Ischemic Stroke And Carotid Endarterectomy

Forward Head Posture Fix

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Under the sternocleidomastoid, the internal jugular vein and the common facial vein, a branch of the internal jugular, are identified, double-ligated and divided. Care should be taken not to injure the spinal accessory nerve, which is at risk for transection and stretching. Gentle lateral retraction of the internal jugular exposes the carotid artery. Opening the carotid sheath then proceeds, starting inferiorly by the anterior surface of the artery to the level of the omohyoid muscle. Dissection of the CCA, ECA and ICA is gently carried out and vessel loops are placed around these vessels. Some surgeons, at this point, inject the carotid sinus with 2-3 cc of 2% plain lidocaine to minimize the potential bradycardia and hypotension that results from manipulating this structure. Proximal control of the CCA is obtained by dissecting the posterior wall to where the vagus is found. An 0-silk tie is passed through a wire loop, which is then pulled through a rubber sleeve (Rummel tourniquet). The superior thyroid artery, the ECA and the ICA are then dissected at the region of the bifurcation. Distal dissection along the ICA proceeds

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Fig. 38.3. Illustration of the maneuver used to expose the upper margin of the internal carotid artery by mobilizing the hypoglossal nerve. Normally, the hypoglossal nerve is tethered against the external and internal carotid artery by either the occipital artery or the first branch from the occipital artery after it emerges from the external carotid artery, the sternomastoid artery (upper). This small artery is usually associated with a small vein and enters the sternocleidomastoid muscle. Dividing the sternomastoid artery (lower) will allow mobilization of the occipital artery and the hypoglossal nerve. This allows dissection to proceed further distally along the internal carotid artery, allowing better exposure for more distal lesions or for shunt placement. If greater exposure is needed, then the digastric muscle can be divided.

Fig. 38.3. Illustration of the maneuver used to expose the upper margin of the internal carotid artery by mobilizing the hypoglossal nerve. Normally, the hypoglossal nerve is tethered against the external and internal carotid artery by either the occipital artery or the first branch from the occipital artery after it emerges from the external carotid artery, the sternomastoid artery (upper). This small artery is usually associated with a small vein and enters the sternocleidomastoid muscle. Dividing the sternomastoid artery (lower) will allow mobilization of the occipital artery and the hypoglossal nerve. This allows dissection to proceed further distally along the internal carotid artery, allowing better exposure for more distal lesions or for shunt placement. If greater exposure is needed, then the digastric muscle can be divided.

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