Early carotid endarterectomy in patients with small, fixed neurologic deficits

Whittemore, Anthony D.; Ruby, Steven T.; Couch, Nathan P.; Mannick, John A.

doi:10.1016/0741-5214(84)90011-9

Cited by 56 publications

(20 citation statements)

References 8 publications

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“…Patients with a stable acute stroke and normal CT scan can undergo CEA with no increased risk shortly after diagnosis. 11,14,15,17,22 Advancements in thrombolytic therapy currently provide patients a significant opportunity for neurological recovery after an acute ischemic event. tPA has been shown to be safe and effective in the treatment of acute stroke when administered within 3 hours.…”

Section: Discussionmentioning

confidence: 99%

Early Carotid Endarterectomy for Critical Carotid Artery Stenosis After Thrombolysis Therapy in Acute Ischemic Stroke in the Middle Cerebral Artery

McPherson

Woo

Cohen

et al. 2001

Stroke

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Background and Purpose — Tissue plasminogen activator (tPA) has been shown to be effective for acute ischemic stroke. However, if a high-grade cervical carotid stenosis remains despite tPA therapy, patients are at risk for recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in symptomatic patients with high-grade cervical carotid stenosis in reducing the risk of stroke, but it is unknown whether CEA can be performed safely after tPA thrombolysis. We describe our experience with 5 patients who underwent early (<48 hours) CEA for residual high-grade cervical carotid stenosis after thrombolytic therapy for acute ischemic stroke in the middle cerebral artery territory. Methods — All patients had a critical (>99%) carotid artery stenosis on the symptomatic side after tPA therapy. All patients received intravenous tPA; 3 patients also received intra-aortic tPA. Three patients received intravenous heparin infusion immediately after administration of tPA. All patients showed marked improvement in their National Institutes for Health Stroke Scale scores after treatment with tPA. CEA was then performed within 45 hours (6 hours in 1 patient, 23 hours in 2, 26 hours in 1, and 45 hours in 1). Results — All 5 patients underwent successful CEA. There were no complications related to surgery. At discharge, 2 patients had a normal examination, and the remaining patients had mild deficits. In a long-term follow-up of 5 to 22 months, no patient had a recurrent cerebrovascular event. Conclusions — Early CEA can be performed safely and successfully in patients after tPA treatment for acute ischemic stroke in appropriately selected patients.

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Section: Discussionmentioning

confidence: 99%

Early Carotid Endarterectomy for Critical Carotid Artery Stenosis After Thrombolysis Therapy in Acute Ischemic Stroke in the Middle Cerebral Artery

McPherson

Woo

Cohen

et al. 2001

Stroke

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“…26,27 Therefore, it is prudent to exclude patients with mental status changes or severe hemiparesis from surgical intervention. 11,14,16,19 That severity of neurologic deficit as classified by the modified Rankin score did not significantly influence outcome in our series (Table 6), does not refute this experience but underscores the importance of patient selection, excluding from immediate surgery patients with severely debilitating deficits.…”

Section: Discussionmentioning

confidence: 73%

“…2 Several authors have since reported favorable results with a more aggressive approach to selected patients with recent neurologic deficit reporting combined stroke/mortality rates between 0.9 and 7.4%. 10,11,[14][15][16][17][18][19] Although selection criteria have varied individually, several general principles are beginning to emerge.…”

Section: Discussionmentioning

confidence: 99%

Early Carotid Surgery for Recent Neurologic Deficit

Schunn¹,

Hetzel²,

Lange³

et al. 2000

Perspectives in Vascular Surgery

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Early carotid endarterectomy after recent neurologic deficit is controversial. Traditionally, an interval of at least 4 to 6 weeks has been recommended based on poor historical results of early surgical intervention after recent strokes and fear of hemorrhagic transformation of the infarct. On the other hand, recurrent strokes have been observed in up to 9.5% of patients while awaiting carotid repair. Since 1996 we have adopted a more aggressive approach to a highly selected group of patients with fresh ischemic deficits, prolonged reversible ischemic neurologic deficit (PRIND), or crescendo transient ischemic attacks (TIAs). Of 2824 patients who underwent carotid endarterectomy between August 1996 and December 1998, 112 patients (3.9%) underwent 123 carotid operations within less than 30 days (median interval: 8 days) after a nondisabling stroke, PRIND, or TIA. Postoperatively five patients (4.4%) suffered a stroke, one patient a transient worsening of his preoperative deficit, and one patient a TIA. Six patients died, three of which were due to their stroke (mortality 5.3%). One of these fatal strokes was due to an intracerebral hemorrhage in a patient with normal preoperative computed tomography. The combined 30-day permanent neurologic stroke and death rate was 7.1%. Functional neurologic outcome was excellent with 74.1% of patients suffering no or minimal deficit (Rankin scale 0-1). Patients with unstable or progressing neurologic deficit were found to have a significantly increased postoperative stroke rate (25%). Early carotid endarterectomy after nondisabling neurologic deficit may be performed with acceptable risk in carefully selected patients. The benefit of early versus delayed surgery, however, can only be determined in a prospective randomized study. 95

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“…In weiteren Auswertungen der ECST-und NASCET-Daten konnten klinische und morphologische Subgruppen mit einer [16,23,40,58].…”

Section: Klinische Subgruppenunclassified