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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Urgent carotid endarterectomy for stroke in evolution
R Brandl1, R B Brauer, P C Maurer
1Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Germany. r.brandl@t-online.de
Insights
Emergency carotid endarterectomy (CEA) can benefit selected stroke patients with fluctuating deficits. Careful patient selection and experienced surgical teams are crucial for positive outcomes in these urgent cases.
Area of Science:
- Vascular Surgery
- Neurology
- Emergency Medicine
Background:
- Carotid endarterectomy (CEA) is standard for symptomatic carotid stenosis.
- The effectiveness of emergency revascularization for acute stroke is debated.
Purpose of the Study:
- To evaluate the outcomes of emergency CEA in patients with evolving stroke.
- To identify criteria for selecting patients for urgent carotid revascularization.
Main Methods:
- Retrospective analysis of 445 CEAs over 5 years.
- Focused on 16 patients undergoing emergency CEA (4-24 hours post-symptom onset).
- Strict selection criteria included fluctuating neurological deficits and significant carotid stenosis.
Main Results:
- Neurological deficits resolved completely in 9 patients.
- Symptoms improved in 4 patients; 2 experienced worsening.
- Most patients (14/16) discharged within 8 days with no deterioration during follow-up.
Conclusions:
- Emergency CEA may be beneficial for carefully selected stroke patients.
- Success depends on strict adherence to selection criteria, intraoperative shunting, and post-operative care.
Background:
Carotid endarterectomy (CEA) is well established as the elective treatment for moderate or severe carotid stenoses with a history of neurologic symptoms. In contrast, the merits of carotid revascularisation performed in emergency in patients with acute stroke or fluctuating neurological deficit remain controversial.
Patients And Methods:
A total of 445 CEAs were performed on 424 patients for 212 (48%) asymptomatic and 233 (52%) symptomatic carotid stenoses within a 5 years period between January, 1995, and December, 1999. Of the latter, CEA was performed in emergency on 16 patients (3.8%) within 4 to 24 hours after the onset of symptoms. Patients selected for urgent surgery fulfilled the following criteria: acute onset of fluctuating hemispheric neurological symptoms, significant carotid pathology, absence of cerebral hemorrhage, uncompromised vigilance and stable cardiopulmonary conditions. Selected patients presented with a crescendo-TIA (n = 7) or fluctuating neurological deficits (n = 9) corresponding to a contralateral carotid stenosis.
Results:
Following CEA, the neurological deficits improved instantaneously to complete recovery in 9 patients. The symptoms of 4 patients improved to non-disabling deficits, remained unchanged in one and worsened in 2 patients from hemihypaesthesia to hemiparesis. 14/16 patients were discharged within 8 days after admission. The neurologic status after discharge did not deteriorate in any of the patients during follow up of 19.3 +/- 13 months, but improved in 4 of the patients.
Conclusion:
Our retrospective study suggests that rescue CEA may be beneficial for selected patients with stroke in evolution and fluctuating neurological deficits. Careful adherence to selection criteria, intraoperative shunting, intensive care post surgery surveillance and an experienced team are recommended.
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