The Carotid Surgery for Ischemic Stroke trial: a prospective observational study on carotid endarterectomy in the early period after ischemic stroke

Perioperative stroke

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

Gradual Expansion of a Stent to Prevent Periprocedural Complications after Carotid Artery Stenting for Vulnerable Severe Stenotic Lesions with Intraplaque Hemorrhages: A Retrospective Observational Study

Vulnerable lesions with intraplaque hemorrhages are associated with a high incidence of complications following carotid artery stenting (CAS). CAS for vulnerable lesions has not been established; therefore, we gradually expand stents in such patients. This study aimed to compare the incidences of complications between gradual-expansion CAS for vulnerable lesions and standard CAS for non-vulnerable lesions. For gradual-expansion CAS, we used 3.0 or 4.0 mm balloons for minimal luminal diameters (MLDs) <2.0 or ≥2.0 mm, respectively, for pre-stenting angioplasty (SA) and did not overinflate them. By contrast, for standard CAS, we used a 4.0 mm balloon and overinflated it to 4.23 mm. A closed-cell stent was deployed, and post-SA was not performed in both groups. We evaluated the MLD before and minimal stent diameter (MSD) immediately after CAS, as well as periprocedural complications of combined stroke, death, and myocardial infarction within 30 days after CAS. In the vulnerable and non-vulnerable groups, 30 and 38 patients were analyzed, the MLDs were 0.76 and 0.96 mm before CAS, the MSDs were 2.97 mm and 3.58 mm after CAS, and the numbers of complications were 0 and 1, respectively. Gradual-expansion CAS for vulnerable lesions was as safe as standard CAS for non-vulnerable lesions.

Relevance of Infarct Size, Timing of Surgery, and Peri-operative Management for Non-ischaemic Cerebral Complications After Carotid Endarterectomy

OBJECTIVE

To assess the incidence of post-operative non-ischaemic cerebral complications as a pivotal outcome parameter with respect to size of cerebral infarction, timing of surgery, and peri-operative management in patients with symptomatic carotid stenosis who underwent carotid endarterectomy (CEA).

METHODS

Retrospective analysis of prospectively collected single centre CEA registry data. Consecutive patients with symptomatic carotid stenosis were subjected to standard patch endarterectomy. Brain infarct size was measured from the axial slice of pre-operative computed tomography/magnetic resonance imaging demonstrating the largest infarct dimension and was categorised as large (> 4 cm²), small (≤ 4 cm²), or absent. CEA was performed early (within 14 days) or delayed (15 - 180 days) after the ischaemic event. Peri-operative antiplatelet regimen (none, single, dual) and mean arterial blood pressure during surgery and at post-operative stroke unit monitoring were registered. Non-ischaemic post-operative cerebral complications were recorded comprising haemorrhagic stroke and encephalopathy, i.e., prolonged unconsciousness, delirium, epileptic seizure, or headache.

RESULTS

646 symptomatic patients were enrolled of whom 340 (52.6%) underwent early CEA; 367 patients (56.8%) demonstrated brain infarction corresponding to stenosis induced symptoms which was small in 266 (41.2%) and large in 101 (15.6%). Post-operative non-ischaemic cerebral complications occurred in 12 patients (1.9%; 10 encephalopathies, two haemorrhagic strokes) and were independently associated with large infarcts (adjusted odds ratio [OR] 6.839; 95% confidence interval [CI] 1.699 - 27.534) and median intra-operative mean arterial blood pressure in the upper quartile, i.e., above 120 mmHg (adjusted OR 13.318; 95% CI 2.749 - 64.519). Timing of CEA after the ischaemic event, pre-operative antiplatelet regimen, and post-operative blood pressure were not associated with non-ischaemic cerebral complications.

CONCLUSION

Infarct size and unintended high peri-operative blood pressure may increase the risk of non-ischaemic complications at CEA independently of whether performed early or delayed.

Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients

BACKGROUND

The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis.

METHODS

we conducted a single-center retrospective review of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors predictors of post-operative stroke. A literature systematic review was conducted using the terms "carotid endarterectomy" "stroke", "transient ischemic attack", "symptomatic carotid stenosis", and "shunt".

RESULTS

two-hundred-sixty-three CEAs were performed for TIA (n=178, 47%) or acute ischemic stroke (n=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR 5.14, 95%CI 1.32-24.93; P=.023), use of anticoagulants (OR 10.57, 95%CI 2.67-51.86; P=.001), preoperative stroke (OR 5.34, 95%CI 1.62-69.21; P=.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR 5.96, 95%CI 1.52-28.59; P=.013) were associated with early neurological complications. Statin medication (OR 0.18, 95%CI 0.04-0.71; P=.019) and CEA timing <2 days (OR 0.14, 95%CI 0.03-0.55; P=.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=.201) and operator's volume (P=.768). Four studies described the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results.

CONCLUSIONS

Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.

