Reoperation for Acute Hemispheric Stroke after Carotid Endarterectomy: Is There Any Value?

Abstract

In this series, approximately one-half of hemispheric strokes complicating CEA had an underlying correctable lesion (occlusion or stenosis), and these patients typically had delayed-onset strokes. Approximately one-half of these patients improved early as a result of reopening, although computed tomography revealed new infarcts in most of them. Urgent carotid repair may benefit a minority of selected patients who have a major stroke after CEA.

Acute Stroke After Carotid Endarterectomy

“…14 The frequency of perioperative strokes in NASCET is in line with other reports that cite a 0.8% to 3.9% incidence. 4,[8][9][10]12,15 Perioperative strokes after CEAs are usually due to postoperative surgical site thrombosis and embolism. 16 Several studies have attempted to identify risk factors for these immediate strokes.…”

“…In the case of acute post-CEA stroke, many centers have begun incorporating CT angiography before re-exploration. 4,10,12 This imaging modality can delineate not only whether the carotid is occluded but also whether there is a tandem intracranial occlusion from an embolus, for example, an M1 middle cerebral artery occlusion. This is important because an intracranial occlusion cannot be addressed with a surgical exploration.…”

Emergency placement of stent-graft for symptomatic acute carotid artery occlusion after endarterectomy

“…Acute thrombosis after CEA is the most common cause of perioperative stroke, accounting for up to 75% of cases 4. Distal intimal flap represents another important cause of such a complication 3…”

“…Other causes include carotid artery (CA) dissection, hypotension, embolization, and intracerebral hemorrhage 1. Controversy exists with regard to which diagnostic tests should be performed and which definitive therapy is optimal 4 5. We recently experienced a case in which stent-graft placement was used for treatment of a symptomatic occlusion of the CA that occurred immediately after CEA.…”

Rescue Use of Tirofiban for Acute Carotid In-Stent Thrombosis

“…However, as acute thrombosis is rare, it is difficult to accumulate evidence for a preferred treatment strategy. Setacci et al reported positive results of embolectomy, with or without stent removal, in cases of acute stent thrombosis following stenting while surgical treatment was commonly used in cases of thrombosis after endarterctomy 9,15,16. We chose medical management rather than surgery, because the event occurred in the angiography suite allowing immediate drug infusion.…”