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Blood brain barrier breaking. Is still an absolute contraindication to early surgical reperfusion of the brain?
E Sbarigia1, F Speziale, M Colonna
1Universita degli studi di Roma, La Sapienza, I cattedra de chirurgia vascolare, Policlinico Umberto I, Italie.
Insights
Early carotid endarterectomy (CEA) may be safe and effective for patients with internal carotid artery stenosis and blood-brain barrier (BBB) breakdown. This approach aims to prevent stroke progression and improve recovery outcomes.
Area of Science:
- Neurology
- Vascular Surgery
- Neuroimaging
Background:
- Internal carotid artery stenosis poses a risk for cerebrovascular insufficiency.
- Blood-brain barrier (BBB) breakdown is often a contraindication for early carotid endarterectomy (CEA).
- Delayed surgery (4-6 weeks) is typically recommended due to hemorrhage risk.
Observation:
- Four cases of early CEA in patients with BBB are presented.
- Preoperative non-invasive tests (duplex scanning, transcranial Doppler) assessed stenosis and intracranial artery viability.
- CEA was performed under loco-regional anesthesia with careful blood pressure monitoring and management.
Findings:
- Early reperfusion via CEA can be beneficial even with BBB.
- Aggressive management aims to eliminate embolic sources and improve neurological recovery.
- Satisfactory results were observed in previous literature and in the presented cases.
Implications:
- Early CEA may be a viable option for selected patients with stroke risk factors.
- This challenges the traditional approach of delaying surgery in cases of BBB.
- Further research could refine patient selection for early intervention.
Abstract:
In the early treatment of the patients with cerebrovascular insufficiency due to internal carotid artery stenosis, the presence of a cerebral infarct and especially the blood brain barrier breaking (BBB) are considered by many as a contraindication to early reperfusion by carotid endarterectomy (CEA). Generally, it has been recommended to differ the operation at least for 4-6 weeks because of the high risk to convert an ischemic infarct into an hemorrhagic one. On the other hand, because unfavorable natural history has been reported as for the progressing unstable neurological deficit as for the minor recent strokes, respectively by Millikan and Dosik, it seem to be justified a more aggressive management with the aim of: 1) eliminating the stenosis as embolic source of emboli; 2) obtaining early brain reperfusion to increase the probability of good recovery. Some previous experiences reported in the literature demonstrated satisfactory results of early reperfusion even in presence of BBB. The Authors present 4 cases of early CEA in patients with BBB. After the CT scan the patients have been submitted preoperatively to non invasive tests (duplex scanning and transcranial Doppler sonography) to assess the presence of the internal carotid artery stenosis and the viability of the intracranial cerebral arteries with special regard to the middle cerebral artery. All the patients underwent CEA in loco-regional anesthesia and particularly systemic blood pressure was carefully monitored and any hypertensive status was early corrected by prompt antihypertensive therapy (i.v. nitrates and or calcium blocking agents).(ABSTRACT TRUNCATED AT 250 WORDS)