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Ostrý S, Nevšímal M, Reiser M, Voldřich R, Krtička O, Kubále J, Nevšímalová M, Fiedler J. Intraoperative neurophysiological monitoring during urgent surgical extracranial internal carotid artery recanalization. Clin Neurophysiol 2022; 138:221-230. [DOI: 10.1016/j.clinph.2022.01.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/23/2021] [Accepted: 01/18/2022] [Indexed: 12/14/2022]
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Noh YH, Chung JW, Ko JH, Koo HW, Lee JY, Yoon SM, Song IH, Lee MR, Oh JS. Efficacy and Safety of Emergency Extracranial-Intracranial Bypass for Revascularization within 24 Hours in Resolving Large Artery Occlusion with Intracranial Stenosis. World Neurosurg 2021; 155:e9-e18. [PMID: 34246823 DOI: 10.1016/j.wneu.2021.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/03/2021] [Accepted: 07/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) is less effective for intracranial atherosclerosis-induced emergent large vessel occlusion. Extracranial-intracranial (EC-IC) bypass surgery is a possible treatment option to augment cerebral blood flow in the perfusion defect area. We compared the efficacy and safety of EC-IC bypass surgery with those of EVT and maximal medical treatment for acute ischemic stroke. METHODS The data from 39 patients, for whom vessel revascularization had failed despite mechanical thrombectomy, were retrospectively analyzed. Of the 39 patients, 22 had undergone percutaneous transluminal angioplasty or intracranial stenting (PTA/S), 10 had undergone emergency EC-IC bypass surgery within 24 hours of symptom onset, and 7 had received maximal medical treatment (MMT) only. The patency, perfusion status, and postoperative infarct volume were evaluated. The clinical outcomes were assessed at 6 months postoperatively using the modified Rankin scale. RESULTS The mean reperfusion time was significantly longer for the EC-IC bypass group (14.9 hours) compared with that in the PTA/S group (4.1 hours) and MMT group (7.5 hours; P < 0.05). The postoperative infarct volume on diffusion-weighted magnetic resonance imaging was significantly lower in the emergency EC-IC bypass group (11.3 cm3) than in the MMT group (68.0 cm3) but was not significantly different from that of the PTA/S group (14.0 cm3; P < 0.05). The proportion of patients with a modified Rankin scale score of 0-2 at 6 months after surgery was significantly higher in the EC-IC bypass group (80%) than in the PTA/S (59%) and MMT (14%) groups (P < 0.05). CONCLUSIONS Emergency EC-IC bypass surgery is an effective and safe treatment option for intracranial atherosclerosis-induced acute ischemic stroke for which EVT is inadequate.
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Affiliation(s)
- Yun Ho Noh
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Jae Woo Chung
- Department of Neurosurgery, Dankook University, College of Medicine, Dankook University Hospital, Cheonan, Republic of Korea
| | - Jung Ho Ko
- Department of Neurosurgery, Dankook University, College of Medicine, Dankook University Hospital, Cheonan, Republic of Korea
| | - Hae Won Koo
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Republic of Korea
| | - Ji Young Lee
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Seok Mann Yoon
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - In-Hag Song
- Department of Thoracic and Caridovacular Surgery, College of Medicine, Soonchunhyang University, Cheonan Hospital, Cheonan, Republic of Korea
| | - Man Ryul Lee
- Soonchunhyang Institute of Medi-bio Science, Soon Chun Hyang University, Cheonan, Republic of Korea
| | - Jae Sang Oh
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea.