Impact of intraoperative neurologic deficits in carotid endarterectomy under regional anesthesia

OBJECTIVE

Patients undergoing carotid endarterectomy (CEA) may experiment neurologic deficits during the carotid cross-clamping due to secondary cerebral hypoperfusion. An associated risk of postoperative stroke incidence is also well established. This work aimed to assess the postoperative adverse events related to neurologic deficits in the awake test after clamping and to determine its predictive factors. Methods. From January 2012 to January 2018, 79 patients from a referral hospital that underwent CEA with regional anesthesia for carotid stenosis and manifested neurologic deficits were gathered. Consecutively selected controls (n = 85) were submitted to the same procedure without developing neurological changes. Postoperative complications such as stroke, myocardial infarction, all-cause death, and Clavien-Dindo classification were assessed 30 days after the procedure. Univariate and binary logistic regressions were performed for data assessment. Results. Patients with clamping associated neurologic deficits were significantly more obese than the control group (aOR = 9.30; 95% CI: 2.57-33.69; p = .01). Lower degree of ipsilateral stenosis and higher degree of contralateral stenosis were independently related to clamping intolerance (aOR = 0.70; 95% CI: 0.49-0.99; p = .047 and aOR = 1.30; 95% CI: 1.06-1.50; p = .009, respectively). Neurologic deficits were a main 30-day stroke predictor (aOR = 4.30; 95% CI: 1.10-16.71; p = .035). Conclusions. Neurologic deficits during carotid clamping are a predictor of perioperative stroke. Body mass index > 30 kg/m², a lower degree of ipsilateral stenosis, and a higher degree of contralateral stenosis are independent predictors of neurologic deficits and, therefore, might play a role in the prevention of procedure-related stroke.

Carotid Endarterectomy is often not Possible after an Unheralded Stroke: Unheralded Stroke in Carotid Artery Stenosis

OBJECTIVES

The ongoing literature recommends carotid endarterectomy (CEA) primarily for patients with neurological symptoms, however CEA can be precluded by the onset of a severe stroke or a total carotid occlusion. The present study aims to evaluate the effect of unheralded strokes in patients with a previously asymptomatic carotid stenosis (ACS) possibly considered for CEA.

MATERIALS AND METHODS

From 2009 to 2019, patients with an unheralded stroke from an ACS were considered. By neurological examination, patients were divided in unfit-for-CEA (uCEA) - either for the severity of the stroke (according to modified Rankin-Scale - mRS) or the onset of a total carotid occlusion - and patients submitted to CEA. Predictors for uCEA and stroke severity were evaluated.

RESULTS

Over a total of 532 patients with symptomatic carotid stenosis, 277 (52%) with unheralded stroke were included in the study. One hundred and one (36%) were considered uCEA: 64(23%) due to their neurological conditions (mRS:5) and 37 (13%) because of the onset of carotid occlusion. One hundred seventy-six (64%) patients underwent CEA. The preoperative medical therapy was similar in uCEA vs CEA patients. Age≥80 years and female sex were independently associated with uCEA (OR:5.9, 95%CI:3.1-11.4, P<.01; OR:3.9, 95%CI:2.0-7.6, P<.01. respectively). Patients submitted to CEA had mRS: 0-2 in 102(37%) cases and mRS:3-4 in 74 (27%). The contralateral carotid occlusion (CCO) was independently associated with mRS:3-4 (OR:8.4, 95%CI 1.8-79, P=.01). Postoperative stroke rate after CEA was 2.9% (4/167); patients with preoperative mRS:3-4 had a higher risk for postoperative stroke compared to those with mRS:0-2 (5.9% vs. 0%. P=.02).

CONCLUSIONS

An unheralded stroke in patients with ACS leads to a severe neurological damage in more than half of cases, either precluding CEA (36%) or increasing the risk of postoperative complications (27%). Female sex, age≥80 and CCO are independent predictors of these occurrences and should be considered in ACS patients.

The benefit of deferred carotid revascularization in patients with moderate-severe disabling cerebral ischemic stroke

OBJECTIVE

Symptomatic carotid artery stenosis needs revascularization within 2 weeks by carotid endarterectomy (CEA) to reduce the risk of symptom recurrence; however, the optimal timing of intervention is yet to be defined in patients with large-volume cerebral ischemic lesion (LVCIL) and modified Rankin scale (mRS) score ≥3. The aim of this study was to determine the most appropriate timing for CEA in patients with a recent stroke and LVCIL.

METHODS

Data from patients with symptomatic carotid stenosis with LVCIL and mRS score of 3 or 4 from 2007 to 2017 were considered. Patients were submitted to CEA if they had a stable clinical condition and life expectancy >1 year. LVCIL was defined as a cerebral ischemic lesion of volume >4000 mm³. Perioperative stroke and death were evaluated by stratifying for timing of CEA by χ² test and multiple logistic regression. Patients with similar characteristics (LVCIL and mRS score of 3 or 4) unfit for CEA served as the control group for recurrence of stroke at 1-year follow-up.

