Thrombolysis and expedited carotid revascularization

With the move towards expedited carotid endarterectomy (CEA) in patients presenting with a transient ischemic attack/minor stroke and for offering intravenous thrombolysis <3 hours to patients with acute ischemic stroke, it is inevitable that surgeons will be asked to consider CEA in patients who have made a good recovery from their stroke after thrombolysis and who have a 50-99% internal carotid artery stenosis. The key question is: "how long after thrombolysis should I delay CEA to minimise the perioperative risk (especially intracranial hemorrhage [ICH]), whilst also minimizing the risks of further embolization and stroke?". Thirteen series have published outcomes in 361 patients. Only a very small proportion of all thrombolysis patients (<5%) might be considered for expedited CEA and the majority underwent CEA <14 days (some <48 hours). The 30-day death/stroke rate was 13/361 (3.6%), while the prevalence of ICH was 4/159 (2.5%). Most studies reported no increase in procedural risk if CEA was carried out soon after lysis, but one study questioned whether it was appropriate to perform CEA <72 hours because of an increased risk of ICH. The literature contains details of the complex effect that recombinant tissue plasminogen activator has on coagulation systems and on the integrity of the blood brain barrier, both of which will predispose towards ICH. The available literature suggests that CEA can be performed safely <14 days of lysis, but it is unclear whether surgery <72 hours is more dangerous. The key lesson for the surgeon is to adopt an aggressive policy regarding the treatment of post-CEA hypertension.