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Most patients experiencing 30-day postoperative stroke after carotid endarterectomy will initially experience disability. J Vasc Surg 2019; 70:1499-1505.e1. [DOI: 10.1016/j.jvs.2019.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/13/2019] [Indexed: 11/22/2022]
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Kang J, Park TH, Lee KB, Park JM, Ko Y, Lee SJ, Hong KS, Cho YJ, Lee JS, Lee J, Lee BC, Yu KH, Kim DH, Cha JK, Lee J, Jang MS, Han MK, Bae HJ. Symptomatic steno-occlusion in patients with acute cerebral infarction: prevalence, distribution, and functional outcome. J Stroke 2014; 16:36-43. [PMID: 24741563 PMCID: PMC3961813 DOI: 10.5853/jos.2014.16.1.36] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/23/2013] [Accepted: 01/13/2014] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Symptomatic steno-occlusion (SYSO) in acute ischemic stroke has a significant impact on treatment options and prognosis. However, the prevalence, distribution, clinical characteristics, and outcome of SYSO are not well known. Methods We retrospectively identified 3,451 patients hospitalized because of ischemic stroke within 24 hours of symptom onset at 9 stroke centers in South Korea. Patients who did not undergo magnetic resonance imaging were excluded. SYSO was defined as stenosis or occlusion of cerebral arteries with relevant ischemic lesions in the corresponding arterial territory. The number, location, and severity of SYSOs and their effects on functional outcome were analyzed. Results In total, 1,929 of 3,057 subjects (63.1%) had SYSO. The most frequently affected vessels were the middle cerebral artery (34.6%), extracranial internal carotid artery (14%), vertebral artery (12.4%), and basilar artery (8.7%). SYSO predicted poor outcome on the modified Rankin Scale 3-6 (odds ratio, 1.77; 95% confidence interval, 1.46-2.15) with adjustments. Involvement of 2 or more vessels was observed in 30.6% of patients with SYSO and independently increased the risk of poor outcome (odds ratio, 2.76; 95% confidence interval, 2.12-3.59). The severity of SYSO was associated with outcome and showed a significant dose-response trend (P<0.001). The effect of SYSO on outcome did not significantly differ by individual arterial location (P for contrast=0.21). Conclusions Approximately 60% of patients with acute ischemic stroke had SYSO, and the severity and number were inversely correlated with outcome. The results suggest that SYSO could predict stroke outcome.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea. ; Department of Neurology, Samsung Changwon Medical Center, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Youngchai Ko
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Koyang, Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Koyang, Korea
| | - Ji Sung Lee
- Department of Biostatistics, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Korea
| | - Myung Suk Jang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
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Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits. J Vasc Surg 2013; 59:440-6. [PMID: 24246539 DOI: 10.1016/j.jvs.2013.08.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of the study was to assess the outcomes of carotid endarterectomy (CEA) performed in an urgent setting on acutely symptomatic patients selected through a very simple protocol. METHODS From January 2002 to January 2012, 193 symptomatic patients underwent CEA. Of these, 90 presented with acute symptoms, and after a congruous carotid stenosis was identified, underwent urgent operations (group 1): 27 patients had transient ischemic attack (group 1A), 52 patients had mild to moderate stroke (group 1B), and 11 patients had stroke in evolution (group 1C). The remaining 103 patients with a nonrecent neurologic deficit were treated by elective surgery in the same period (group 2). End points were 30-day neurologic morbidity and mortality. RESULTS The median delay of urgent CEA (U-CEA) from deficit onset was 48 hours (interquartile range, 13-117 hours). Groups 1 and 2 were comparable in demographics. Acute patients showed a higher rate of stroke at presentation (70% vs 37%; P = .001) and of history of coronary artery disease (30% vs 13.5%; P = .007). Acute patients sustained six postoperative strokes (6.6%). Neurologic outcomes were correlated to clinical presentation: no strokes occurred in group 1A patients, and 5.8% group 1B patients and 27.3% group 1C patients had postoperative stroke (P < .01). Postoperative mortality was 4.4% for U-CEA: one fatal myocardial infarction, one intracranial hemorrhage, and two thromboembolic strokes. Elective patients sustained four postoperative strokes (3.9%), with one death (0.9%) as a consequence of hyperperfusion cerebral edema. U-CEAs performed ≤48 hours from symptom onset had a lower postoperative stroke rate than those performed >48 hours (4.4% vs 8.8%; P = .3). Among patients presenting with a stroke (group 1B), the National Institutes of Health Stroke Scale (NIHSS) assessment at discharge showed improvement in 79% (although only 25% had ≥4 points in reduction), stability in 17%, and deterioration in 4%. Patients with moderate stroke were slightly better in NIHSS improvement than those with mild stroke (median NIHSS variation at discharge, -3 vs -1; P = .001). CONCLUSIONS Our results with U-CEA confirm that this population has a higher risk profile compared with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis.
