Article

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events.

Vascular Surgery Division, Department of Surgery Paride Stefanini, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (impact factor: 3.52). 03/2011; 53(3):622-7; discussion 627-8. DOI:10.1016/j.jvs.2010.09.016
Source: PubMed

ABSTRACT This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event.
The study involved patients with acute neurologic impairment, defined as ≥ 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis ≥ 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation ≥ 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or ≥ 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging.
Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 ± 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 ± 3.41 on admission and 3.11 ± 3.62 at discharge in the entire group (P < .01). Patients with an NIHSS score of ≥ 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 ± 1.03 preoperatively vs 1.31 ± 1.7 postoperatively, NIHSS ≥ 8 10.32 ± 1.94 vs 4.03 ± 3.67; P < .001).
In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis ≤ 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome.

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    Article: Urgent Carotid Surgery: Is It Still out of Debate?
    C Battocchio, C Fantozzi, L Rizzo, F Persiani, S Raffa, M Taurino
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    ABSTRACT: Patients with symptomatic tight carotid stenosis have an increased short-time risk of stroke and an increased long-term risk of ischaemic vascular events compared with the general population. The aim of this study is to assess the safety, efficacy, and limitations of urgent CEA or CAS, in patients with carotid stenosis greater than 70% and clinically characterized by recurrent TIA or brain damage following a stroke (<2.5 cm). This study involved 28 patients divided into two groups. Group A consisted of sixteen patients who had undergone CEA, and group B consisted of twelve patients who had undergone CAS. Primary endpoints were mortality, neurological morbidity (by NIHSS) and postoperative hemorrhagic cerebral conversion, at 30 days. Ten patients (62.5%) of group A experienced an improvement in their initial neurological deficit while in 4 cases (26%) the deficit remained stable. Two cases of neurologic mortality are presented. At 1 month, 9 patients (75%) of group B experienced an improvement in their initial neurological deficit while 3 patients (25%) had a neurological impairment. Urgent or deferred surgical or endovascular treatment have a satisfactory outcome considering the profile in very high-risk patient population. Otherwise in selected patients CEA seems to be preferred to CAS.
    International journal of vascular medicine 01/2012; 2012:536392.
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    Article: Carotid embolectomy and endarterectomy for symptomatic complete occlusion of the carotid artery as a rescue therapy in acute ischemic stroke.
    Sami Curtze, Jukka Putaala, Marika Saarela, Pirkka Vikatmaa, Ilkka Kantonen, Turgut Tatlisumak
    [show abstract] [hide abstract]
    ABSTRACT: Emergency endarterectomy of an occluded internal carotid artery (ICA) has not been investigated as an option of rescue therapy for severe acute ischemic stroke in the era of intravenous (IV) thrombolysis treatment neither as a primary treatment nor after failed IV thrombolysis. Data from the pre-IV thrombolysis era are conflicting and therefore emergency endarterectomy has not been recommended. The number of patients reaching the emergency room within the IV thrombolysis time window has vastly grown due to advanced acute stroke treatment protocols. The efficacy of mechanical thrombectomy as a primary or add-on to IV thrombolysis therapy option is being actively investigated. We herein report 2 cases of acute ischemic stroke with computerized tomography (CT) angiography-documented occlusion of an ICA that were treated with emergency carotid endarterectomy and embolectomy to restore cerebral blood flow. Both cases presented with severe stroke symptoms and signs not responding to IV thrombolysis and showed severe CT-perfusion deficits mainly representing ischemic penumbra. Blood flow was surgically restored after 5 h of symptom onset. Both patients achieved a favorable outcome. We conclude that timely surgical approach of acute ICA occlusion after failed thrombolysis as a rescue therapy may be a viable option in well-selected patients.
    Case Reports in Neurology 09/2011; 3(3):301-8.
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Keywords

6 hours
 
acute neurologic impairment
 
bigger score reduction
 
carotid disease
 
carotid duplex scanning
 
carotid stenosis ≥ 50%
 
head computed tomography
 
Health Stroke Scale
 
ischemic neurologic recurrence
 
lower NIHSS score
 
magnetic resonance imaging
 
mean NIHSS score
 
National Institutes
 
new ischemic lesions
 
NIHSS score
 
significant NIHSS score
 
significant NIHSS score improvement
 
urgent carotid endarterectomy
 
variation ≥ 4
 
≥ 4 points