RESULTS

In an 11-year period, of a total 4020 CEAs, 126 (2.9%) were performed in patients with a moderate stroke and LVCIL occurring in the same admission. The patients' median age was 69 years (interquartile range [IQR], 10 years); 72% (91) were male, with mRS score of 3 (IQR, 1) and LVCIL volume of 20,000 mm³ (IQR, 47,000 mm³). The median time elapsed from symptoms to CEA was 7 weeks (IQR, 8 weeks). Overall perioperative stroke/death was 7.3% (eight strokes and one death). By selective timing evaluation of the postoperative events, CEA performed within 4 weeks was associated with a significantly higher rate of stroke/death compared with patients operated on after 4 weeks: 11.9% (8/67) vs 1.7% (1/59; P = .03). By logistic regression, CEA within 4 weeks was an independent (from sex, cerebral ischemic lesion volume, dyslipidemia, and carotid stenosis) predictor of postoperative stroke/death (odds ratio, 8.2; 95% confidence interval, 1.01-73). In the same period, 101 patients were considered unfit for CEA for dementia (n = 22), severe comorbidities (n = 55), or short (<1-year) life expectancy (n = 24), and 43 (43%) survived at 1 year. At 1 year, the perioperative/recurrent stroke after CEA vs patients unfit for CEA was similar (6.2% vs 13.9%; P = .11), but CEA performed after 4 weeks led to significantly lower perioperative/recurrent stroke (1.7% vs 13.9%; P = .02).

CONCLUSIONS

The surgical risk of CEA in patients with a recent moderate-severe ischemic stroke and LVCIL is high. However, if the intervention is delayed >4 weeks, its benefit seems significant.

Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk

OBJECTIVE

Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke.

METHODS

The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches.

RESULTS

There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022).

CONCLUSIONS

In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.

Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy

Background

Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated.

Methods

A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I² statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5 % risk of type I error, being the standard in most meta- analyses and systematic reviews.

Results

58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95 % CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I² = 36 %), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95 % CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95 % CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95 % CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men.

Conclusions

Metanalyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.

Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis

BACKGROUND

The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients.

METHODS

All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups.

RESULTS

During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups.

CONCLUSION

During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.

Very urgent carotid endarterectomy does not increase the procedural risk

OBJECTIVES

The timing of CEA for symptomatic internal carotid artery (ICA) stenosis remains a matter of controversy. Recent registry data showed a significantly increased risk, especially in the very early days after the onset of symptoms. In this study the outcome of CEA in the hyperacute phase has been investigated.

METHODS

The outcome of CEA for symptomatic ICA stenosis between January 2004 and December 2013 has been retrospectively analyzed. Patients were divided into four timing groups: surgery within 0 and 2 days, between 3 and 7 days, 8 and 14 days, and thereafter. The post-operative 30 day stroke and death rates were assessed.

RESULTS

A total of 761 symptomatic patients (40.1% with transient ischemic attack [TIA], 21.3% with amaurosis fugax, and 38.6% with ischemic stroke) were included, with an overall peri-operative stroke and death rate of 3.3%. A stroke and death rate of 4.4% (9/206) for surgery within 0 and 2 days, 1.8% (4/219) between 3 and 7 days, 4.4% (6/136) between 8 and 14 days, and 2.5% (5/200) in the period thereafter (p = .25 for the difference between the groups) was observed. The timing of surgery did not influence the peri-operative outcome in a multivariate regression analysis (OR 0.93 [0.63-1.36], p = .71).

CONCLUSIONS

These data show that very urgent surgery in symptomatic patients can be performed without increased procedural risk. Given the fact that ruptured plaques with neurological symptoms carry the highest risk of a recurrent ischemic event in the first 2 days, treating patients as soon as possible to offer the highest benefit in stroke prevention is recommended.

Standardized protocols enable stroke recognition and early treatment of carotid stenosis

OBJECTIVE

This study examined the effect of acute ischemic stroke (AIS) care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA).

METHODS

A standardized AIS protocol was instituted between vascular surgery and stroke neurology services in an academic hospital (group I) that included: (1) rapid patient evaluation and imaging inclusive of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound imaging or conventional arteriogram, or both; (2) patient admission to a dedicated stroke unit with minimum 1:2 intensive care nurse-to-patient staffing and a 24-hour available neurointensivist; (3) treatment of all patients with ipsilateral moderate or severe carotid stenosis by CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from undergoing expeditious CEA included (1) stroke in evolution, and (2) dense neurologic deficit or National Institutes of Health Stroke Scale score >15 (severe), or both. Comparisons of data were performed between group I patients and those treated in outlying hospitals (group II) for similar indications. All data were prospectively collected in a computerized database and outcomes evaluated retrospectively.

RESULTS

From November 2002 to November 2012, 369 patients underwent CEA for AIS ≤1 week of presentation. There were 192 patients in group I and 177 in group II. There were no differences in group I and II in mean stroke-to-CEA interval (3.4 vs 3.9 days) or in the performance of eversion CEA (94% vs 97%), respectively. Intraoperative shunt use was greater in group I (28%) than in group II (18%; P = .021). Fewer total neurologic events (stroke or transient ischemic attack) occurred in group I (6 [3.1%] vs 14 [7.3%]; P = .03). No patients died in either group. Postoperative National Institutes of Health Stroke Scale scores available in group I patients showed improvement from preoperative baseline in mild and moderate stroke patients (P < .001).

CONCLUSIONS

In patients with stable acute stroke, early CEA is feasible and relatively safe. Stroke or death occurs in only 1%, and most complications are of nonfatal cardiac origin. A standardized stroke team protocol that is inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of an acute stroke.

Very urgent carotid endarterectomy confers increased procedural risk

BACKGROUND AND PURPOSE

Current Swedish guidelines recommend that carotid endarterectomy should be performed within 14 days of a qualifying neurological event, but it is not clear if very urgent surgery after an event is associated with increased perioperative risk. The aim of this study was to determine how the time between the event and carotid endarterectomy affects the procedural risk of mortality and stroke.

