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International Angiology 2003 December;22(4):426-30


language: English

Emergency and early carotid endarterectomy in patients with acute ischemic stroke selected with a predefined protocol. A prospective pilot study

Sbarigia E. 1, Toni D. 2, Speziale F. 1, Falcou A. 2, Sacchetti M. L. 2, Panico M. A. 1, Fiorelli M. 2, Argentino C. 2, Ducasse E. 1, Fiorani P. 1

1 Vascular Surgery Section, “La Sapienza” University, Rome, Italy 2 Neurologic Intensive Care Unit, Department of Neurological Sciences, “La Sapienza” University, Rome, Italy


Aim. The appro­pri­ate­ness of early carot­id endar­te­rec­to­my (CEA) in ­patients with acute ischem­ic ­stroke is still unset­tled. The aim of this study was to ver­i­fy the safe­ty and fea­sibil­ity of early CEA in a con­sec­u­tive ­series of ­patients with acute ischem­ic ­stroke ­observed in an emer­gen­cy Depart­ment ­Stroke Unit.
Meth­ods. Dur­ing a 24-month study, out of 756 ­patients with acute ischem­ic ­stroke 33 (4.4%) were sched­uled for early CEA. Endar­te­rec­to­my pro­ce­dures were dis­tin­guished accord­ing to the time ­between the onset of ­stroke and oper­a­tion as emer­gen­cy (with­in 8 hours), early CEA (1-18 days). ­Patients with ­impaired con­scious­ness or an ­infarct larg­er than 2.5 cm on com­put­ed tom­o­graph­ic (CT) or mag­net­ic res­o­nance (MR) scans or both were exclud­ed from sur­gery. All ­patients under­went spi­ral CT, echo-color-Dop­pler (ECD) sonog­ra­phy, trans­cra­ni­al Dop­pler (TCD) sonog­ra­phy and, when nec­es­sary, MR angio­gra­phy with­in 6 hours of admis­sion. No ­patient under­went con­ven­tion­al angio­gra­phy. Most ­patients were oper­at­ed on under cer­vi­cal block (CB) anes­the­sia; gen­er­al anes­the­sia (GA) was used only for those with an ­unstable neu­ro­log­i­cal def­i­cit. Selec­tive shunt­ing was used on the basis of intra-oper­a­tive trans­cra­ni­al Dop­pler in ­patients under GA and the onset or wors­en­ing of neu­ro­log­i­cal def­i­cit under CB anes­the­sia.
­Results. Of the 6 ­patients oper­at­ed on with­in a ­median 6 hours after the onset of ­stroke, 1 (16.5%) had a fatal hemor­rhag­ic trans­for­ma­tion of the ­infarct, while the remain­ing 5 (83.5%) ­stopped fluc­tu­at­ing or pro­gress­ing and had a favour­able neu­ro­log­i­cal out­come. Of the 16 ­patients oper­at­ed on with­in a ­median 36 hours and of the 11 ­patients oper­at­ed on with­in 7 days, none dete­ri­orat­ed after oper­a­tion.
Con­clu­sion. Emer­gen­cy CEA is fea­sible for acute ischaem­ic ­stroke pro­vid­ed that ­strict selec­tion cri­te­ria are ­applied and the door-to-sur­gery inter­val is kept short (with­in 8 hours). Early CEA for sec­on­dary pre­ven­tion is fea­sible and safe, con­firm­ing that a ­delayed oper­a­tion is in most cases unwar­rant­ed. Large ran­dom­ized ­trials are war­rant­ed ­before imple­ment­ing emer­gent and early CEA in rou­tine clin­i­cal prac­tice.

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