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Published on: January 18, 2018
Control of emboli in patients with recurrent or crescendo transient ischaemic attacks using preoperative transcranial
N S Lennard1, C Vijayasekar, C Tiivas
1Coventry and Warwickshire County Vascular Unit, Coventry University Hospital, Clifford Bridge Road, Walsgrave, Coventry CV2 2DX, UK.
Insights
Transcranial Doppler (TCD)-guided Dextran 40 effectively controlled symptoms and emboli in high-risk patients awaiting carotid endarterectomy. This safe approach warrants further investigation for preventing stroke.
Area of Science:
- Neurology
- Vascular Surgery
- Pharmacology
Background:
- Carotid endarterectomy is a procedure to remove plaque from carotid arteries.
- Early postoperative thrombosis is a risk after carotid endarterectomy.
- Transcranial Doppler (TCD) monitoring can detect microemboli.
Purpose of the Study:
- To assess the efficacy of intravenous Dextran 40 in managing symptoms and emboli.
- To evaluate Dextran 40's role before carotid endarterectomy in high-risk patients.
- To determine if TCD-guided Dextran 40 is a safe pre-operative treatment.
Main Methods:
- Prospective study of patients with >70% internal carotid artery stenosis and recent TIAs.
- Dextran 40 infusion initiated and titrated based on TCD-detected emboli and symptom control.
- Carotid endarterectomy performed on the next available elective surgical list.
Main Results:
- All 19 patients with recurrent TIAs and emboli achieved symptom and emboli control with Dextran 40.
- One patient died pre-operatively from myocardial infarction.
- One of 18 surgically treated patients experienced a non-disabling stroke postoperatively.
Conclusions:
- TCD-guided Dextran 40 is a safe pre-operative strategy for high-risk patients.
- This treatment approach shows promise in reducing embolic events before carotid endarterectomy.
- Further research is recommended to validate these findings.
Background:
Transcranial Doppler (TCD)-directed Dextran 40 treatment after carotid endarterectomy reduces the rate of early postoperative thrombosis. This study assessed the efficacy of intravenous Dextran 40 at controlling symptoms and emboli before elective carotid endarterectomy in patients with recurrent or crescendo transient ischaemic attacks (TIAs).
Methods:
In a prospective study, patients with more than 70 per cent internal carotid artery stenosis who had two or more symptomatic episodes within 30 days and TCD-detected microemboli were studied. Dextran 40 was commenced at 20 ml/h and TCD was repeated to reassess the rate of embolization. The infusion was increased in 20-ml/h increments until symptoms and emboli were controlled. The patient then had carotid surgery on the next elective list.
Results:
Nineteen patients with internal carotid stenosis greater than 70 per cent, recurrent symptoms and TCD-detected emboli were studied. All patients had symptoms and emboli controlled with Dextran 40. One patient with both unstable angina (awaiting urgent operation) and crescendo TIAs died from a myocardial infarct before undergoing operation. Of the 18 patients who had an operation, one suffered a non-disabling stroke on the third postoperative day.
Conclusion:
TCD-directed Dextran 40 offers a safe approach to high-risk patients before elective carotid endarterectomy, and warrants further study.
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