title: Intravenous tissue-type plasminogen activator therapy is an independent risk factor for symptomatic intracerebral hemorrhage after carotid endarterectomy.
abstract: BACKGROUND
  Carotid endarterectomy (CEA) for symptomatic carotid artery stenosis and intravenous tissue-type plasminogen activator (IV-tPA) for acute ischemic stroke are proven therapies; however, the safety of CEA in stroke patients who recently received IV-tPA has not been established.
  
  
  OBJECTIVE
  To evaluate the safety of CEA in stroke patients who recently received IV-tPA.
  
  
  METHODS
  A retrospective review of patients who underwent CEA for symptomatic carotid artery stenosis was performed. The primary end point was postoperative symptomatic intracerebral hemorrhage (sICH). A univariate analysis of potential risk factors for sICH, including IV-tPA therapy, timing of CEA, degree of stenosis, and stroke severity, was performed. Factors with a value of P < .1 on univariate analysis were tested further.
  
  
  RESULTS
  Among 142 patients, 3 suffered sICH after CEA: 2 of 11 patients treated with IV-tPA (18.2%) and 1 of 131 patients not treated with IV-tPA (0.8%). Both IV-tPA patients suffering sICH underwent CEA within 3 days of tPA administration. On univariate analysis, IV-tPA (P = .02), female sex (P = .09), shorter time between ischemic event and CEA (P = .06), and lower mean arterial pressure during the first 48 hours of admission (P = .08) were identified as risk factors for sICH. On multivariate analysis, IV-tPA was the only significant risk factor (P = .002 by stepwise logistic regression; P = .03 by nominal logistic regression).
  
  
  CONCLUSIONS
  This study indicates that IV-tPA is an independent risk factor for sICH after CEA. This suggests that CEA should be pursued cautiously in patients who recently received IV-tPA. Early surgery may be associated with an increased risk for sICH.
  
  
  BACKGROUND
  CEA, carotid endarterectomyIV-tPA, intravenous recombinant tissue-type plasminogen activatorMAP, mean arterial pressureNASCET, North American Symptomatic Carotid Endarterectomy TrialNIHSS, National Institutes of Health Stroke ScaleNINDS, National Institute of Neurological Disorders and StrokesICH, symptomatic intracerebral hemorrhageTIA, transient ischemic attack.
authors: *Department of Neurological Surgery, ‡Mallinckrodt Institute of Radiology, and §Department of Neurology, Washington University School of Medicine, St. Louis, Missouri; ‖Department of Neurosurgery, University of Florida, Gainesville, Florida.
authors: Ananth K
authors: AK
authors: Vellimana
authors: Chester K
authors: CK
authors: Yarbrough
authors: Spiros
authors: S
authors: Blackburn
authors: Russell G
authors: RG
authors: Strom
authors: Thomas K
authors: TK
authors: Pilgram
authors: Jin-Moo
authors: JM
authors: Lee
authors: Robert L
authors: RL
authors: Grubb
authors: Keith M
authors: KM
authors: Rich
authors: Michael R
authors: MR
authors: Chicoine
authors: Ralph G
authors: RG
authors: Dacey
authors: Colin P
authors: CP
authors: Derdeyn
authors: Gregory J
authors: GJ
authors: Zipfel
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D001794:Blood Pressure / Q000187:drug effects; D016893:Carotid Stenosis / Q000601:surgery; D002543:Cerebral Hemorrhage / Q000188:drug therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator