Response to Comments on: “Early Carotid Endarterectomy after Intravenous Thrombolysis for Acute Ischemic Stroke”

Abstract

We appreciate the opportunity to respond to the thoughtful letter from Rashid et al. concerning our article “Early Carotid Endarterectomy after Intravenous Thrombolysis for Acute Ischemic Stroke”. Concerning the timing of carotid endarterectomy (CEA) after intra venous thrombolysis (IVT) we based our policy mainly on the reanalysis of NASCET and ECST results in 2004.1Rothwell P.M. Eliasziw M. Gutnikov S.A. Warlow C.P. Barnett H.J. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.Lancet. 2004; 363: 915-924Google Scholar For neurological stable individuals, the authors demonstrated clearly that surgery provide the highest benefit over medical management when CEA is performed within the first two weeks after the patient's last symptoms. In our opinion IVT may not change so much the natural history of atheromatous symptomatic carotid stenosis. Additionally, it has been also reported that the presence of a severe ipsilateral carotid stenosis was associated with poor clinical outcome after IVT and it might be recommended to adopt for those specific patients an aggressive reperfusion strategy.2Rubiera M. Alvarez-Sabin J. Ribo M. Montaner J. Santamarina E. Arenillas J.F. et al.Predictors of early arterial reocclusion after tissue plasminogen activator-induced recanalization in acute ischemic stroke.Stroke. 2005; 36: 1452-1456Google Scholar, 3Molina C.A. Montaner J. Arenillas J.F. Ribo M. Rubiera M. Alvarez-Sabin J. Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes.Stroke. 2004; 35: 486-490Google Scholar Finally, in our experience nine out of twelve patients had a remaining carotid stenosis ≥90% after IVT. Restoring quickly a normal blood flow in a freshly recanalized vessel may prevent reocclusion and allow us to verticalize the patient maintained strictly supine until surgery to avoid any worsening of the symptoms due to cerebral hypoperfusion. Therefore, we recommend performing surgery after IVT as soon as possible following our strict criteria of operability which are more numerous compared to those applied by Rashid et al. We agree that actually literature evidence remains extremely poor on this subject, and we may probably never have randomized control trials comparing immediate versus delayed CEA after IVT for stroke. However, we believe that in the near future we will observe in the literature some short series from high volume centers and meta analysis of them may provide sensible evidence base on the stroke and death rate that might be expected in such situation to provide better information to the patient. Comment on “Early Carotid Endarterectomy after Intravenous Thrombolysis for Acute Ischaemic Stroke, Bartolia MA et al. May 2009”European Journal of Vascular and Endovascular SurgeryVol. 38Issue 4PreviewWe read the article with great interest. The timing of carotid endarterectomy (CEA) post thrombolysis is an area requiring further evidence. Bartolia et al. found that performing early CEA in patients post thrombolysis could reduce the risk of recurrent stroke. The sample of 12 patients yielded a stroke and death rate of 8.3%.1 Full-Text PDF Open Archive