title: Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients.
abstract: OBJECTIVE
  This study documented with independent neurologic assessment the 30-day and 90-day outcomes in selected patients with severe internal carotid artery (ICA) stenosis who underwent carotid endarterectomy (CEA) in the acute phase of stroke-in-evolution (SIE).
  
  
  METHODS
  From January 2003 to December 2010, data from patients who had surgery ≤2 weeks of an SIE with high-grade carotid stenosis were extracted from two prospectively collected databases. Clinical assessment was by the vascular neurologist using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale score. All patients had computed tomography or magnetic resonance brain imaging ≤3 hours of stroke onset. Those eligible received thrombolysis. Duplex ultrasound imaging was initially used for the diagnosis of severe (≥60%) ICA stenosis, and further assessment was by magnetic resonance or computed tomography angiography, or both. Perioperative medical treatment and operative techniques were standardized. Stroke, death, major cardiac events, and functional outcome were analyzed.
  
  
  RESULTS
  Twenty-seven patients underwent carotid revascularization in the acute phase of SIE. Fluctuating or progressive neurologic deficit was the presenting pattern in 20 patients and occurred after otherwise successful thrombolytic therapy in the remaining 7 (26%). Median NIHSS score at admission was 8. Median delay to surgery from the index event was 6 days. The mean degree of ICA stenosis was 87%. All patients received antiplatelet and statin therapy during the intervening period. Procedures were conventional CEA with patch angioplasty (polytetrafluoroethylene) in 26 patients (96.3%) and redo interposition bypass grafting in 1 patient. CEA was done under local anesthesia in 23 patients (85.2%), with selective shunting in 3 (13.0%), and under general anesthesia, with systematic shunting in 4. At discharge and at 1 and 3 months, no recurrent stroke or death, and one nonfatal myocardial infarction occurred in this series, with a 100% complete follow-up. At 3 months, all patients had a favorable functional outcome defined as a modified Rankin Scale score of ≤2.
  
  
  CONCLUSIONS
  This short series demonstrates that CEA in the acute phase of SIE with strict selection criteria and close blood pressure monitoring is safe, even after recent thrombolytic therapy, and is effective in functional outcome at 3 months. Larger series of patients are required to confirm the safety and efficacy of this management.
authors: Department of Vascular and Thoracic Surgery, Bichat-Claude Bernard University Hospital, Denis Diderot University and Medical School Paris VII, Assistance Publique-Hopitaux de Paris, Paris, France. guy.leseche@bch.aphp
authors: Guy
authors: G
authors: Leseche
authors: Jean-Marc
authors: JM
authors: Alsac
authors: Rabih
authors: R
authors: Houbbalah
authors: Yves
authors: Y
authors: Castier
authors: Francis
authors: F
authors: Fady
authors: Mikael
authors: M
authors: Mazighi
authors: Pierre
authors: P
authors: Amarenco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D002343:Carotid Artery, Internal / Q000503:physiopathology / Q000601:surgery*; D016893:Carotid Stenosis / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D019992:Databases as Topic; D004185:Disability Evaluation; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D010297:Paris; D018579:Patient Selection; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology* / Q000503:physiopathology; D015912:Thrombolytic Therapy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors