705 Urgent or Emergent Endovascular Intervention for Neurological Deficits Post-carotid Endarterectomy: A Single-institutional Case Series and Systematic Review of the Literature

Abstract

INTRODUCTION: Historically the management of acute neurological deficit following carotid endarterectomy (CEA) has been operative re-exploration; however, given the proliferation of endovascular techniques, and utilization of CT angiography, endovascular intervention is an alternative to redo-CEA. METHODS: All patients undergoing CEA in the Department of Neurosurgery at Rhode Island Hospital (Providence, RI) were reviewed. A systematic literature review was conducted in PubMed according to PRISMA guidelines to identify papers relevant to endovascular procedures addressing acute neurological deficits following CEA, which yielded 2499 unique articles. Review by 2 investigators revealed 12 relevant articles. RESULTS: Four patients from our institutional cohort met inclusion criteria. Among these, stenting was technically successful in 3 patients, 2 of which achieved near-full recovery. One patient underwent successful carotid stenting and ipsilateral M2 thrombectomy for tandem occlusion. Stent placement was unsuccessful in the remaining patient due to mechanical constriction. Articles obtained through the literature review revealed 57 further relevant cases. Of those with sufficiently complete data, 30/39 (76.9%) were male with an age range of 43 - 78 years old. Twenty-eight of 32 (87.5%) patients underwent CEA for symptomatic carotid stenosis. Post-CEA angiographic evaluation was most commonly conducted for routine completion imaging (21/57, 36.8%), non-specific stroke symptoms (15/57, 26.3%), and extremity weakness (7/57, 12.3%). Thrombotic stenosis (23/43, 53.4%) and arterial dissection (15/43, 34.9%) were the most common angiography findings. Two (3.5%) stent procedures were unsuccessful, and in the immediate postoperative period 8 patients (14.0%) had significant neurological deficits and only 3 deaths (5.3%) were reported. CONCLUSIONS: Endovascular intervention may be considered in situations where patients have neurological deficit after CEA. Direct comparison of outcomes in patients who have endovascular intervention vs. redo CEA may help identify the optimal management strategy.