With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of nontraumatic subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade ! 4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.

Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.

Carotid endarterectomy (CEA) remains an effective treatment for severe carotid artery stenosis in symptomatic and asymptomatic patients. Therefore, CEA is an essential surgical technique for neurosurgeons to perform. In this study, we describe preoperative and operational maneuvers and techniques for CEA. When done under general anesthesia, neuromonitoring offers better sensitivity for predicting postoperative neurological deficits. Individual surgeons must opt for a selective or routine shunt that they are more comfortable with. The neck is extended and turned away from the side being operated on. Longitudinal or combined skin incisions is common. Most surgeons use a microscope to dissect the artery and plaque. Surgeons cut the ansa cervicalis at the origin to lift the hypoglossal nerve for dissection of the highly positioned plaque. If the occipital artery disturb to secure the distal internal carotid artery (ICA) site, it can be cut. Patch angioplasty reduces the risk of stroke and restenosis compared with primary closure. However, only a few surgeons in Japan perform patch angioplasty; most surgeons encounter only a small volume of CEA cases in Japan. Therefore, training programs and the development of in vivo training models are important.

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