METHODS

We prospectively analyzed data on all patients who underwent carotid endarterectomies for symptomatic carotid stenosis between May 12, 2008, and May 31, 2011, with records in the Swedish Vascular Registry (Swedvasc). Patients were divided according to time between the qualifying event and surgery (0-2 days, 3-7 days, 8-14 days, 15-180 days). Stroke rate and mortality at 30 days postsurgery were determined.

RESULTS

We analyzed data for 2596 patients and found that the combined mortality and stroke rate for patients treated 0 to 2 days after qualifying event was 11.5% (17 of 148) versus 3.6% (29 of 804), 4.0% (27 of 677), and 5.4% (52 of 967) for the groups treated at 3 to 7 days, 8 to 14 days, and 15 to 180 days, respectively. In a multivariate analysis, time was an independent risk factor for perioperative complications: patients treated at 0 to 2 days had a relative OR of 4.24 (CI, 2.07-8.70; P<0.001) compared with the reference 3- to 7-day group.

CONCLUSIONS

In this study of patients treated for symptomatic carotid disease, it was safe to perform surgery as early as Day 3 after a qualifying neurological event in contrast to patients treated within 0 to 2 days, which has a significantly increased perioperative risk.

Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients

Background

Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic (>50%) and asymptomatic (>60%) carotid artery stenosis. Here we report the midterm results of a microsurgical non-patch technique and compare these findings to those in the literature.

Methods

From 1998 to 2009 we treated 586 consecutive patients with CEA. CEA was performed, under general anesthesia, with a surgical microscope using a non-patch technique. Somatosensory evoked potential and transcranial Doppler were continuously monitored. Cross-clamping was performed under EEG burst suppression and adaptive blood pressure increase. Follow-up was performed by an independent neurologist. Mortality at 30 days and morbidity such as major and minor stroke, peripheral nerve palsy, hematoma and cardiac complications were recorded. The restenosis rate was assessed using duplex sonography 1 year after surgery.

Results

A total of 439 (75%) patients had symptomatic and 147 (25%) asymptomatic stenosis; 49.7% of the stenoses were on the right-side. Major perioperative strokes occurred in five (0.9%) patients [n = 4 (0.9%) symptomatic; n = 1 (0.7%) asymptomatic patients]. Minor stroke was recorded in six (1%) patients [n = 4 (0.9%) symptomatic; n = 2 (1.3%) asymptomatic patients]. Two patients with symptomatic stenoses died within 1 month after surgery. Nine patients (1.5%) had reversible peripheral nerve palsies, and nine patients (1.5%) suffered a perioperative myocardial infarction. High-grade (>70%) restenosis at 1 year was observed in 19 (3.2%) patients [n = 12 (2.7%) symptomatic; n = 7 (4.7%) asymptomatic patients].

Conclusions

The midterm rate of restenosis was low when using a microscope-assisted non-patch endarterectomy technique. The 30-day morbidity and mortality rate was comparable or lower than those in recently published surgical series.

Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes

INTRODUCTION

The impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events.

METHODS

CEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ(2) or Fisher's exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors.

RESULTS

A total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21).

CONCLUSIONS

Resident surgeon participation during CEA is not associated with risk of adverse perioperative events.

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

OBJECTIVES

This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.

RACE to protect brains

INTRODUCTION

Rapid-access carotid endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48 h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE.

SUBJECTS AND METHODS

A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CEAs) performed. Outcomes were compared between elective (ECE) and rapid-access operations.

RESULTS

In 1 year, 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. Twenty-three (30%) of ECE were for asymptomatic stenoses; no other significant differences in surgical indication were seen. Of symptomatic ECE, 43% were for completed stroke versus 55% for RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was one death following ECE (1.3%) and one stroke after RACE (5%), all not significant. Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time.

CONCLUSIONS

The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service, we have treated 50% of suitable patients within 48 h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.

Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery

Background and Purpose— Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke.

Methods— We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel–Haenszel meta-analysis.

Results— Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus ≥1 week, OR=1.2, 0.9 to 1.7, P =0.17; <2 weeks versus ≥2 weeks, OR=1.2, 0.9 to 1.6, P =0.13).

Conclusions— Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.

Urgency of Carotid Endarterectomy for Secondary Stroke Prevention

Background and Purpose— The benefit of carotid endarterectomy for preventing recurrent stroke is maximal when surgery is performed within 2 weeks after ischemic stroke or transient ischemic attack; the benefit is reduced when surgery is delayed >2 weeks and essentially lost if delayed >3 months. Guidelines recommend endarterectomy within 2 weeks poststroke/transient ischemic attack for patients with symptomatic carotid stenosis. This study examined time to endarterectomy at designated stroke centers as a measure of evidence-based best practices for stroke prevention.

Methods— From the Registry of the Canadian Stroke Network, we identified all consecutive patients presenting with acute ischemic stroke or transient ischemic attack at 12 provincial stroke centers (Ontario, Canada, 2003 to 2006) and selected those with unilateral symptomatic carotid stenosis of moderate (50% to 69%) or severe (70% to 99%) degree. Using linkages to administrative databases, we identified patients who underwent carotid endarterectomy within 6 months after the symptomatic event and calculated the time intervals between the index event and surgery. We compared the timing of surgery according to age, sex, degree of stenosis, index event, geographic region, and year. Logistic regression assessed variables associated with early surgery.