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Lee SB, Huh PW, Kim DS, Yoo DS, Lee TG, Cho KS. Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke. Clin Neurol Neurosurg 2013; 115:1238-44. [DOI: 10.1016/j.clineuro.2012.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 11/20/2012] [Accepted: 11/24/2012] [Indexed: 01/20/2023]
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Kono K, Tanaka Y, Yoshimura R, Fujimoto T, Okada H, Shintani A, Terada T. Emergent carotid artery stenting using a flow reversal system for acute atherosclerotic occlusion of the internal carotid artery. Acta Neurochir (Wien) 2011; 153:2175-80. [PMID: 21892634 DOI: 10.1007/s00701-011-1142-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Accepted: 08/23/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Kenichi Kono
- Department of Neurological Surgery, Wakayama Rosai Hospital, Japan.
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Beitzke M, Enzinger C, Beitzke D, Niederkorn K, Offenbacher H, Niederkorn-Duft M, Fazekas F. Multimodality MRI and MRA for Decision Making in Minor Stroke: A Case with Internal Carotid and Distal Middle Cerebral Artery Occlusion. J Neuroimaging 2011; 21:e156-8. [DOI: 10.1111/j.1552-6569.2010.00501.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Hwang G, Oh CW, Bang JS, Jung CK, Kwon OK, Kim JE, Bae HJ, Han MK. Superficial Temporal Artery to Middle Cerebral Artery Bypass in Acute Ischemic Stroke and Stroke in Progress. Neurosurgery 2011; 68:723-9; discussion 729-30. [DOI: 10.1227/neu.0b013e318207a9de] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Surgical reperfusion may be beneficial in patients with acute ischemic stroke who are ineligible for thrombolysis.
OBJECTIVE:
To evaluate the outcome of superficial temporal artery to middle cerebral artery (STA-MCA) bypass in acute stroke and stroke in progress.
METHODS:
The clinical and radiological data of 9 patients treated by STA-MCA bypass requiring urgent reperfusion but ineligible for intra-arterial thrombolysis (IAT) were reviewed. Pooled analysis was performed of published literature concerning STA-MCA bypass in acute stroke (21 cases in 2 articles).
RESULTS:
Of the 9 patients enrolled, symptom aggravation occurred during medical treatment in 4 patients and after IAT in 2. Three patients were ineligible for IAT despite being within 8 hours of symptom onset. Bypass significantly improved National Institutes of Health Stroke Scale scores (preoperatively, 12.4 ± 4.88; 3 days postoperatively, 8.6 ± 6.39, P = .046; discharge, 5.4 ± 5.15, P = .008; 3 mo postoperatively 3.7 ± 4.82, P = .008) without significant infarction growth by diffusion weighted imaging (preoperatively, 15.0 ± 8.87 mL; 7 days postoperatively, 15.2 ± 8.28 mL; P = .110). Abnormal perfusion regions (mean transit time >145% of contralateral side value) were reduced in all cases (2.63 ± 0.93 mL). Good outcomes (modified Rankin scale ≤2) were achieved by 6 patients. Pooled analysis with our patients showed a significant neurological improvement (P < .001) and a good outcome in 25 (83.3%) patients without hemorrhage or complication.
CONCLUSION:
STA-MCA bypass may be beneficial to patients with acute stroke or stroke in progress who are ineligible for IAT. Furthermore, it appears safe when the infarction is small. These findings indicate that STA-MCA bypass could be considered as a treatment option in selected patients with acute stroke or stroke in progress.
