The main blood supply to the brain consists of the carotid arteries in the front of the neck and the vertebral arteries in the back of the neck. Within the brain, these arteries connect with one another through the Circle of Willis. Interruption in blood flow through any of these blood vessels may cause stroke. Although stroke may be caused due to lack of blood flow to the brain, more commonly, stroke is caused by atheroembolic debris, which originates in the carotid artery. As plaque builds up within the carotid artery, it may fragment, and pieces of the plaque may become lodged in the small arteries within the brain. This results in lack of oxygen to an area of the brain, which causes stroke, or a small area of brain death. As arteries become more blocked with plaque, they become more likely to fragment, embolize, and cause stroke.

Patients may have severe blockage in the carotid arteries without symptoms. These patients have "Asymptomatic Carotid Stenosis". If patients have had stroke or "ministroke" (TIA) they have "Symptomatic Carotid Stenosis". In either case, patients may require treatment of their carotid artery plaques. Nonsurgical treatment for carotid artery plaques has included blood thinners, and antiplatelet agents such as aspirin. However, no medical therapy has been as effective as surgery in preventing stroke. In the last ten years, the two most important papers regarding carotid stenosis have been published in the medical literature. "Endarterectomy for Asymptomatic Carotid Artery Stenosis" was published in JAMA. 1995; 273: 1421-1428. This trial is known as the ACAS Trial. Here, carotid endarterectomy for asymptomatic carotid stenosis proved more beneficial than medical management. The most important trial regarding symptomatic carotid stenosis was published in the New England Journal of Medicine, 1991;325:445-453. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated that carotid stenosis was more beneficial than medical therapy for patients with symptomatic high grade carotid artery stenosis.

The diagnosis of carotid artery stenosis may be entertained if patients have a "bruit" in the neck. This is a whooshing sound, which may be heard with a stethoscope. Even patients without bruits may have severe blockage within the carotid artery. The diagnosis of carotid artery stenosis is made noninvasively. Duplex scan (or ultrasound) is the most common first test in the diagnosis of carotid artery stenosis. Magnetic Resonance Angiogram (MRA) may also be useful in the diagnosis of carotid artery stenosis. This is a noninvasive modality for imaging the carotid arteries using MRI.

Once the diagnosis of significant carotid stenosis is made, the most appropriate therapy is vascular surgery. At New York University Division of Vascular Surgery, 85% of carotid endarterectomies are performed under local anesthesia. Patients are admitted to the hospital on the same day of surgery. A local anesthetic is administered and surgery is undertaken. An incision is made along the side of the neck, and the carotid artery is explored. The artery is opened, plaque is removed, and the artery is closed with a patch commonly made of Dacron fabric. The surgery takes approximately 1.5 hours, and patients typically stay in the hospital overnight for observation. After discharge, patients typically feel well in a matter of days. While carotid endarterectomy has been proven to reduce the risk of stroke, the most common complication associated with surgery is, in fact, stroke, itself. New York University Division of Vascular Surgery boasts one of the lowest perioperative complication rates in the world, at 1-2%.

Recently, carotid artery balloon angioplasty and stenting has become a possible treatment modality. Currently this remains an experimental technique. There have been no scientific trials demonstrating the benefit of angioplasty or stent over carotid surgery. However, in certain type of patients this may be advantageous. We, at New York University are actively continuing to evaluate the use of angioplasty and stents in selected patients. While available at NYU, surgery remains the "gold standard" in the treatment of carotid artery atherosclerosis.

We have published extensively in the area of carotid artery disease, and these papers may be seen in the "Curriculum Vitae" of our surgeons.