Results— One hundred five patients underwent endarterectomy for unilateral symptomatic carotid stenosis (50% to 99%) within 6 months of the index event. The median time from index event to surgery was 30 days (interquartile range, 10 to 81). Only one third (38 of 105) received endarterectomy within the recommended 2-week target timeframe, and in one fourth (26 of 105), surgery was delayed >3 months. Surgery within 2 weeks was more likely if the index event was a transient ischemic attack rather than a stroke. Access to early endarterectomy varied markedly between hospitals across the province and improved over time from 2003 to 2006.

Conclusions— In this hospital-based cohort, the majority of patients undergoing carotid endarterectomy after a transient ischemic attack or stroke had surgery delayed well beyond the period of maximum effectiveness. To enhance secondary stroke prevention, greater efforts are needed to minimize delays to diagnosis and surgical treatment for patients with symptomatic carotid stenosis.

The importance of early carotid endarterectomy in symptomatic patients

INTRODUCTION

Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients.

PATIENTS AND METHODS

A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan-Meier analysis and predictive factors identified using Cox regression analysis.

RESULTS

A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2-360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan-Meier survival analysis). Age (HR 1.059; 95% CI 1.014-1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7-621 days) after the first event. Eleven of 60 (18%) patients waiting < or = 97 days for surgery and 23 of 58 (40%) patients waiting > 97 days had repeat events. (P = 0.011, chi-squared test).

CONCLUSIONS

Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.

Urgent Carotid Endarterectomy for Patients with Unstable Symptoms: Systematic Review and Meta-Analysis of Outcomes

Current evidence suggests that carotid endarterectomy (CEA) performed within 2 weeks of symptoms produces better long-term results than if it is delayed. Urgent endarterectomy following unstable presentations such as crescendo transient ischemic attack (cTIA) or progressive stroke has been associated with variable results. The evidence for this treatment strategy required reviewing. A systematic review of articles related to urgent CEA between 1980 and 2008 was performed. For cTIA, there was an odds ratio of 5.6 (95% confidence interval 3.3–9.7, p ≤ .0001) for combined stroke or death compared with surgery for “standard” indications. For unstable stroke, the odds ratio was 5.5 (95% confidence interval 3.1–9.3, p ≤ .0001). Patients with unstable neurologic presentations are at higher risk of complications if operated on urgently. Clearer definitions would help more precise patient selection to avoid inadvertently operating on patients with an unacceptably high risk of poor outcome.

Prosthetic carotid bypass grafts for atherosclerotic lesions: a prospective study of 198 consecutive cases

OBJECTIVES

Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. The goal of this study was to determine the outcome and durability of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to CEA.

METHODS

This is a prospective series of 198 consecutive patients with PCB, representing 12.4% of 1595 patients with a carotid reconstruction procedure performed in our department between September 1986 and December 2006. Qualifying event was stroke in 67 patients (34%) and transient ischaemic attack (TIA) in 45 (23%), and 86 patients (43%) were asymptomatic. Primary indications for PCB were extensive atherosclerotic lesions (n=71; 36%), carotid stenosis associated with kinking (n=49; 25%), recurrent stenosis (n=47; 23%), stenosis after radiation therapy (n=18; 9%) and technical failure of CEA (n=13; 7%), with excessive arterial wall thinning and perforation after endarterectomy (n=10) or intimal flap on completion digital angiography (n=3).

RESULTS

The combined stroke and death rate at 30 days were 0.5% (one stroke). Median follow-up was 9.5 years (interquartile range (IQR): 6.2-18.3 years). At 10 years, primary patency was 97.9+/-3.4%. Six PCBs (3.0%) became occluded during follow-up; one patient had a restenosis greater than 50% and 18 patients (9.1%) had a restenosis of less than 50%. Five patients had an ipsilateral stroke (one postoperative stroke, one at 103 days with a patent PCB and three related to occlusion of the PCB at 4, 13 and 15 years after the procedure). At 10 years, cumulative stroke-free survival was 98.4+/-3.2%, and cumulative survival was 78.8+/-7.0%.

CONCLUSIONS

PCB is a safe surgical alternative and is durable, with a low incidence of graft restenosis, when CEA seems hazardous.

Delay from symptoms to carotid endarterectomy

OBJECTIVES

To investigate the time between cerebrovascular symptom and carotid endarterectomy (CEA), what prolongs this time and if and when the patients suffer additional cerebrovascular events.

DESIGN

Observational.

SETTING

Single Centre study at a specialized Stroke Centre.

SUBJECTS

A total of 275 patients with > or =50% symptomatic carotid stenosis (according to the NASCET-criteria) between 1 January 2004 and 31 March 2006.

MAIN OUTCOME MEASURES

Time between cerebrovascular symptom and CEA, time between different parts of the investigation, additional cerebrovascular symptoms before CEA and as perioperative complication.

RESULTS

A total of 128 patients underwent CEA. The median time between symptom and CEA was 11.7 weeks in the beginning and 6.9 weeks at the end of the study. Seven per cent were operated within 2 weeks and 11% between 2 and 4 weeks after their cerebrovascular symptom. The time delays were most pronounced between symptom onset and arrival at the Umeå Stroke Centre from the secondary hospitals and between the decision to recommend CEA and the CEA. Twenty-eight per cent of the patients who were intended for surgery suffered additional cerebrovascular events, 1.4% suffered a major stroke which excluded the indication of CEA and 3.0% of the CEA patients suffered a stroke with functional dependence within 30 days of the operation.