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Affiliation(s)
- Gyojun Hwang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University and Postgraduate School, Gangwon University, Chuncheon, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheol Kyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Jun Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Koo Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
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Lee HO, Koh EJ, Choi HY. Emergency Carotid Artery Stent Insertion for Acute ICA Occlusion. J Korean Neurosurg Soc 2010; 47:428-32. [PMID: 20617087 DOI: 10.3340/jkns.2010.47.6.428] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/02/2010] [Accepted: 05/23/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE An effective intervention has not yet been established for patients with acute occlusion of the internal carotid artery (ICA). The aim of our study was to investigate the feasibility, safety, and efficacy of emergent stent placement of carotid artery to improve neurologic symptoms and clinical outcome. METHODS Of 84 consecutive patients with severe ICA stenosis who were admitted to our institution from March 2006 to May 2009, 10 patients with acute ICA occlusion (11.9%) underwent emergency carotid artery stent placement. We reviewed their records for neurologic outcome using the National Institutes of Health Stroke Scale (NIHSS) score, before and at 7 days after stent placement; clinical outcome using the modified Rankin Scale score (mRS) and Glasgow Outcome Scale (GOS); frequency of procedure-related complications; and recurrence rate of ipsilateral ischemic stroke within 90 days. RESULTS Carotid lesions were dilated completely in all patients. Median NIHSS scores before emergency stent placement and at 7 days were 16.6 and 6, respectively, showing significant improvement. Eight patients (80%) had favorable outcomes (mRS score 0-2 and GOS 4-5). Complications occurred in two patients (20%): stent insertion failed in one and an intracerebral hemorrhage occurred in the other. Ipsilateral ischemic stroke did not recur within 3 months. CONCLUSION Emergency carotid artery stent placement can improve the 7-day neurologic outcome and the 90-day clinical outcome in selected patients with acute cerebral infarction.
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Affiliation(s)
- Hai Ong Lee
- Department of Neurosurgery, Research Institute of Clinical Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
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Nussbaum ES, Janjua TM, Defillo A, Lowary JL, Nussbaum LA. Emergency extracranial-intracranial bypass surgery for acute ischemic stroke. J Neurosurg 2010; 112:666-73. [DOI: 10.3171/2009.5.jns081556] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to evaluate the safety and efficacy of urgent extracranial-intracranial (ECIC) bypass in the management of intracranial cerebrovascular disease and acute cerebral ischemic injury in carefully selected patients.
Methods
The authors reviewed the medical records and neuroimaging studies in 13 consecutive patients who underwent urgent surgical cerebral revascularization to treat acute cerebral ischemia. None were thought to be appropriate candidates for endovascular therapy. The patients' ages ranged from 21 to 65 years (mean 41.2 years). The mean follow-up review was 3.5 years, and no patient was lost to follow-up.
Results
Preoperative angiographic evaluation identified critical narrowing of the supraclinoid internal carotid artery (ICA) in 8 patients, the M1 segment of the middle cerebral artery (MCA) in 3, and the cervical/petrous ICA in 2. All patients had progressive, refractory symptoms associated with enlarging areas of infarction on diffusion weighted MR imaging, despite maximal medical therapy, which included anticoagulation and antiplatelet agents, blood pressure elevation, and fluid resuscitation. All patients underwent superficial temporal artery–MCA anastomosis on an urgent basis. In every case, the bypass prevented further stroke progression. In 2 cases, revascularization was followed by rapid, dramatic improvement of preoperative neurological deficits.
Conclusions
In the authors' experience, emergency EC-IC bypass in patients with acute ischemic injury was both safe and effective. This population was characterized by relatively young patients with severely limited collateral circulation. In this series of 13 carefully selected patients, bypass was successful in arresting progression of stroke, and in some cases resulted in rapid neurological improvement.
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Karkos CD, Hernandez-Lahoz I, Naylor AR. Urgent Carotid Surgery in Patients with Crescendo Transient Ischaemic Attacks and Stroke-in-Evolution: A Systematic Review. Eur J Vasc Endovasc Surg 2009; 37:279-88. [PMID: 19162516 DOI: 10.1016/j.ejvs.2008.12.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Accepted: 12/01/2008] [Indexed: 11/29/2022]
Affiliation(s)
- C D Karkos
- Department of Vascular and Endovascular Surgery, Leicester Royal Infirmary, Leicester, UK.
