Early Carotid Endarterectomy for Residu al Critical Carotid Artery Stenosis after Intraveno us Thrombolysis

Česká verzia

Authors: J. Mraček ¹; I. Holečková ¹; J. Mork ¹; P. Ševčík ²; V. Rohan ²
Authors place of work: Ne urochirurgické oddělení LF UK a FN Plzeň, 2Ne urologická klinika LF UK a FN Plzeň ¹
Published in the journal: Cesk Slov Neurol N 2009; 72/105(2): 173-177
Category: Short Communication

Summary

Objective:
The objective of the study is to contribute to the knowledge regarding the safety of carotid endarterectomy for residu al critical interi or carotid artery stenosis shortly after intraveno us thrombolysis due to acute cerebral stroke.

Introducti on:
In the case of intraveno us thrombolysis, reperfusi on is achi eved by the diluti on of the clot witho ut this having an effect on arteri al sclerotic changes as such. Homolateral tight residu al stenosis of the carotid artery after thrombolysis poses the danger of e arly recurrence of cerebral infarcti on and closure of the artery. The timing of carotid endarterectomy after a cerebrovascular accident remains a controversi al issue in clinical practice and safe performance of surgery shortly after thrombolysis is uncertain.

Method:
The a uthors assess, on a retrospective basis, a gro up of seven pati ents for the peri od from 01/ 2006 to 05/ 2008, who underwent e arly endarterectomy for critical residu al stenosis of the homolateral interi or carotid artery after intraveno us thrombolysis for acute cerebral infarcti on in the middle cerebral artery. All pati ents were men aged from 52 to 74.

Results:
Thrombolysis was successful in all cases, with the ne urological picture normalising quickly in three cases and parti ally in fo ur cases (Nati onal Institutes of He alth Stroke Scale – 1, 3, 4, 11). CT exam was negative or showed small hypodensity. The pati ents’ ne urological findings before the surgery were normal or showing just slight ne urological deficit. The surgery (performed at 5th to 15th day after thrombolysis [the medi an being 8], total anesthesi a, electrophysi ological monitoring) and the post‑op co urse were free from complicati ons. In pati ents with a ne urological deficit pri or to surgery further improvement of the deficit was recorded (Nati onal Institutes of He alth Stroke Scale: 1– 0, 3– 2, 4– 3, 11– 6). 30- day morbidity and mortality was nil. No recurrence of cerebral infarcti on was recorded in the co urse of a six- month follow‑up.

Conclusi on:
Early carotid endarterectomy can be safely performed in the selected gro up of pati ents with critical residu al stenosis of the interi or carotid artery after intraveno us thrombolysis for acute ischemic cerebral accident.

Key words:
carotid artery stenosis – carotid endarterectomy – timing – thrombolysis – stroke

Zdroje

1. Adams HP jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A et al. Guidelines for the e arly management of adults with ischemic stroke. Stroke 2007; 38(5): 1655– 1711.

2. Europe an Stroke Organisati on (ESO) Executive Comittee; ESO Writing Committee. Guidelines for management of ischemic stroke and transi ent ischaemic attack 2008. Cerebrovasc Dis 2008; 25(5): 457– 507.

3. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D et al. Thrombolysis with alteplase 3 to 4.5 ho urs after acute ischemic stroke. N Engl J Med 2008; 359(13): 1317– 1329.

4. Europe an Carotide Surgery Tri alists’ Collaborative Gro up. MRC Europe an Carotid Surgery Tri al: interim results for symptomatic pati ents with severe (70– 90%) or with mild (0– 29%) carotid stenosis. Lancet 1991; 337(8752): 1235– 1243.

5. North American Symptomatic Carotid Endarterectomy Tri al Collaborators. Benefici al effect of carotid endarterectomy in symptomatic pati ents with high‑grade carotid stenosis. N Engl J Med 1991; 325(7): 445– 453.

6. Barnett HJ, Taylor DW, Eli asziw M, Fox AJ, Ferguson GG, Haynes RB et al. Benefit of carotid endarterectomy in pati ents with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Tri al Collaborators. N Engl J Med 1998; 339(20): 1415– 1425.

