Acute ischemic stroke is a medical emergency. The initial evaluation of the potential stroke patient often occurs in a high-acuity area. Medical personnel responsible for establishing intravenous access, initiating cardiorespiratory monitoring, performing blood draws, and performing electrocardiography compete for the patient's attention. Additionally, the presence of aphasia or neglect may limit the patient's ability to provide accurate information. The neurological examination should focus on identifying signs of lateralized hemispheric or brainstem dysfunction consistent with stroke. The National Institutes of Health Stroke Scale (NIHSS) is a validated scale that has gained widespread acceptance as a standard clinical assessment tool. The chapter discusses evidence-based ischemic stroke treatment strategies. Determination of stroke mechanism and prompt initiation of secondary stroke preventative strategies such as anti-thrombotic therapy, aggressive risk-factor management, and carotid revascularization in carefully selected patients provide an opportunity to reduce the future burden of stroke.

This chapter reviews the major clinical trials on carotid endarterectomy and carotid angioplasty, and summarizes the technique used by the authors for carotid endarterectomy. The evolution of carotid endarterectomy, carotid angioplasty, and stenting and extracranial-intracranial (EC-IC) has been predicated on the results of clinical trials. The EC-IC bypass trial introduced the concept of multicenter prospective randomized trials to the neurosurgical community. The ongoing carotid revascularization endarterectomy versus stent trial (CREST) is prospectively randomizing patients with symptomatic carotid stenosis to either carotid endarterectomy or carotid angioplasty, and stenting with distal embolic protection (DEP), regardless of perioperative risk stratification. Assessing perioperative risk is essential in the evaluation of patients in whom carotid endarterectomy, carotid angioplasty and stenting or EC-IC bypass is being considered. Patients with symptomatic carotid occlusions may benefit from EC-IC revascularization provided they suffer from diminished cerebrovascular reserve.