Emergency Carotid Endarterectomy Research Articles

動揺性脳卒中で発症した進行結腸癌患者に緊急CEAを施行した1例

動揺性脳卒中で発症した進行結腸癌患者に緊急CEAを施行した1例

Factors associated with stroke or death after carotid endarterectomy in Northern New England

This study investigated risk factors for stroke or death after carotid endarterectomy (CEA) among hospitals of varying type and size participating in a regional quality improvement effort. We reviewed 2714 patients undergoing 3092 primary CEAs (excluding combined procedures or redo CEA) at 11 hospitals in Northern New England from January 2003 through December 2007. Hospitals varied in size (25 to 615 beds) and comprised community and teaching hospitals. Fifty surgeons reported results to the database. Trained research personnel prospectively collected >70 demographic and clinical variables for each patient. Multivariate logistic regression models were used to generate odds ratios (ORs) and prediction models for the 30-day postoperative stroke or death rate. Across 3092 CEAs, there were 38 minor strokes, 14 major strokes, and eight deaths (5 stroke-related) < or =30 days of the index procedure (30-day stroke or death rate, 1.8%). In multivariate analyses, emergency CEA (OR, 7.0; 95% confidence interval [CI], 1.8-26.9; P = .004), contralateral internal carotid artery occlusion (OR, 2.8; 95% CI, 1.3-6.2; P = .009), preoperative ipsilateral cortical stroke (OR, 2.4; 95% CI, 1.1-5.1; P = .02), congestive heart failure (OR, 1.6; 95% CI, 1.1-2.4, P = .03), and age >70 (OR, 1.3; 95% CI, 0.8-2.3; P = .315) were associated with postoperative stroke or death. Preoperative antiplatelet therapy was protective (OR, 0.4; 95% CI, 0.2-0.9; P = .02). Risk of stroke or death varied from <1% in patients with no risk factors to nearly 5% with patients with > or =3 risk factors. Our risk prediction model had excellent correlation with observed results (r = 0.96) and reasonable discriminative ability (area under receiver operating characteristic curve, 0.71). Risks varied from <1% in asymptomatic patients with no risk factors to nearly 4% in patients with contralateral internal carotid artery occlusion (OR, 3.2; 95% CI, 1.3-8.1; P = .01) and age >70 (OR, 2.9; 95% CI, 1.0-4.9, P = .05). Two hospitals performed significantly better than expected. These differences were not attributable to surgeon or hospital volume. Surgeons can "risk-stratify" preoperative patients by considering the variables (emergency procedure, contralateral internal carotid artery occlusion, preoperative ipsilateral cortical stroke, congestive heart failure, and age), reducing risk with antiplatelet agents, and informing patients more precisely about their risk of stroke or death after CEA. Risk prediction models can also be used to compare risk-adjusted outcomes between centers, identify best practices, and hopefully, improve overall results.

Platelet Mapping and Desmopressin Reversal of Platelet Inhibition During Emergency Carotid Endarterectomy

POSTOPERATIVE BLEEDING WITH cervical hematoma is a possible complication of carotid endarterectomy (CEA). Its incidence is about 5%, with 99% of the events occurring within 8 hours of the operation. 1 Sheehan M.K. Baker W.H. Littooy F.N. et al. Timing of postcarotid complications: A guide to safe discharge planning. J Vasc Surg. 2001; 34: 13-16 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar

Synthetic patch angioplasty proves useful in carotid endarterectomy

Patch angioplasty is performed to prevent recurrent stenosis after carotid endarterectomy (CEA). Controversy surrounds the selection of the patch material, with supporters for both autogenous tissue and synthetic patches. We reported on the efficacy of synthetic patch angioplasty. Thirty-four carotid endarterectomies with synthetic patch angioplasty, Hemashield Finesse® and Gore-Tex®, were performed on 32 patients. Twenty-eight of the thirty-four cases were classified as elective CEA and six were emergency CEA. The clinical outcome, perioperative complications, and incidence of recurrent stenosis (> or =50%), as detected by MRA and ultrasonography, were examined. Postoperatively, one severe acute stroke patient who underwent emergency CEA died from gastrointestinal bleeding. The perioperative permanent neurologic morbidity was 0% in elective CEA, and five of the six emergency CEA patients recovered. The total permanent morbidity and mortality rate in all CEA with synthetic patch angioplasty was 2.9%. No recurrent stenosis or further stroke occurred in the postoperative long-term follow-up period. Synthetic patch angioplasty in CEA is considered useful to prevent recurrent stenosis, and to avoid vein harvest site complications and patch rupture as previously described with vein patch angioplasty. Finally, there have been no thrombotic complications using synthetic patch angioplasty in emergency CEA.

