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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients
Ehsan Yousefian Jazi1, Martin Wiesmann1, Arno Reich2
1Department of Neuroradiology, University Hospital, 569121RWTH Aachen University, Aachen, Germany.
Insights
Emergency carotid endarterectomy during thrombectomy is safe without neuromonitoring. This study found no increased stroke risk, even with complex cases like tandem occlusions.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Neuroradiology
Background:
- Tandem occlusions of the internal carotid artery and middle cerebral artery present a high risk of poor neurological outcomes.
- Performing emergency carotid endarterectomy (CEA) concurrently with thrombectomy in the angiography suite is a viable strategy.
- The absence of electrophysiological neuromonitoring during these combined procedures raises concerns about potential additional ischemic events.
Purpose of the Study:
- To evaluate the safety and efficacy of performing emergency CEA in the same anesthesia session as mechanical thrombectomy.
- To determine if combining these procedures without neuromonitoring increases the risk of additional infarctions.
- To identify factors influencing stroke outcomes in patients undergoing combined CEA and thrombectomy.
Main Methods:
- Retrospective analysis of 47 patients who underwent thrombectomy with emergency CEA between June 2013 and November 2020.
- Assessment of initial CT scans for pre-existing infarcts, cerebral perfusion, and Circle of Willis (CoW) collateralization.
- Follow-up imaging analysis to detect new infarctions potentially related to the surgical or endovascular procedures.
Main Results:
- Only 2 patients (4%) experienced new infarctions, attributed to embolism during thrombectomy, not the CEA.
- A complete CoW was present in 11% of patients; 38% had contralateral internal carotid artery stenosis or occlusion.
- Larger final infarct size was associated with contralateral ICA stenosis/occlusion (P=.038); CoW anatomy and shunt use were not risk factors for additional infarction.
Conclusions:
- Emergency CEA performed in the angiography suite concurrently with thrombectomy, even without neuromonitoring, is not associated with an increased rate of additional strokes.
- The procedure appears safe for managing tandem occlusions, with complications primarily linked to the thrombectomy itself.
- Contralateral ICA disease is a significant factor impacting final infarct size in these patients.
Abstract:
Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion (P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.
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