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Patterson BO, Holt PJ, Hinchliffe RJ, Thompson MM, Loftus IM. Urgent Carotid Endarterectomy for Patients with Unstable Symptoms: Systematic Review and Meta-Analysis of Outcomes. Vascular 2009; 17:243-52. [DOI: 10.2310/6670.2009.00038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
| | - Peter J. Holt
- *Department of Vascular Surgery, St George's Vascular Institute, London, UK
| | | | - Matt M. Thompson
- *Department of Vascular Surgery, St George's Vascular Institute, London, UK
| | - Ian M. Loftus
- *Department of Vascular Surgery, St George's Vascular Institute, London, UK
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Carotid endarterectomy, stenting, and other prophylactic interventions. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18793902 DOI: 10.1016/s0072-9752(08)94065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Miyamoto N, Naito I, Takatama S, Shimizu T, Iwai T, Shimaguchi H. Urgent stenting for patients with acute stroke due to atherosclerotic occlusive lesions of the cervical internal carotid artery. Neurol Med Chir (Tokyo) 2008; 48:49-55; discussion 55-6. [PMID: 18296872 DOI: 10.2176/nmc.48.49] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute symptomatic occlusion of the cervical internal carotid artery (ICA) can be treated by intravenous administration of tissue plasminogen activator, percutaneous transluminal angioplasty, and carotid endarterectomy. Carotid artery stenting (CAS) is now indicated for cervical ICA stenosis, but the safety and the efficacy of urgent CAS have not been established. We retrospectively reviewed 10 patients treated by urgent CAS for atherosclerotic occlusive lesions of cervical ICA with acute stroke. Five patients had complete occlusions and five had near total occlusions. Five of the 10 patients had intracranial tandem occlusions. Indication for urgent CAS was determined by mismatch of diffusion-weighted and perfusion-weighted magnetic resonance imaging findings. Stents were successfully deployed in all lesions. Three of five patients with concomitant intracranial tandem occlusions were treated by additional intraarterial fibrinolysis after the CAS. Intracranial artery occlusions were completely recanalized in one patient, and partially recanalized in two by fibrinolysis. Hyperperfusion syndrome did not occur in any of the patients. A favorable outcome (modified Rankin Scale < or =1) was obtained in all of the five patients with isolated cervical ICA occlusion and one of the five patients with intracranial tandem occlusions. Urgent CAS is a safe and effective treatment in patients with isolated cervical ICA occlusion. Treatment of intracranial tandem occlusions is an issue that must be resolved.
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Affiliation(s)
- Naoko Miyamoto
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan.
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Rothwell PM. Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis. Cerebrovasc Dis 2007; 24 Suppl 1:116-25. [PMID: 17971647 DOI: 10.1159/000107387] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
There is still considerable uncertainty about the place of carotid stenting in patients with recently symptomatic carotid bifurcation stenosis. Most reviews of carotid endarterectomy versus carotid stenting concentrate on technical aspects and advances in stenting, but the techniques involved in both carotid endarterectomy and stenting are evolving. In addition to reviewing the results of the various randomised controlled trials of carotid endarterectomy versus stenting for symptomatic carotid stenosis, this review considers recent advances and current best practice for endarterectomy. Ongoing randomized trials will determine whether or not the procedural risk of stroke and death is definitely lower with endarterectomy than with stenting, but the key issue that remains to be determined reliably is how the procedural risks of stenting vary with patient characteristics - perhaps the most important question being not whether endarterectomy is better than stenting or vice versa, but for whom is one technique likely to be better than the other.
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Affiliation(s)
- Peter M Rothwell
- University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK.
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Karkos CD, McMahon G, McCarthy MJ, Dennis MJ, Sayers RD, London NJM, Naylor AR. The value of urgent carotid surgery for crescendo transient ischemic attacks. J Vasc Surg 2007; 45:1148-54. [PMID: 17543679 DOI: 10.1016/j.jvs.2007.02.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 02/06/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study audited operative risk in patients undergoing urgent carotid surgery for crescendo transient ischemic attacks (TIAs). METHODS Interrogation of the vascular unit database (January 1992 to July 2004) identified 42 patients operated on urgently for crescendo TIAs, which were defined as>or=3 TIAs within the preceding 7 days. Stroke, death, and any major cardiac events were analyzed. RESULTS Thirty-nine patients underwent conventional endarterectomy, and three underwent interposition vein bypass. Crescendo TIA patients had sustained a median of five TIAs (range, 3 to 20) in the 7 days before surgery. Three patients died or had a stroke after surgery, for a combined stroke/death rate of 7%. This compares with 2.4% in 1000 patients undergoing elective carotid endarterectomy in this unit during the same time period. The combined stroke/death/major cardiac event rate was 14% (n=6). CONCLUSIONS The combined risk of neurologic and cardiac complications after urgent carotid surgery for crescendo TIA is higher than that expected after elective cases but is still acceptable considering the natural history of patients with unstable neurologic symptoms.
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Affiliation(s)
- Christos D Karkos
- Department of Vascular and Endovascular Surgery, Leicester Royal Infirmary, Leicester, United Kingdom.
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the Early Management of Adults With Ischemic Stroke. Circulation 2007; 115:e478-534. [PMID: 17515473 DOI: 10.1161/circulationaha.107.181486] [Citation(s) in RCA: 657] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose—
Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.
Methods—
Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.
Results—
Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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21
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655-711. [PMID: 17431204 DOI: 10.1161/strokeaha.107.181486] [Citation(s) in RCA: 1508] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. METHODS Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. RESULTS Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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22
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Gupta R, Jovin TG. Endovascular management of acute ischemic stroke: advances in patient and treatment selection. Expert Rev Neurother 2007; 7:143-53. [PMID: 17286548 DOI: 10.1586/14737175.7.2.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Selection of patients for acute-stroke therapy has traditionally been based on rigid time criteria in clinical trials. Recent advances in radiographic imaging have allowed clinicians to estimate brain physiology and thus utilize radiographic parameters to select patients for acute-stroke therapies. Both a better understanding and the quantification methods of salvageable tissue versus irreversibly injured tissue can help guide clinicians to which treatment modality to utilize. The evolution of endovascular techniques to treat acute stroke has resulted in treatment modalities that include mechanical and chemical methods to revascularize occluded cerebral arteries. Prior technical limitations to accessing distal-cerebral arteries have been partially overcome by modifications in technology. Patient and treatment-modality selection can help reduce hemorrhagic complication rates and also potentially increase revascularization rates, which may translate into improved clinical outcomes. We review the recent advances in radiographic imaging that have advanced patient selection in treating acute ischemic stroke and also consider current endovascular treatment options that are available to interventionalists performing these procedures.
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Affiliation(s)
- Rishi Gupta
- Michigan State University, Department of Neurology, Division of Cerebrovascular Diseases, East Lansing, MI 48824, USA.
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23
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Sbarigia E, Toni D, Speziale F, Acconcia MC, Fiorani P. Early Carotid Endarterectomy after Ischemic Stroke: The Results of a Prospective Multicenter Italian Study. Eur J Vasc Endovasc Surg 2006; 32:229-35. [PMID: 16772113 DOI: 10.1016/j.ejvs.2006.03.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2005] [Accepted: 03/18/2006] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- E Sbarigia
- I Cattedra di Chirurgia Vascolare, Università di Roma La Sapienza, Viale del Policlinico, Rome, Italy.
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24
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Aleksic M, Rueger MA, Lehnhardt FG, Sobesky J, Matoussevitch V, Neveling M, Heiss WD, Brunkwall J, Jacobs AH. Primary Stroke Unit Treatment Followed by Very Early Carotid Endarterectomy for Carotid Artery Stenosis after Acute Stroke. Cerebrovasc Dis 2006; 22:276-81. [PMID: 16788302 DOI: 10.1159/000094016] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 03/24/2006] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- M Aleksic
- Division of Vascular Surgery, Department of Visceral and Vascular Surgery, University Clinic of Cologne, Cologne, Germany.
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25
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Imray CHE, Tiivas CAS. Are some strokes preventable? The potential role of transcranial doppler in transient ischaemic attacks of carotid origin. Lancet Neurol 2005; 4:580-6. [PMID: 16109365 DOI: 10.1016/s1474-4422(05)70169-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transient ischaemic attacks (TIA) are more than just ministrokes. The high frequency of early stroke following TIA has resulted in the recent publication of guidelines in the UK. The guidelines recommend that patients attend a neurovascular clinic within 7 days of the index event to expedite investigation and treatment and so reduce the risk of a subsequent (potentially more serious) neurological event. After a TIA or stroke caused by carotid-artery disease, there is an increase in cerebral microemboli detectable by transcranial doppler (TCD). High microembolic loads appear to be surrogate markers for future neurological events, and the pharmacological efficacy of therapeutic interventions can now be rapidly and non-invasively assessed in the clinic or at the bedside. Medical treatments can now be optimised, avoiding the need for urgent or emergency carotid surgery and therefore allowing patients to undergo safer elective surgery when appropriate.