Indications for and perioperative management of emergency carotid endarterectomy—report on six cases

Emergency carotid endarterectomy (CEA) can be indicated to restore neurological functions or help prevent further stroke in impending stroke patients. We report on our experience of emergency CEA and perioperative patient management in six patients who underwent emergency CEA. We operated on 32 patients with carotid artery stenosis in the last 4 years, 6 of whom were classified as “emergency” patients. Two patients had a crescendo TIA, two had stroke in evolution, and the remaining two had acute severe stroke. In all cases, CEA was performed within 48 h of the last ischemic attack. Postoperatively two patients, each with crescendo TIA and stroke in evolution, and one acute severe stroke patient made a full recovery. One patient with acute stroke died from hypovolemic shock caused by gastrointestinal bleeding. The final postoperative neurological status, as graded by the modified Rankin scale, was Grade 0, of which we had four patients and Grade 2, which described one of our patients. No patient suffered further stroke after CEA in long-term follow-up. Transient postoperative complications occurred in two patients, and angina pectoris in the other. Emergency CEA is beneficial for patients with Crescendo TIA and stroke in evolution in perioperative and long-term follow-up. Postoperatively, however, blood pressure, coronary artery disease, and hemorrhagic complications such as gastrointestinal bleeding must be carefully managed.

５．脳梗塞超急性期の主幹動脈病変に対する外科的治療―特に頚動脈内膜切除術の意義と限界―

In this report, I reviewed lireratures and our clinical experiences of surgical revascularization ; carotid endarterectomy (CEA), intracranial embolectomy, and EC-IC bypass on emergency basis after ischemic cerebral stroke. Especially, in the cases with symptomatic and critical stenosis/complete occlusion of the internal carotid artery (ICA), current topics about efficacy and treatment algolism of emergency or ultra-emergency CEA in this clinical category. In summary ; 1) Crescendo TIAs and stroke in evolution are characteristic symptoms of the critical ICA stenosis and these cases will be absolute indication for emergency CEA. Significance of these symptoms should be more emphasized for early diagnosis in this clinical category. 2) Ultra-emergency thrombolysis and CEA should be the only successful procedure in the serious ICA occlusion group. Proper and quick examination system for true diagnosis, especially for evaluation of effectiveness and risk of surgical revascularization, must be considered.

Emergency carotid endarterectomy

Although carotid endarterectomy (CEA) is an established treatment, evaluation of emergency revascularization is still obscure, especially in patients with stroke. The purpose of this study is to discuss the efficacy and limitation of emergency CEA. The subjects are 88 patients who had acute atherothrombotic TIAs or stroke, and angiographically critical stenosis (>90%) of the cervical ICA. A patient with apparent low-density lesion on the initial CT was not included. There were 86 men and 4 women, aged 49 to 78 years. All patients were admitted and diagnosed within 6 h after the last attack, and treated by CEA in different timing or medical treatment. Results of treatment were evaluated. In 33 patients with only TIAs, results of CEAs were excellent compared with medical treatment group. In 29 with mild neurologic deficits, results of CEAs were more satisfactory in emergency procedures in comparison with delayed surgery. In other 26 patients with profound deficits, sufficient results were not obtained in any treatments. In conclusion, emergency CEA should be selected without hesitation, in patients with critical ICA stenosis and TIAs or mild ischemic stroke. We also present our small experiences and discuss about endovascular PTA/stenting in this clinical category.

