Safety of urgent carotid endarterectomy following thrombolysis

Impact of presenting stroke severity and thrombolysis on outcomes following urgent carotid interventions

BACKGROUND

Carotid interventions are increasingly performed in select patients following acute stroke. We aimed to determine the effects of presenting stroke severity (National Institutes of Health Stroke Scale [NIHSS]) and use of systemic thrombolysis (tissue plasminogen activator [tPA]) on discharge neurological outcomes (modified Rankin scale [mRS]) after urgent carotid endarterectomy (uCEA) and urgent carotid artery stenting (uCAS).

METHODS

Patients undergoing uCEA/uCAS at a tertiary Comprehensive Stroke Center (January 2015 to May 2022) were divided into two cohorts: (1) no thrombolysis (uCEA/uCAS only) and (2) use of thrombolysis before the carotid intervention (tPA + uCEA/uCAS). Outcomes were discharge mRS and 30-day complications. Regression models were used to determine an association between tPA use and presenting stroke severity (NIHSS) and discharge neurological outcomes (mRS).

RESULTS

Two hundred thirty-eight patients underwent uCEA/uCAS (uCEA/uCAS only, n = 186; tPA + uCEA/uCAS, n = 52) over 7 years. In the thrombolysis cohort compared with the uCEA/uCAS only cohort, the mean presenting stroke severity was higher (NIHSS = 7.6 vs 3.8; P = .001), and more patients presented with moderate to severe strokes (57.7% vs 30.2% with NIHSS >4). The 30-day stroke, death, and myocardial infarction rates in the uCEA/uCAS only vs tPA + uCEA/uCAS were 8.1% vs 11.5% (P = .416), 0% vs 9.6% (P < .001), and 0.5% vs 1.9% (P = .39), respectively. The 30-day stroke/hemorrhagic conversion and myocardial infarction rates did not differ with tPA use; however, the difference in deaths was significantly higher in the tPA + uCEA/uCAS cohort (P < .001). There was no difference in neurological functional outcome with or without thrombolysis use (mean mRS, 2.1 vs 1.7; P = .061). For both minor strokes (NIHSS ≤4 vs NIHSS >4: relative risk, 1.58 vs 1.58, tPA vs no tPA, respectively, P = .997) and moderate strokes (NIHSS ≤10 vs NIHSS >10: relative risk, 1.94 vs 2.08, tPA vs no tPA, respectively; P = .891), the likelihood of discharge functional independence (mRS score of ≤2) was not influenced by tPA.

CONCLUSIONS

Patients with a higher presenting stroke severity (NIHSS) had worse neurological functional outcomes (mRS). Patients presenting with minor and moderate strokes were more likely to have discharge neurological functional independence (mRS of ≤2), regardless of whether they received tPA or not. Overall, presenting NIHSS is predictive of discharge neurological functional autonomy and is not influenced by the use of thrombolysis.

Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine

BACKGROUND

This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association.

METHODS

GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations.

RESULTS

The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]).

CONCLUSIONS

This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Efficacy and mechanism of stellate ganglion block in patients undergoing carotid endarterectomy

OBJECTIVES

Carotid endarterectomy (CEA) is an effective technique for carotid artery stenosis and has been widely used. Stellate ganglion block (SGB) has good effect on the treatment of both painful and non-painful diseases. To investigate the efficacy of SGB in terms of cerebral protection in patients undergoing CEA and to analyze its mechanism.

METHODS

In this retrospective analysis, 120 patients who underwent CEA were enrolled and divided into study group (SG) (60 cases, general anesthesia and SGB) and control group (CG) (60 cases, general anesthesia). The differences in hemodynamic indexes, middle cerebral artery (MCA) hemodynamic indexes, and endocrine-related indexes between the two groups at the baseline, after induction of anesthesia (induction), and skin incision (incision) were compared. The differences in neurological function and pain level between two groups 1 day pre-operatively (pre-op 1), 1 day postoperatively (POD 1), 2 day postoperatively (POD 2), and 7 day postoperatively (POD 7) were also evaluated. Perioperative adverse events and intraoperative anesthetics dosage were compared between two groups.

RESULTS

The systolic blood pressure, diastolic blood pressure, mean pulse pressure difference, and heart rate of SG at incision were lower than those of the CG (p < 0.05); Vs, Vd, and Vm of MCA were significantly higher in the SG than in CG at induction and incision (p < 0.05). Cortisol and aldosterone levels were lower and potassium and insulin levels were higher in the SG than in CG at induction and incision (p < 0.05); At pre-op 1, POD 1, POD 2, and POD 7, the VAS scores of patients in the SG were significantly lower than those in CG at POD 1, POD 2, and POD 7 (p < 0.05). The patients in SG showed decreased incidence of perioperative adverse events compared with the CG (p < 0.05); The consumption of anesthetics in the SG was lower than that in CG (p < 0.05).

CONCLUSION

SGB in patients undergoing CEA treatment can improve perioperative cerebral blood supply and reduce the consumption of anesthetics and the incidence of perioperative adverse events, which is safe and feasible as a cerebral protection measure. Meanwhile, SGB may also help stabilize patients' perioperative hemodynamic indexes, but the result still needs to be supported by further large sample data.

Difficult questions of intravenous thrombolytic therapy in ischemic stroke

The article reflects the current achievements in the field of reperfusion therapy for ischemic stroke. The data are presented that allow a practicing neurologist to make informed decisions about intravenous thrombolysis in difficult clinical situations: minor stroke, suspected stroke "mask", atypical clinical picture, patient's age over 80 years, posterior circulation stroke, isolated dizziness, severe neurological deficit, large artery occlusion, chronic neuroimaging changes, polymorbidity and low functional level before stroke. It has been shown that an increase in the number of candidates for intravenous thrombolysis can be achieved by intensifying the selection of patients within the 4.5-hour therapeutic window, which primarily implies the optimization of local stroke treatment protocols with a reduction in the door-to-needle time, as well as, in the short term, expanding the therapeutic window. Approaches to reduce the risk of symptomatic hemorrhagic transformation are discussed. We are also talking about a rare but life-threatening complication angioedema. Thus, the intensification of intravenous thrombolysis, as well as an increase in its effectiveness and safety are the primary tasks of each stroke department.