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Affiliation(s)
- Christopher H E Imray
- Coventry and Warwickshire County Vascular Unit, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK.
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26
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Teso D, Edwards RE, Frattini JC, Dudrick SJ, Dardik A. Safety of carotid endarterectomy in 2,443 elderly patients: lessons from nonagenarians--are we pushing the limit? J Am Coll Surg 2005; 200:734-41. [PMID: 15848366 DOI: 10.1016/j.jamcollsurg.2004.12.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Revised: 12/11/2004] [Accepted: 12/15/2004] [Indexed: 11/25/2022]
Abstract
BACKGROUND Elderly patients are a rapidly expanding segment of the population. Recent studies suggest that octogenarians have mortality and morbidity after carotid endarterectomy (CEA) similar to that in their younger cohort. Outcomes of CEA performed in nonagenarians have not been commonly reported; this study seeks to determine the safety of CEA in nonagenarians in general practice. STUDY DESIGN All patients in nonfederal Connecticut hospitals undergoing CEA between 1990 and 2002 were identified using the state discharge database (Chime Inc; ). RESULTS A total of 14,679 procedures were performed during the 12 study years. Sixty-four patients were nonagenarians (0.4%). Perioperative mortality was higher among nonagenarians (3.1%) compared with younger patients, including the 2,379 octogenarians (0.6%; p = 0.008, chi-square; odds ratio = 9.1, p = 0.006). No statistically significant difference was noted in perioperative stroke rates between nonagenarians (3.1%) and octogenarians (1.2%; p = 0.35, chi-square; odds ratio 2.3, p = 0.28). Nonagenarians had longer hospital lengths of stay (7.3 days, p < 0.0001), intensive care unit lengths of stay (1.2 days, p = 0.0013), and greater hospital charges ($17,967 +/- $1,907, p < 0.0001) than younger patients. Nonagenarians underwent operative procedures more frequently in an emergent setting (22%) compared with octogenarians (11%, p < 0.001) and had a greater percentage of symptomatic presentations (stroke: 14% versus 11%, p = 0.04; transient ischemic attack: 8% versus 5%, p = 0.04, respectively). All perioperative deaths and strokes occurred in symptomatic nonagenarians (15% versus 0%, p = 0.038; 15% versus 0%, p = 0.038; respectively). CONCLUSIONS Carotid endarterectomy is performed in nonagenarians, as a group, with greater rates of perioperative mortality and morbidity than in younger patients, including octogenarians. But nonagenarians have a greater rate of symptomatic and emergent presentations than younger patients, which may account for their increased mortality, morbidity, length of stay, and incurred charges. Asymptomatic nonagenarians have similar outcomes after carotid endarterectomy compared with younger patients, including octogenarians, with low rates of mortality and morbidity.
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Affiliation(s)
- Desarom Teso
- Department of Surgery, St Mary's Hospital, Waterbury, CT, USA
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27
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Berthet JP, Marty-Ané CH, Picard E, Branchereau P, Mary H, Veerapen R, Alric P. Acute Carotid Artery Thrombosis: Description of 12 Surgically Treated Cases. Ann Vasc Surg 2005; 19:11-8. [PMID: 15714361 DOI: 10.1007/s10016-004-0074-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The morbidity and mortality of stroke secondary to acute internal carotid artery thrombosis range from 40 to 69% and from 15 to 55%, respectively, after purely medical treatment. This report describes a series of 12 patients who underwent urgent surgical treatment for primary acute carotid artery thrombosis between January 1999 and December 2002. Upon admission, all patients had severe neurologic deficits contralateral to carotid artery thrombosis. One patient experienced ongoing changes in the level of consciousness. The interval between the onset of symptoms and admission was less than 6 hr in all cases. Initial work-up in all patients included a brain computed tomographic scan with contrast injection and carotid duplex scan. The operative procedure consisted of carotid thomboemdarterectomy after shunt placement with prosthetic patch closure. Intraoperative angiography was performed in all cases. Following treatment, we observed deterioration of neurologic status leading to death in one case; improvement with partial regression of initial neurologic deficit in two cases, including one patient who died from causes unrelated to carotid artery disease; and full neurologic recovery in nine cases. The delay to revascularization was longer than 6 hr in both patients who died. These data support surgical intervention for carotid artery thrombosis in selected patients without major disturbances of consciousness or hemorrhagic infarction, provided that the delay to revascularization is less than 6 hr.