Endovascular treatment for cervical carotid artery stenosis presenting with progressing stroke: three case reports

BACKGROUND Progressing stroke is said to occur when symptoms and signs worsen in cases of ischemic stroke. Although conservative methods using volume expansion with antithrombotic or anticoagulative agents are widely used for progressing stroke, in some hospitals, emergency carotid endarterectomy (CEA) has been performed for carotid stenosis, with mixed results. Here we report three cases with progressing ischemic stroke that were managed by endovascular surgical intervention. CASE DESCRIPTION We performed endovascular surgery in three patients with cervical carotid artery stenosis presenting with progressing stroke or crescendo transient ischemic attacks. Endovascular treatment was less invasive and feasible for acute phase treatment. While local thrombolysis alone was found to be less effective, stent placement induced complete resolution of stenosis, but may result in hyperperfusion syndrome or hemorrhagic infarction. CONCLUSIONS In an emergency, percutaneous transluminal angioplasty with proper dilatation is preferred, and then CEA or stenting should be considered after the patient’s condition stabilizes.

急性期脳虚血患者に対する緊急CEAの適応と手術の要点

急性期脳虚血患者に対する緊急CEAの適応と手術の要点

Combined therapeutic approach of intra-arterial thrombolysis and carotid endarterectomy in selected patients with acute thrombotic carotid occlusion

Purpose: The feasibility and clinical outcome of intra-arterial thrombolysis followed by carotid endarterectomy (CEA) for acute thrombotic occlusion of the internal carotid artery (ICA) were evaluated. Methods: Intra-arterial thrombolysis and CEA were performed in four patients with acute thrombotic ICA occlusion. Computed tomography scans, cerebral angiograms, and the severity of carotid plaques were examined, and the patients' clinical outcome was evaluated. Results: All 4 patients had severe hemiparesis; 3 patients were alert, and 1 patient was lethargic at the time of hospital admission. New lesions were not shown by means of the initial computed tomography scan. ICA occlusion was indicated in all four patients by means of cerebral angiograms; in three patients, middle cerebral artery occlusion was noted. Collateral circulation was manifested in all patients. Partial recanalization of the occluded ICA was obtained in all patients. Two patients with severe residual ICA stenosis underwent an emergency CEA soon after thrombolysis; the other two patients were treated by means of CEA in the subacute or chromic stage. Plaque rupture and intraplaque hemorrhage were seen in all four patients. All four patients recovered completely, and restenosis of the ICA was not shown by means of follow-up angiograms. Conclusion: Intra-arterial thrombolysis followed by CEA may be an effective therapeutic approach for treating acute thrombotic ICA occlusion. The optimal timing of CEA remains controversial. (J Vasc Surg 2001;34:532-40.)

Emergency Carotid Endarterectomy

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.

Profound deficitを呈した急性期頸部内頸動脈閉塞に対する血栓内膜剥離術

Emergency carotid endarterectomy (CEA) was performed in 10 patients with proximal internal carotid artery occlusion associated with profound neurological deficits. All patients visited our clinic within 5 hours from the onset, and flow of the IC was restored 4.9 hours after the onset on average. Of the 10 patients, the outcome was excellent in 3, good in 4, severe disability in 2, and 1 died. For these patients, prevention of distal embolism after CEA is most important.According to the intraoperative findings, namely, whether or not back-flow from the distal IC was demonstrated by arteriotomy of the IC distal to the occlusion, and whether or not clotting existed in the distal IC, the 10 patients were divided into 3 groups.Group A (3 cases): Back-flow from the distal IC was demonstrated and clotting of the distal IC was not demonstrated.Group B (2 cases): Both back-flow from the distal IC and clotting of the distal IC were demonstrated.Group C (5 cases): Back-flow from the distal IC was not demonstrated because of packed clotting in the distal IC.In group A, restoration of the flow will be established without distal embolism by not only CEA but also fibrinolysis followed by percutaneous transluminal angioplasty (PTA). For group B and group C, clotting of the distal IC shoud be removed by forceps or aspiration through the distal tube of the internal shunt during CEA to prevent the distal embolism. At present, it is best to use CEA for patients with proximal IC occlusion to prevent the distal embolism, because it is impossible to know whether or not clotting exsists in the distal IC.

