Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke.
After intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS), a severe cervical internal carotid artery (ICA) stenosis may remain and increase the risk of recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in reducing the risk of stroke. However, it is not well known whether CEA can be performed safely after thrombolysis, and, if so, when. We report a prospective study of CEA for residual high-grade cervical ICA stenosis performed within 15 days after IVT for AIS.


METHODS
All the patients had a brain magnetic resonance imaging (MRI) within 3h of the stroke onset. One day after IVT in neurovascular unit, computed tomography (CT) angiography was performed to assess the brain and the patency of cervical arteries. CEA was performed on neurologically stable patients after full cerebral artery re-canalisation. Blood pressure was controlled with particular caution before and after CEA.


RESULTS
Between January 2005 and January 2008, we operated consecutively on 12 patients. Their median National Institutes of Health Stroke Scale (NIHSS) score was 12 (range: 5-21). Combined intracranial (ICA)-middle cerebral artery (MCA) occlusion was present in 58.3% of the patients. The median time between onset of symptoms until CEA was 8 days (range: 1-16 days). Stroke and death rate at 30 days was 8.3% (one nonfatal haemorrhagic stroke). At 90 days, nine patients had a Rankin score of 0-1, one had a score of 2 and two had a score of 3.


CONCLUSIONS
In patients with residual cervical ICA stenosis after IVT, we achieved full patency of the occluded artery and good functional prognosis at 3 months in all cases. We advocate for an extremely close monitoring of the blood pressure in the pre-, peri- and post-operative course and a close collaboration between neurologist and surgeon to determine the best timing for CEA.
Bartoli
M A
MA
Faculté de Médecine de Marseille, Université de la Méditerranée, Assistance Publique Hôpitaux de Marseille, Hôpital de la Timone, Service de Chirurgie Vasculaire, 13005 Marseille, France.
Squarcioni
C
C
Nicoli
F
F
Magnan
P-E
PE
Malikov
S
S
Berger
L
L
Lerussi
G B
GB
Branchereau
A
A
D000368:Aged; D020520:Brain Infarction / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D002343:Carotid Artery, Internal; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005500:Follow-Up Studies; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007275:Injections, Intravenous; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015912:Thrombolytic Therapy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D006493:Heparin