Pathology, natural history, and treatment of cerebrovascular disease

The topic of cerebrovascular disease encompasses vascular pathology extending from the aortic arch cephalad and includes lesions in both the anterior and posterior cerebral circulations. Most of the disease processes are related to atherosclerosis and involve either occlusive or aneurysmal changes. Other pathologic entities, such as kinks, coils, and carotid body tumors, do occur but are much less common. Of the 500,000 new strokes that occur each year in the United States, it is estimated that up to 60% are related to atherosclerosis of the carotid bifurcation. It is therefore not surprising that carotid endarterectomy has become one of the most frequently performed operations on the vascular tree. In this review, we limit our discussion to carotid artery bifurcation occlusive disease. Specifically, we have concentrated on the pathology, natural history, preoperative evaluation, and perioperative management of these conditions. Although there have been contributions to all aspects of the management of cerebrovascular disease, these areas have witnessed the most significant changes during the current review period.