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28
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Zaidat OO, Alexander MJ, Suarez JI, Tarr RW, Selman WR, Enterline DS, Smith TP. Early Carotid Artery Stenting and Angioplasty in Patients with Acute Ischemic Stroke. Neurosurgery 2004; 55:1237-42; discussion 1242-3. [PMID: 15574205 DOI: 10.1227/01.neu.0000143164.66698.c9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2003] [Accepted: 04/08/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
To determine the safety of early percutaneous endovascular carotid angioplasty and stenting (CAS) after an ischemic stroke.
METHODS:
The neurointerventional database was reviewed for patients who underwent CAS after an acute ischemic stroke in two university hospitals. Clinical and radiological data were reviewed. Outcomes were worsening stroke, new stroke, or stroke-related death up to 30 days after the procedure. Procedure-related complications were also documented.
RESULTS:
A total of 38 patients with 39 procedures were identified. The mean age was 67 ± 15 years; 31 of 38 patients were Caucasian and 24 were female. Hypertension was found in 21 patients, peripheral vascular disease in 12, diabetes in 13, and coronary artery disease in 18. The median initial National Institutes of Health Stroke Scale score was 8. The carotid artery showed severe to high-grade stenosis in 28 patients, dissection was present in 6, and the rest had an acute occlusion treated with thrombolysis followed by CAS. The mean time from stroke onset to CAS was 55 ± 34 hours. The mean degree of stenosis at baseline was 86 ± 11%. In 37 procedures, complete recanalization was achieved, defined as less than 10% residual narrowing; in 2 procedures, the residual stenosis was mild (10–20%). Neurological deterioration occurred after three procedures (7.7%), with minor nondisabling stroke in two and death from intracranial hemorrhage in one.
CONCLUSION:
If deemed necessary and in certain circumstances, early CAS seems to be safe after acute ischemic stroke if infarction volume is small and neurological deficit is mild.
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Affiliation(s)
- Osama O Zaidat
- Division of Interventional Neuroradiology, Duke University Health System, Durham, North Carolina 27710, USA
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29
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Swadron SP, Selco SL, Kim KA, Fischberg G, Sung G. The acute cerebrovascular event: surgical and other interventional therapies. Emerg Med Clin North Am 2004; 21:847-72. [PMID: 14708811 DOI: 10.1016/s0733-8627(03)00065-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Over the next decade, more early and aggressive treatments will become available for acute stroke. As EPs have been forced to push their skills and knowledge significantly further with the advent of time-sensitive interventions for myocardial ischemia, a similar sophistication will undoubtedly emerge in the management of acute stroke. Certain components of the neurological examination will likely assume a new significance and, as with the renewed focus on the nature of ST segment change on the ECG in ACS, there will be new attention to early imaging findings in stroke. Although it is unclear whether the balance of future advances in treatment will come from the world of neurosurgery, neurology, or interventional radiology, the EP is relatively assured to play a central role in their implementation.
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Affiliation(s)
- Stuart P Swadron
- Department of Emergency Medicine, LAC + USC Medical Center, Keck School of Medicine, 1200 North State Street, Room G1011, Los Angeles, CA 90033, USA.
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30
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Adams HP, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003; 34:1056-83. [PMID: 12677087 DOI: 10.1161/01.str.0000064841.47697.22] [Citation(s) in RCA: 785] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Acute ischemic stroke is now considered a neurological emergency for which there are new therapies. Neurosurgeons and neurologists need to remain apprised of advances in this field. The authors discuss approved and emerging therapies for patients suffering from acute ischemic stroke, based on a review of recent publications. Currently, intravenous tissue-type plasminogen activator is the only Food and Drug Administration–approved therapy for acute ischemic stroke. Intraarterial delivery of thrombolytics is a promising treatment and may be effective in selected patients. Other therapies for acute cerebral ischemia are intriguing but still in the investigational stages.
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Affiliation(s)
- D D Kindler
- Department of Neurology, University of Virginia, Charlottesville, Virginia 22908, USA
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