American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Etiology of stroke.

The diagnosis of arterial stroke differentiates ischemia from hemorrhage. The former may be due to arterial occlusion or stenosis, the latter to leakage or rupture of an artery. Computed tomography (CT) and magnetic resonance imaging (MRI) have shown that this basic differentiation cannot be reliably made from the history and clinical examination alone. Of the clinical stroke syndromes, only Wallenberg’s syndrome has not been reported to be due to hemorrhage. When CT or MRI is not available for diagnosis, spinal tap is reliably positive only when the aneurysm or arteriovenous malformation has ruptured into the subarachnoid space; the results are often normal when a small hemorrhage occurs in the parenchyma. For some therapies, notably neuroprotective agents, the potential benefits for ischemia do not seem to be offset by potential harm in the case of hemorrhage. However, because fibrinolytics, antithrombotic agents, or surgery are treatment options, diagnostic certainty is essential to avoid harming the patient. Most—but not all—strokes have a sudden or rapidly evolving onset. Differential diagnosis of sudden change in focal neurological status includes seizures or postepileptic paralysis, hemorrhage into a tumor (itself a form of stroke), and migraine. Neuroimaging helps to differentiate between these and the cause of short-lived symptoms (transient ischemic attack [TIA]) usually presumed due to ischemia but possibly due to new-onset infarction or hemorrhage. More precise classification of stroke into a pathogenic subtype (embolism, thrombosis, decreased perfusion or “lacunar” infarction, leakage, or rupture) evades the best clinical skills. The classification of stroke mechanism depends on the presence of risk factors for stroke (preexisting condition or circumstance epidemiologically related to stroke) and etiologies (disease directly causing the mechanism) that implicate the cause of stroke in a given patient. However, more than one risk factor and etiology are frequently present in the same patient and may be related …

Acute pathologic features with angiographic correlates of the nearly or completely occuluded lesions of the cervical internal carotid artery

The true pathologic process of nearly or completely occluded lesions of the cervical internal carotid artery (ICA) has not been studied sufficiently. This information is important in determining the critical indications for endarterectomy. Acute pathologic features of these advanced occlusive lesions of the ICA were studied in 40 patients who underwent emergency carotid endarterectomy. Gross morphologic and histopathologic features of these occlusive lesions were examined, and the relationship between the clinical information and the pathologic characteristics was investigated. Thirty-seven lesions had histologic features of advanced atherosclerosis complicated by fresh intraplaque hemorrhages with or without transintimal extension. Thinwalled neovessels were thought to be an important etiologic factor in producing intraplaque hemorrhage. The remaining three lesions without these changes had strangulated embolic material at the occluded portion. A good correlation between these pathologic features and angiographic findings was found. The presented results clearly indicate that intraplaque hemorrhage is the most important factor in producing and determining the acute pathologic features of symptomatic and advanced atheromatous occlusive ICA lesions.

