Neurosurgery

Fig. 19.5. a Axial CT scan post-contrast, showing a large right frontal meningioma with extensive oedema posteriorly. b Selective injection into the right middle meningeal artery branches, showing extensive blush from the meningioma. c Post-embolization with PVA particles and one 5-mm straight coil. The tumor bed has been completely embolized, with no blush showing.

Fig. 19.5. a Axial CT scan post-contrast, showing a large right frontal meningioma with extensive oedema posteriorly. b Selective injection into the right middle meningeal artery branches, showing extensive blush from the meningioma. c Post-embolization with PVA particles and one 5-mm straight coil. The tumor bed has been completely embolized, with no blush showing.

risks of stroke are significantly reduced by carotid surgery in suitable patients with recent symptoms and severe carotid stenosis greater than 70%. These trials establish carotid endarterectomy as a standard treatment for severe symptomatic carotid artery stenosis but not without risk. NASCET had a perioperative stroke and death rate of 5.8% and ECST 7.5%. The risks of surgery are even higher in other reported series (see chapter on ischemic stroke).

Rothwell [14] has shown that in published series, complication rates are highest where they have been assessed by an independent observer, with lower rates from single-author surgeons reporting their own series. Randomized prospective trials probably give the most accurate assessment of risk and benefit.

For asymptomatic stenosis, the risks and benefits are finely balanced. Surgery reduces the risk of stroke by around 30%, with a wide

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