Emergency Carotid Endarterectomy

Abstract

Objective: Evaluation of the therapeutical efficacy of emergency carotid endarterectomy (CEA) in neurologically unstable patients. Patients and Methods: Three groups of a consecutive series of 71 emergency CEAs performed from 1980 to July 1998 were classified: (1) acute onset of severe stroke (n = 16), (2) progressive stroke/stroke in evolution (n = 34), and (3) crescendo transient ischemic attacks (n = 21). Cerebral coma, cerebral haemorrhage, and major ischemic stroke established in cranial computed tomography scans were contraindications for surgery. The neurological outcome was assessed by the modified Rankin scale. Long-term survival and long-term stroke recurrences were analyzed. Results: The recovery/minor stroke rates (Rankin 0–3) in acute stroke, progressive stroke, and crescendo transient ischemic attacks were 56.3, 76.4 and 80.9%, respectively; the combined major stroke/mortality rates (Rankin 4–6) were 43.7, 23.6 and 19.1%, respectively. Intraoperative angiography in 39 patients detected early carotid reocclusions in 2 and intracranial embolism in 7 patients. Local application of thrombolytic agents (n = 5) may contribute to a better neurological outcome in emergency CEA. Life table probabilities of major strokefree survival were 74.5, 71.6, and 53.7% after 1, 2, and 5 years, respectively (including perioperative strokes). Life table probabilities to suffer no stroke recurrence during follow-up were 96.7, 96.7 and 85.3%, respectively (perioperative strokes excluded). Conclusions: Emergency CEA may be worthwhile in selected patients. Completion angiography is mandatory. Emergency CEA should be included in therapeutic strategies for ischemic stroke.

Guidelines for the Early Management of Adults With Ischemic Stroke

“…However, some surgeons report encouraging results from emergency operations for patients with severe stenosis or occlusion of the internal carotid artery existing for Յ24 hours. 324,386,[451][452][453][454][455][456][457][458][459][460] In general, improvement after surgery was found among patients with mild to moderate neurological impairments. Still, the data are limited, and the usefulness of urgent surgery among patients with severe neurological deficits is even less clear.…”

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

“…Consequently, the attempt of revascularization of recent ICA occlusions should be considered with caution, as also illustrated by the poor results with mortality rates of 12.5% [11]. However, a contralateral, even though asymptomatic, ICA stenosis should be operated upon early to prevent further restriction of cerebral perfusion after such symptomatic ipsilateral ICA occlusion.…”

Current Status of Carotid Endarterectomy and Stenting for Symptomatic Carotid Stenosis

“…The optimal timing of surgery has been controversial [41, 42], but it is increasingly clear that surgery should be performed as soon as it is reasonably safe to do so, given the very high early risk of stroke during the first few days and weeks after the presenting TIA or stroke in patients with symptomatic carotid stenosis [43, 44]. Any increased operative risk due to early surgery must be balanced against the substantial risk of stroke occurring prior to delayed surgery [44, 45].…”