Handbook of interventional radiologic procedures

Microsurgical carotid endarterectomy Julian Bailes and Robert Spetzler, Philadelphia, 1996, Lippincott-Raven, 220 pages, $150. This text of 200 pages contains 10 chapters by the senior editors, neurologic surgeons at Allegheny General Hospital (Pittsburgh) and the Barrow Neurologic Institute (Phoenix), as well as 15 other authors who are neurosurgeons, neuroanesthesiologists, neurologists, and neuroradiologists. Introductory chapters include overviews on the epidemiology and natural history of carotid stenosis, preoperative risk assessment, and patient selection for carotid endarterectomy. The next chapter reviews carotid angiography, magnetic resonance, and magnetic resonance arteriography, followed by chapters describing the anesthetic management during carotid endarterectomy and the operative technique itself, which is beautifully illustrated. The final chapters in the text discuss the postoperative medical management of the carotid endarterectomy patient and the unique management of total occlusion. As stated by the authors, the purpose of this text was to “collect the entire spectrum of care associated with microsurgical carotid endarterectomy into one reference volume.” Most of the chapters in the text are competent review and overview sections, but do not add new information to previously published texts on the management of the patient with cerebrovascular disease. Indeed, the significance of the 36-page chapter on “Rationale and Protocol for Microsurgical Carotid Endarterectomy” escapes this reviewer. The operative instructions offered are those that have been well described for decades, except the arteriotomy closure is performed with an operating microscope in lieu of loop magnification. The section, however, on perioperative complications including postoperative thrombosis, intracerebral hemorrhage, and controversies in carotid endarterectomy (ie, carotid patch angioplasty, intraoperative shunting) is quite good. The chapter discussing intraoperative transcranial Doppler (TCD) is well written and well-illustrated. The illustrative case examples of “competent vs incompetent collateral reserves,” microembolization, and carotid thrombosis were helpful in understanding TCD as an adjunct for cerebral surveillance during operation. The most intriguing chapter in the text was on management of total carotid occlusion. The authors reviewed and documented the natural history and operative results of internal carotid artery occlusion and report their results in 42 patients who underwent “emergency carotid endarterectomy for appropriate symptoms.” The authors opened 24 arteries with thromboembolectomy, performed internal carotid “stumpectomy” with external carotid ligation in nine, and stumpectomy with external carotid endarterectomy and EC-IC bypass in four. The long-term follow-up results demonstrate an 88% patency rate by color-flow ultrasonography in patients who initially were thrombectomized. The authors conclude that the natural history of carotid occlusion has been ill defined, and the authors believe they have improved their ability to reopen occluded arteries. An algorithm is presented as a management guideline. In general, this text is beautifully illustrated, well documented, and well written. It does not, however, offer much new about carotid endarterectomy, but would serve as an appropriate reference text. The receipt of the books listed below is acknowledged. This listing is regarded as appropriate return for the courtesy of the sender. The books that are of particular interest will be reviewed and the review published as space permits. Arterial aneurysms: Diagnosis and management Michael Horrocks, Oxford, Mass., 1995, Butterworth-Heinemann, 246 pages, $110. Noninvasive electrocardiology: Clinical aspects of Holter monitoring Arthur Moss and Shlomo Stern, Philadelphia, 1996, W.B. Saunders, 541 pages, $59. Computer analysis of cardiovascular signals M. DiRenzio, G. Marcia, G. Parati, H. Pedotti, A. Zanchetti, Amsterdam, 1995, IOS Press, 315 pages. Surgical treatment of aortic dissection Hams Borst, Markus Heinemann, and Christopher Stone, New York, 1996, Churchill Livingstone, 357 pages, $119.95. Venous disorders: A manual of diagnosis and treatment G. Belcaro, A.N. Nicolaides, and M. Veller, Philadelphia, 1995, W.B. Saunders, 204 pages, $35. Handbook of venous disorders: Guidelines of the American Venous Forum Peter Gloviczki and James S. T. Yao, London, 1996, Chapman & Hall Medical, 686 pages. Renal vascular disease Andrew Novick, John Sobule, and George Hamilton, Philadelphia, 1996, W.B. Saunders, 550 pages, $97. Atlas of cardiovascular pathology Renu Virmani, Allen Burke, and Andrew Farb, Philadelphia, 1996, W.B. Saunders, 234 pages, $169. Handbook of interventional radiologic procedures Krishna Kandarpa and John Aruny, Boston, 1996, Little, Brown and Company, 508 pages, $37.95.

Carotid endarterectomy and local intraarterial thrombolysis: Simultaneous procedure in acute occlusion of the internal carotid artery and middle cerebral artery embolism

