title: Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery.
abstract: OBJECTIVE
  Tissue plasminogen activator (tPA) has been shown to be effective for acute ischemic stroke. However, if a high-grade cervical carotid stenosis remains despite tPA therapy, patients are at risk for recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in symptomatic patients with high-grade cervical carotid stenosis in reducing the risk of stroke, but it is unknown whether CEA can be performed safely after tPA thrombolysis. We describe our experience with 5 patients who underwent early (<48 hours) CEA for residual high-grade cervical carotid stenosis after thrombolytic therapy for acute ischemic stroke in the middle cerebral artery territory.
  
  
  METHODS
  All patients had a critical (>99%) carotid artery stenosis on the symptomatic side after tPA therapy. All patients received intravenous tPA; 3 patients also received intra-aortic tPA. Three patients received intravenous heparin infusion immediately after administration of tPA. All patients showed marked improvement in their National Institutes for Health Stroke Scale scores after treatment with tPA. CEA was then performed within 45 hours (6 hours in 1 patient, 23 hours in 2, 26 hours in 1, and 45 hours in 1).
  
  
  RESULTS
  All 5 patients underwent successful CEA. There were no complications related to surgery. At discharge, 2 patients had a normal examination, and the remaining patients had mild deficits. In a long-term follow-up of 5 to 22 months, no patient had a recurrent cerebrovascular event.
  
  
  CONCLUSIONS
  Early CEA can be performed safely and successfully in patients after tPA treatment for acute ischemic stroke in appropriately selected patients.
authors.affiliation: Neuroscience Institute, University of Cincinnati, Department of Neurosurgery, Cincinnati, Ohio, USA.
authors.forename: C M
authors.initials: CM
authors.lastname: McPherson
authors.forename: D
authors.initials: D
authors.lastname: Woo
authors.forename: P L
authors.initials: PL
authors.lastname: Cohen
authors.forename: A M
authors.initials: AM
authors.lastname: Pancioli
authors.forename: B M
authors.initials: BM
authors.lastname: Kissela
authors.forename: J A
authors.initials: JA
authors.lastname: Carrozzella
authors.forename: T A
authors.initials: TA
authors.lastname: Tomsick
authors.forename: M
authors.initials: M
authors.lastname: Zuccarello
mesh_terms: D000208:Acute Disease; D000368:Aged; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy*; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000150:complications / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator