Time Is Brain? - Surgical Revascularization of Acute Symptomatic Occlusion of the Internal Carotid Artery up to One Week
Department for Vascular Surgery and Kidney Transplantation, University Hospital of Düsseldorf Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany. Electronic address: . Annals of Vascular Surgery
(Impact Factor: 1.17).
02/2013; 27(4). DOI: 10.1016/j.avsg.2012.05.023
Clinical outcome and surgical success rate of open surgical reconstruction for acute symptomatic internal carotid artery (ICA) occlusion up to 1 week after stroke onset were analyzed to determine a cutoff time, after which risk exceeds clinical benefit.
From November 1997 to March 2007, a total of 5369 patients were examined at the authors' stroke unit; 502 from this cohort underwent ICA reconstruction. A subgroup of 49 patients underwent surgical revascularization of acute ICA occlusion within 168 hr at a mean of 42.5±38.7 hr after stroke onset. Preoperative diagnostic measures consisted of extracranial/intracranial duplex sonography (n=49), cerebral computed tomography (n=31), magnetic resonance imaging and angiography (n=37), and digital subtraction angiography (n=24). All 49 patients experienced a complete ICA occlusion and an ipsilateral recent ischemic infarction. Modified Rankin scale score (mRS) before surgery was 0 to 3 in 20 patients (41%) and 4 to 5 in 29 patients (49%).
ICA patency could be restored in 38 patients (78%). The following clinical outcomes were noted: clinical improvement in mRS by at least 1 point in 23 of 49 of patients (47%), no change in 14 of 49 (28%), deterioration in mRS by at least 1 point in 6 of 49 (12%), and death within 30 days in 6 of 49 (12%). A total of 21 patients (43%) experienced perioperative cerebral events (new infarction, new intracranial hemorrhage or enlargement, or hemorrhagic transformation of the preexisting infarction). Univariate analysis showed that clinical improvement correlated significantly with success of recanalization and with early recanalization within 72 hr. Age, gender, and preoperative Rankin stage did not have influence. Clinical deterioration or death was only associated with perioperative cerebral events and seemed to be time-independent. Multivariate analysis did not have enough statistical power to analyze the impact of different risk factors on outcome after urgent revascularization.
In patients who undergo surgery after 72 hr from symptom onset, the risk seems to outweigh the benefit.
Available from: Alexander Oberhuber
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ABSTRACT: Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.
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