Patients with severe neurologic deficits caused by acute occlusion of the internal carotid artery represent a prognostically unfavorable group with a persistent neurologic deficit of 40% to 69% and a mortality rate of 16% to 55%.1Meyer FB Sundt Jr, TM Piepgras DG Sandok BA Forbes G. Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits.Ann Surg. 1986; 203: 82-89Crossref PubMed Scopus (199) Google Scholar We report a case of a 66-year-old man with symptomatic stenosis of the left internal carotid artery (> 90%). Two weeks before he was admitted, he had two left hemispheric transient ischemic attacks with right arm and facial weakness. At the first neurologic examination a 90% stenosis of the internal carotid artery was diagnosed by Doppler study and magnetic resonance angiography. The computed tomography scan of the brain revealed small lacunar infarctions but no fresh cortical ischemia. Carotid endarterectomy of the symptomatic carotid artery stenosis was recommended, but the patient refused any treatment until a third episode of brachiofacial weakness occurred. After he was admitted to the Department of Vascular Surgery, the patient had a severe left hemispheric stroke even though he was given therapeutic levels of heparin (25,000 IU intravenously daily), with complete hemiplegia of the right side, global aphasia, and progressing lack of consciousness. Acute carotid artery occlusion was diagnosed (Doppler study, loss of bruit), and emergency operation by carotid endarterectomy was performed. Intraoperative needle-angiography after eversion endarterectomy revealed partial occlusion of the middle cerebral artery ( Fig. 1 ). We performed additional intraoperative lysis-therapy via the reconstructed internal carotid artery (500,000 IU urokinase). Three hours after operation the patient's hemiplegia and aphasia diminished step-by-step, and after 24 hours the patient recovered almost completely from his neurologic deficits. A selective carotid angiogram obtained 3 days later showed evidence of a normal intracerebral vascular architecture with no residual thromboembolism ( Fig. 2 ). Fig. 2Selective angiography of left carotid artery 3 days after eversion endarterectomy: extracranial part of internal carotid artery (A), intracerebral internal carotid artery with patent middle cerebral artery (B,C).View Large Image Figure ViewerDownload (PPT)Fig. 2Selective angiography of left carotid artery 3 days after eversion endarterectomy: extracranial part of internal carotid artery (A), intracerebral internal carotid artery with patent middle cerebral artery (B,C).View Large Image Figure ViewerDownload (PPT)Fig. 2Selective angiography of left carotid artery 3 days after eversion endarterectomy: extracranial part of internal carotid artery (A), intracerebral internal carotid artery with patent middle cerebral artery (B,C).View Large Image Figure ViewerDownload (PPT)At discharge from the hospital, the patient was free of complaint. A last neurologic examination indicated only a slight weakness of a facial branch and signs of dysdiadochokinesia of the right arm. Although several series of emergency carotid endarterectomies with sometimes dramatic recovery have been presented, acute stroke is generally considered as a contraindication to carotid endarterectomy, with rare exceptions in individual cases.2Gertler JP Blankensteijn JD Brewster DC et al.Carotid endarterectomy for unstable and compelling neurologic conditions: Do results justify an aggressive approach.J VASC SURG. 1994; 19: 32-42Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 3Moore WS Mohr JP Najafi H Robertson JT Stoney RJ Toole JF. Carotid endarterectomy: practice guidelines—report of the Ad Hoc Committee to the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.J VASC SURG. 1992; 15: 469-479Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar The reasons for this include neurologic instability and fear of clinical deterioration by secondary hemorrhage in the infarcted area. It has been demonstrated that acute cerebrovascular arterial occlusion could be treated successfully by local intraarterial and systemic lysis-therapy.4Del Zoppo GJ Pessin MS Mori E Hacke W. Thrombolytic interventions in acute thrombotic and embolic stroke.Semin Neurol. 1991; 11: 368-384Crossref PubMed Scopus (85) Google Scholar, 5Higashida RT Van Halbach V Barnwell SL Dowd CF Hieshima GB. Thrombolytic therapy in acute stroke.J Endovasc Surg. 1994; 1: 4-15Crossref PubMed Scopus (35) Google Scholar Failure of lysis-therapy of an acute carotid artery occlusion can occur in patients with a preexisting high-grade stenosis. Also thrombolysis is not able to treat atherosclerotic carotid artery stenosis sufficiently from a surgical point of view because a high-grade carotid artery stenosis remains, causing the risk of ongoing embolism. Therefore simultaneous carotid endarterectomy and intraoperative lysis-therapy may be a therapeutic alternative in the treatment of acute ischemic stroke by carotid artery occlusion and middle cerebral artery thromboembolism. This is the first case of a simultaneous emergency carotid endarterectomy and intraoperative thrombolysis in the treatment of acute carotid artery occlusion and middle cerebral artery embolism in the literature. This procedure should be taken into consideration in the treatment of acute stroke in patients with a preexisting high-grade carotid artery stenosis.