CONCLUSIONS

The delay between symptom and CEA was substantially longer than the desired 2 weeks. Many patients suffered additional cerebrovascular events before CEA. The risk of a severe additional stroke before CEA was about the same as the risk of a severe complication from the CEA.

Stellenwert der Revaskularisation eines akuten Karotisverschlusses

BACKGROUND AND PURPOSE

We examined indications for emergent revascularisation of acutely occluded internal carotid artery (ICA) using current diagnostic methods.

MATERIAL AND METHODS

From 1997 to 2006 we prospectively followed 34 consecutive patients undergoing emergency revascularisation due to acute extracranial ICA occlusion and acute ischaemic stroke within 72 h after symptom onset (mean 25) and within 36 h after admission (mean 16). Exclusion criteria were occlusion of the intracranial ICA or ipsilateral middle cerebral artery (MCA), ischaemic infarction of more than one third of the MCA perfusion area, or reduced level of consciousness. All patients underwent duplex sonography, cerebral CT, and/or MRI and angiography (MRA and/or DSA). We performed endarterectomy and thrombectomy of the ICA.

RESULTS

Confirmed by postoperative duplex sonography at discharge, ICA revascularisation was successful in 30 (88%) of 34 cases. Postoperative intracranial haemorrhage was detected in two patients (6%) and perioperative reinfarction in one (3%). Compared to the preoperative status, 20 patients (59%) showed signs of clinical improvement by at least one point on the Rankin scale, ten patients (29%) remained stable, and two patients (6%) had deteriorated. The 30-day mortality was 6% (two patients).

CONCLUSION

After careful diagnostic workup, revascularisation of acute extracranial ICA occlusion is feasible with low morbidity and mortality.

Urgent carotid surgery

Early intervention may be better

Pattern of cortex and white matter involvement in severe middle cerebral artery ischemia

BACKGROUND AND PURPOSE

In middle cerebral artery (MCA) stroke, ischemia usually is unevenly distributed within the MCA territory. We sought to investigate which brain structures are critical for the acute neurological deficit in severe MCA stroke.

METHODS

We used magnetic resonance (MR) imaging and statistical parametric mapping in 64 consecutive stroke patients (64 +/-13 years) to study the pattern of the initial perfusion abnormality.

RESULTS

Patients with lesion progression had more severe time-to-peak (TTP) abnormalities (P < .0001) in the inferior frontal gyrus, superior temporal gyrus, insula, and underlying hemispheric white matter than those with lesion regression. Also, patients with lesion progression had more severe T2 abnormalities on day 8 than those with lesion regression. In contrast, the changes of water diffusion were similar among the two groups resulting in a perfusion-diffusion mismatch in lesion progression. TTP-lesions were related to the neurological deficit score (r(s)=-0.563, P < .0001), T2-lesions (r= 0.686, P < .0001), and cerebral artery abnormalities assessed on MR-angiography (r(s)= 0.399, P < .01).

CONCLUSIONS

In major MCA, stroke ischemia was most severe in the central portion of the MCA territory. It is suggested that involvement of hemispheric white matter accentuated the neurological deficit probably by affecting cortico-cortical and cortico-subcortical fibers.

Significance of the perfusion-diffusion mismatch in chronic cerebral ischemia

PURPOSE

To determine whether the perfusion deficit could predict brain infarction in patients with chronic cerebral ischemia who experienced recurring episodes of neurological symptoms and showed a perfusion-diffusion mismatch on magnetic resonance (MR) images.

MATERIALS AND METHODS

In 53 consecutive patients (38 males and 15 females, 62+/-13 years old) with ischemia in the middle cerebral artery (MCA) territory, lesion volumetry was performed on parametric maps of the time-to-peak, the cerebral blood volume, and diffusion-weighted (DW) images. The infarct lesions were assessed on follow-up T2-weighted (T2W) MR images after eight days. Cerebrovascular changes were determined by time-of-flight (TOF) MR angiography (MRA). Inferential and correlation statistics were used.

RESULTS

Patients with chronic ischemic brain disease (N=39) who presented with a severe perfusion-diffusion mismatch in the presence of a normal cerebral blood volume had no or small brain infarctions as found on follow-up T2W images. MRA revealed widespread abnormalities of the basal cerebral arteries compatible with brain perfusion abnormalities. In contrast, in acute stroke patients (N=14) the deficit of cerebral perfusion predicted the infarct lesion in the T2W images.

CONCLUSION

Our results suggest that in chronic cerebral ischemia the normal blood volume was maintained despite the depression of cerebral perfusion and recurring minor insults.

Correction of symptomatic cerebral malperfusion due to acute type I aortic dissection by transcarotid stenting of the innominate and carotid arteries

INTRODUCTION

Acute proximal aortic dissection may be complicated by stroke due to malperfusion of the arch vessels. We report a novel case of successful endovascular treatment of acute cerebral malperfusion due to a dissection involving the aortic arch.