7. Gi ordano JM, Tro ut HH jr, Kozloff L, DePalma RG. Timing of carotid artery endarterectomy after stroke. J Vasc Surg 1985; 2(2): 250– 255.

8. Gasecki AP, Ferguson GG, Eli asziw M, Clagett GP, Fox AJ, Hatchinski V et al. Early endarterectomy for severe carotid artery stenosis after a nondisabling stroke: results from the North American Symptomatic Carotid Endarterectomy Tri al. J Vasc Surg 1994; 20(2): 288– 295.

9. Hunter JA, Juli an DC, Dye WS Javid H. Emergency operati on for acute cerebral ischemi a due to carotid artery obstructi on: revi ew of 26 cases. Ann Surg 1965: 162(5): 901– 904.

10. McPherson CM, Wo o D, Cohen PL, Panci oli AM, Kissela BM, Carrozzella JA at al. Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery. Stroke 2001; 32(9): 2075– 2080.

11. Mraček J, Holečková I, Mork J, Choc M. Timing karotické endarterektomi e. Cesk Slov Ne urol N 2008; 71/ 104(4): 414– 421.

12. Lovett JK, Dennis MS, Sandercock PA, Bamford J, Warlow CP, Rothwell PM. Very e arly risk of stroke after a first transi ent ischemic attack. Stroke 2003; 34(8): 138– 140.

13. Co ull AJ, Lovett JK, Rothwell PM, Oxford Vascular Study. Populati on based study of e arly risk of stroke after transi ent ischemic attack or minor stroke: implicati ons for public educati on and organisati on of services. BMJ 2004; 328(7435): 326.

14. Rothwel PM, Eli asziw M, Gutnikov SA, Warlow CP, Barnett HJ; Carotid Endarterectomy Tri alists Collaborati on. Endarterectomy for symptomatic carotid stenosis in relati on to clinical subgro ups and timing of surgery. Lancet 2004; 363(9413): 915– 924.

15. Rothwell PM, Gibson R, Warlow CP. Interrelati on between plaque surface morphology and degree of stenosis on carotid angi ograms and the risk of ischemic stroke in pati ents with symptomatic carotid stenosis. Stroke 2000; 31(3): 615– 621.

16. Blaser T, Hofmann K, Buerger T, Effenberger O, Wallesch CW, Goertler M. Risk of stroke, transi ent ischemic attack, and vessel occlusi on before endarterectomy in pati ents with symptomatic severe carotid stenosis. Stroke 2002; 33(4): 1057– 1062.

17. Baron EM, Baty DE, Loftus CM. The timing of carotid endarterectomy post stroke. Ne urol Clin 2006; 24(4): 669– 680.

18. Wölfle KD, Pfadenha uer K, Bruijnen H, Becker T, Engelhardt M, Wachenfeld- Wahl C et al. Early carotid endarterectomy in pati ents with a nondisabling ischemic stroke: results of a retrospective analysis. Vasa 2004; 33(1): 30– 35.

19. Paty PS, Darling RC jr, Woratyla S, Chang BB, Krei enberg PB, Shah DM. Timing of carotid endarterectomy in pati ents with recent stroke. Surgery 1997; 122(4): 850– 854.

20. Cerebral Embolism Study Gro up. Immedi ate antico agulati on of embolic stroke: brain hemorrhagi e and management opti ons. Stroke 1984; 15(5): 779– 789.

21. Toni D, Fi orelli M, Basti anello S, Sacchetti ML, Sette G, Argentino C et al. Hemorrhagic transformati on of brain infarct: predictability in the first 5 ho urs from stroke onset and influence on clinical o utcome. Ne urology 1996; 46(2): 341– 345.

22. Herzig R, Král M, Olivi er P, Šaňák D, Bachleda P, Utíkal P et al. Ischemický iktus podmíněný akutní okluzí ACI: roční o utcome paci entů léčených akutní CEA a IVT. Cesk Slov Ne urol N 2007; 70/ 103 (Suppl): S7.