頸部内頸動脈高度狭窄によるprogressing stroke に対してemergency carotid endarterectomyを行った8例

We report 8 patients with progressing stroke who underwent emergency carotid endarterectomy (CEA) successfully.There were 7 males and 1 female, with a mean age of 66 years (range 62 to 74 years). The time from the onset of neurological deficit to the CEA ranged from 2 to 36 hours.Preoperative clinical status included 4 patients with severe deficit, 3 with moderate deficit and 1 with mild deficit according to Walters' grading of 5 categories (intact, mild deficit, moderate deficit, severe deficit, death). Carotid bruit was heard in only 2 patients.Angiographic findings revealed that all patients had severe stenosis (>93%) of the cervical internal carotid artery (ICA) with delay in flow (one of whom had a residual stenosis after recanalization of ICA-occlusion treated with intra-arterial infusion of urokinase), 5 with occlusion of the intracranial arteries caused by artery-to-artery embolism, 4 with cross-filling from the contralateral carotid artery through the anterior communicating artery and 1 with an intraluminal filling defect of carotid artery due to a floating thrombus.On the preoperative CT scanning, none of 4 patients admitted within 5 hours of onset had fresh lesions and all of 4 patients admitted after 5 hours of the onset had small fresh infarction, none of which were enhanced after the administration of contrast material.The postoperative course was excellent in all patients, and the postoperative CT scan did not demonstrate any new lesions in 7 patients but disclosed an asymptomatic small watershed infarction in 1 patient.We discuss indications for emergency carotid endarterectomy for progressing stroke.

虚血発作後早期 (7日以内) に行った頸動脈内膜剥離術の経験 : 特に emergency carotid endarterectomy の適応について

虚血発作後早期 (7日以内) に行った頸動脈内膜剥離術の経験 : 特に emergency carotid endarterectomy の適応について

Emergency carotid endarterectomy.

A retrospective review of carotid endarterectomies performed by the Neurosurgical Service at Massachusetts General Hospital from July, 1976, through December, 1985, disclosed 64 procedures that were performed on an emergency basis. The patients included 40 men and 24 women, with a mean age of 64 years (range 32 to 87 years). Correlation of angiographic findings with outcome revealed that of the 27 patients with severe stenosis, usually with delay in blood flow, 25 (93%) were the same or improved postoperatively; of the 11 patients with stenosis and an intraluminal filling defect (six of whom had an intraluminal clot), eight (73%) were the same or improved after surgery; of the 16 patients with complete occlusion, 14 (88%) were the same or improved (backflow was established in all cases); and of the 10 patients with moderate to severe stenosis and/or severe ulceration (including three with transient ischemic attacks who were receiving heparin), eight (80%) were the same or improved. Pre- and postoperative clinical status were graded into five categories: intact; mild deficit; moderate deficit (significant impairment but able to perform activities of daily living); severe deficit (requiring assistance for daily activities); and death. Of the 36 patients who preoperatively were intact or had mild deficits, 33 (92%) were the same or improved postoperatively, three were worse, and there were no deaths. Among 15 patients presenting with moderate deficits, 12 (80%) were the same or improved, two were worse, and one died. Of the 13 patients with severe deficits, 10 (77%) were the same or improved and three died. Two patients with sudden severe deficits associated with loss of contralateral bruit were operated on without angiography and were intact postoperatively. Of the four deaths in the total series, two were attributed to cardiac causes and two to unrelated disease processes. The indications for emergency carotid endarterectomy are discussed.

Current status of carotid endarterectomy for atheromatous disease.

The authors discuss the indications for both elective and emergency carotid endarterectomy. Reports on the surgical treatment of asymptomatic bruit and contralateral carotid stenosis are reviewed. The results of endarterectomy for symptomatic carotid disease, including transient ischemic attacks, acute neurological deficit, and complete carotid occlusion, are discussed. The complications and risks of carotid surgery are also presented.