CASE REPORT

A 66 year old man was transferred from another hospital with an acute type I aortic dissection and underwent emergent repair of the aortic valve and ascending aorta with a composite graft. Left hemiplegia and altered cognitive function were noted on postoperative day 1. A carotid duplex scan showed partial thrombosis of the right carotid artery with very slow flow and reversal of flow in the right vertebral artery. A head CT was normal, while a head MRI and MR angiogram showed intraluminal defects in the inominate and right carotid arteries and perfusion abnormality of the entire right middle cerebral artery territory, but only small infarcts of watershed areas. The patient underwent stenting of the right carotid and inominate arteries through the right carotid artery with complete resolution of a large pressure gradient that was noted prior to stenting. The patient's left hemiplegia and cognitive impairment subsequently resolved during his inpatient hospitalization. On follow up five months later, he had a normal neurologic exam and MRI showed old watershed infarcts but no perfusion abnormality. On most recent follow-up 2.5 years after treatment, he remains well and a CT angiogram shows that his stented vessels remain patent.

CONCLUSION

Endovascular techniques may be safely applied to correct cerebral malperfusion that results from type I aortic dissection.

Early Carotid Endarterectomy after Ischemic Stroke: The Results of a Prospective Multicenter Italian Study

OBJECTIVES

To evaluate safety of early carotid endarterectomy (CEA) in patients with acute brain ischemia presenting to the emergency department stroke units (EDSU).

METHODS

The neurologists, neuroradiologists and vascular surgeons on duty in emergency departments enrolled 96 patients who underwent very early CEA according to a predefined protocol within two years. The protocol included evaluation of neurological status by National Institute of Health Stroke Scale (NIHSS), neuroimaging assessment, ultrasound of the carotid arteries and Transcranial Doppler. Patients with NIHSS>22 or whose neuroimaging showed brain infarct >2/3 of the middle cerebral artery territory were excluded. All eligible patients underwent CEA as soon as possible. Primary end points of the study were mortality, neurological morbidity by NIHSS and postoperative hemorrhagic conversion on neuroimaging. Statistical analysis was performed by univariate analysis.

RESULTS

The mean time elapsing between the onset of stroke and endarterectomy was 1.5 days (+/-2 days). The overall 30-day morbidity mortality rate was 7.3% (7/96). No neurological mortality occurred. On hospital discharge, three patients (3%) experienced worsening of the neurological deficit (NIHSS score 1 to 2, 1 to 3 and 9 to 10 respectively). Postoperative CT demonstrated there were no new cerebral infarcts nor hemorrhagic transformation. At hospital discharge 9/96 patients (9%) had no improvement in NHISS scores, 37 were asymptomatic and 45 showed a median decrease of 4.5 NIHSS points (range 1-18). By univariate analysis none of the considered variables influenced the clinical outcome.

CONCLUSION

Our protocol selected patients who can safely undergo very early (<1.5 days) surgery after acute brain ischemia. Large randomized multicenter prospective trials are warranted to compare very early CEA versus best medical therapy.

Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes

OBJECTIVE

The optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients.

METHODS

A retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1,158 (45.6%) were in symptomatic patients. Patients who were operated on emergently <or=48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered "early" if performed <or=4 weeks of symptoms, and "delayed" if performed after a minimum of a 4-week interval following the most recent symptom.

RESULTS

Of nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1,046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA.

CONCLUSIONS

In a large institutional experience, patients who underwent CEA <or=4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA.

Recovery from ischemic stroke: a translational research perspective for neurology

Ischemic stroke is the most frequent neurological disease, characterized by an age-related incidence and chronic disability in the majority of patients. A great challenge in acute stroke is to predict the degree to which a patient will eventually recover. Magnetic resonance imaging has revealed that treatment-induced reperfusion limits the extent of ischemic brain damage, thereby enabling rapid and profound recovery. Nevertheless, patients may retain deficits in motor, sensory or cognitive functions due to the residual lesion. Functional neuroimaging and transcranial magnetic stimulation have shown that recovery is associated with abnormal activation in the perilesional vicinity and in brain areas remote from the lesion. This is likely related to altered functional properties or morphological changes in both cerebral hemispheres. Recent neurorehabilitative strategies, including forced use, mental imagery and peripheral nerve or cortex stimulation, aim at modulating these functional networks. Accordingly, translational research has provided new vistas on the neurobiological mechanisms of recovery and opened future avenues for science-based pharmacological and neurophysiological training strategies in stroke.

Primary Stroke Unit Treatment Followed by Very Early Carotid Endarterectomy for Carotid Artery Stenosis after Acute Stroke

BACKGROUND

Although it is recognized that carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery (ICA) stenosis, in the past, very early CEA has been shown to carry substantial risks. We assessed an interdisciplinary concept of very early CEA in patients with high-grade (>70%) symptomatic ICA stenosis at a single center.

PATIENTS AND METHODS

The course of treatment and outcomes of patients who underwent CEA as early as possible after being referred to the stroke unit for symptoms of transient ischemic attack and stroke were prospectively evaluated, including the following parameters: age, severity of ischemia-related symptoms according to the modified Rankin scale, duration of symptoms until admission, multimodal imaging findings (color-coded duplex, cranial computed tomography, magnetic resonance imaging, positron emission tomography), duration until CEA, perioperative course and complications, as well as duration of in-hospital care.

RESULTS

Fifty consecutive patients (median age 68 years, range 44-90) with clinical and imaging signs of transient ischemic attack (n = 19) or stroke (n = 31) were included from January 2000 until December 2004. All except 1 patient showed a preoperative Rankin < 4. There was a median time period of 6 h between the onset of symptoms and admission (range 1 h to 15 days) and a median duration of 4 days after admission until operation (range 1-21 days). Seven patients underwent CEA of the contralateral, severely stenosed ICA after symptomatic ipsilateral ICA occlusion. Four out of 5 patients who primarily underwent systemic thrombolysis recovered almost completely. Three patients (6%) experienced a clinical deterioration before surgery. In the majority of patients (43/50), CEA was performed under local anesthesia with selective shunt use which became necessary in 26%. Three patients (6%) had postoperative worsening due to new infarcts. In 2 cases, an intracerebral hemorrhage occurred, of which 1 remained asymptomatic. In 1 case, surgical revision was necessary because of an ICA thrombosis without permanent neurological decline. Patients were discharged after a median time of 14.5 days (range 4-44).

CONCLUSIONS

After careful selection and preparation in a stroke unit, patients with acute stroke due to carotid stenosis can undergo very early CEA under local anesthesia with a perioperative risk comparable with the risk of later endarterectomy, therefore preventing very early stroke recurrences.

SURGICAL MANAGEMENT OF EXTRACRANIAL INTERNAL CAROTID ANEURYSMS BY CERVICAL APPROACH

BACKGROUND

Extracranial internal carotid artery aneurysms (EICAA) are rare vascular problems with a great potential for lethal thromboembolic episodes.

METHODS

From 1994 to 2004, nine patients with EICAA, seven men and two women, were surgically treated for 10 aneurysms in our department. Aneurysm led to hemispheric symptoms in six cases (two hemispheric strokes and four hemispheric transient ischaemic attacks). The cause was fibrodysplasia in two cases, atherosclerosis in four cases, trauma in two cases and spontaneous dissection in two cases. All aneurysms were treated surgically by the cervical approach using shunting. Extended cervical approach was necessary in four patients with high-lying aneurysms. Nine aneurysms were totally resected and successful revascularization was carried out. Open aneurysmorrhaphy with vein patch angioplasty was carried out in one case of a saccular aneurysm.

RESULTS

There were no perioperative deaths or transient ischaemic attacks or strokes. Four patients developed cranial nerve deficits: one had hoarsness, two had partial facial paralysis (patients with extended cervical approach) and one had tongue deviation. These neurological symptoms were observed in large aneurysms (>4.5 cm) and disappeared within 14 months. No neurological complication was observed in a follow up that ranged from 6 months to 10 years.

CONCLUSIONS

Surgical repair of EICAA, especially with total resection and arterial reconstruction, is strongly recommended. Extended cervical approach has many technical difficulties but can allow treatment of high-lying aneurysms.

American Society of Anesthesiology and Rankin as Predictive Parameters for the Outcome of Carotid Endarterectomy Within 28 Days After an Ischemic Stroke

OBJECTIVE

Recent studies suggest that carotid endarterectomy (CEA) is more effective when performed closer to an ischemic event than after an arbitrary 4- to 6-week delay. Factors need to be identified to evaluate potential perioperative complications after early CEA.

METHODS

We investigated the influence of several clinical and morphological variables on the perioperative combined stroke and mortality rate and their influence on the modified Rankin-scale (mRS). In order to increase the statistical power, we combined data from three clinical studies (one multicenter and two single center trials) concerning the CEA after a waiting period of no more than 28 days. A perioperative stroke was defined as an important of at least 1 score in the mRS. Statistical analysis included univariate and multivariate analysis.

RESULTS

A total of 226 patients (167 male), aged between 30 and 87 years (median 65.05 years) underwent CEA following an ischemic stroke within a period of no more than 28 days (median 12 days). The majority (>90%) showed severe stenosis of the internal carotid artery (>/=70%), 149 patients (66%) were ranked Rankin </=2, 91 (42%) ASA </=2. The perioperative stroke and mortality rate was 8.4%; 10 patients (4.4%) suffered a nondisabling stroke and 8 patients (3.5%) a disabling second ischemic event. One patient died due to a myocardial infarction. The degree of stenosis, use of a shunt, timing of surgery, or demographic data did not significantly influence the perioperative outcome. Only the preoperative ASA classification could be shown to be a significant predictor (ASA >2, P = .0245) for a deterioration of the postoperative neurological status of at least 1 Rankin grade. There was also a trend concerning the Rankin scale at admission (Rankin >2, P = .0658). The logistic regression analysis showed that patients with an ASA classification >2 and a preoperative Rankin >2 that were treated within 12 days after the initial ischemic event had the greatest risk for a perioperative deterioration of their neurological symptoms (odds ratio: 4.4, 1.48-13.0; P = .01).

CONCLUSION

The ASA classification and the neurological status measured by the Rankin scale are predictive variables for the clinical perioperative outcome in patients treated within 28 days after an ischemic stroke. Patients ranked ASA </=2 and/or Rankin </=2 can safely undergo the CEA within a shorter waiting period. In contrast, patients with a more severe neurological deficit and a higher number of comorbidities are at a greater risk if treated too close to the ischemic event.