Introduction

Summary

The chronology of events that have led to the preparation of this book is fascinating and unique. When people of my generation went to medical school they heard very little about the importance of the main artery to the brain. Stroke was universally considered as a consequence of intracerebral hemorrhage or intracerebral arterial thrombosis particularly of the middle cerebral artery. Even the angiographic identification of internal carotid artery stenosis and occlusion in the late 1920s and early 1930s by Moniz failed to stimulate the worldwide medical community to adopt this diagnostic breakthrough, and to focus on the internal carotid artery. Legitimate concerns about the potential hazards of the use of radioactive thorotrast, the contrast medium used by the pioneers, with its biological half-life of hundreds of years, and the custom of cutting down on the carotid artery deterred enthusiasm for the use of the procedure. In the 1940s Hultquist and Fisher carried out postmortem studies of the previously neglected portion of the extracranial carotid artery independently in Sweden and Canada. They identified this vessel as a common site of arteriosclerotic disease causing stroke. Almost coincident with these illuminating publications came the introduction of percutaneous angiography and the recognition of transient ischemic attack as a harbinger of stroke. All this accumulated knowledge led to a 1954 Lancet case-report by Eastcott and Rob at St. Mary's Hospital, London, describing the surgical removal of the diseased portion of a symptomatic carotid artery.