Standardized Protocols Enable Early Stroke Recognition and Treatment of Carotid Stenosis

Abstract

To examine the impact of acute stroke care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA). A standardized acute stroke care protocol was instituted between vascular surgery and stroke neurology services that included expeditious patient evaluation and imaging of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound, and/or conventional arteriogram; patient admission to a dedicated stroke unit with 1:1 intensive care staffing and 24-hour available neurointensivist; and treatment of all patients with ipsilateral moderate or severe carotid stenosis via CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from expeditious CEA included stroke in evolution and dense neurological deficit with National Institutes of Health Stroke Scale score >15. All data in this intent-to-treat study were prospectively collected and outcomes evaluated. From 11/2002 to 11/2012, 196 patients were admitted for acute stroke with a mean carotid stenosis of 84% (range, 50%-100%) and underwent CEA with a mean stroke onset to CEA time of 3.4 days (range, 0-7 days), via eversion CEA (185 [94%]) or standard CEA (11 [6%]). During CEA, shunt was placed electively in the majority of patients receiving general anesthesia (41 [21%]) and emergently for neurologic deterioration in patients receiving cervical block (13 [7%]). Six patients had neurologic events; two ipsilateral strokes (1%) and four ipsilateral transient ischemic attacks (2%), which resolved within 24 hours without residual deficits. Ten (5%) patients had myocardial infarctions; there were no deaths. In appropriately selected patients with acute stroke, early CEA is feasible and relatively safe with stroke-death-myocardial infarction complication of 6%. Stroke-death occurs in only 1%, and most complications are of non-fatal cardiac origin. A standardized stroke team protocol inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of acute stroke.