the vascular surgeon yeah? But as soon as possible.' And this was done and the appointment was for the 26th of April this year, 2005, for admission on the 25th and then for surgery on 26th. 

So anyway the day of surgery arrived and I was given my pre-med, of course I saw of course the anaesthetist and she was lovely, absolutely, and she explained a few things and then I saw somebody from the research centre as well who deal with this type yeah. And I was asked if I would be so kind and it’s that, they called it the plaque, which, the furring of the artery, if I would be so kind and donate, leave this for medical research which I agreed and you have to sign of course the consent form. And I agreed to this and also for some medical students to be present at the surgery but unfortunately they were called up to a lecture yes. But they were there, when I was taken before the general anaesthetic they were in that room. And the anaesthetist she was absolutely superb, very, very understanding and she explained, “I have got a very nervous patient here, very nervous so I’m going to give her some oxygen first and some relaxing as well,” so and that was it. And then I woke up in recovery and I moved my hand and my leg and I said “I am fine.”

Another man decided that surgery was his best option and underwent two different operations to remove blockages from both carotid arteries. Although both operations were eventually successful during the first one there was a problem with his heart and he needed to be resuscitated.

 

During his first carotid endarterectomy he had a problem with his heart and needed to be...

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Age at interview: 84
Sex: Male
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Well, it started in 2003 when I was 82 and it started with small ischemic attacks affecting my eyes and movement of my hand and small things made me feel a little bit dizzy, faint. So later on, I took normal things, aspirin, this, that and the other, later on it developed and got worse. For instance, I was driving along and I'd get a partial vision blank. If I happened to look at a person in the face, I could only see half of the face and reading, I could only see the first part of a word. That lasted, to start off, 5 minutes and then back to normal. 

Then of course that gradually got worse and I went to see the doc, went to hospital and they did a scan check of my carotid in my neck on the left side and they found that there was an obstruction there, so 6 months later when the appointment came up, they carried out an operation on my left carotid in my neck and a endarterectomy and while I was under the operation and it was a it was partial, just a small injection to make me feel a bit sleepy and I could hear everything they were saying and the object of the exercise was if , if there was anything that I could tell them, I still could talk. So halfway through the operation, they said they were, I could listen to them handing over to another doctor to do this, that and the other and then I said my right arm was getting numb. 'Can you move your fingers?' 'No.' 'Can you move your right leg?' 'No.' Then I blacked out. I came round at 2 o'clock in the morning in bed in a ward all wired up and there was a big bruise on my chest where he gave me a thump to start my heart going again and I recovered quite good from that. 

Before you went into the operation, did they, can you tell me about any of the discussions that you had with the doctors? Did they tell, did they discuss the risks that might be involved in the operation?

Yes. I asked, I asked them point blank, 'What's the, what's the percentage risk of me dying?' And they said it was 95% successful, so I thought, 'Well, that's good odds, carry on'. 

So when you'd had the problems during the operation, how did you feel about that after?

Well, first, first, well I thought, 'Well I'm lucky to be alive' and secondly I thought, 'Well, they did their best' in fact, I was very, very pleased about, about it all, especially now, a year later when I feel perfectly alright. Perfectly normal person.

He was awake during both procedures and said that he felt no pain but could feel slight tugs as they worked on his neck.

Both people who had this operation said they recovered quickly and were able to go home within a few days. The woman had felt some slight numbness around her neck and was warned that she may feel some dizziness for a few weeks. This is quite normal and usually fades with time.

Occasionally blood can take a shortcut through a small hole in one of the heart walls, which can result in TIA and stroke and can be treated with anticoagulant medication or implanting a device to block the hole – recent research has not shown that devices work any better than medication.

A few people had heard of pioneering research using stem cell therapy, where stem cells are injected into the brain close to the stroke site, and wondered if it worked. Clinical trials have only just begun to assess its effectiveness.
 

Last reviewed June 2017.
Last updated June 2017.

 

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