title: Safety of carotid intervention following thrombolysis in acute ischaemic stroke.
abstract: OBJECTIVE
  Thrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  MEDLINE and EMBASE were searched on 29 May 2014. Inclusion criteria were (i) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (ii) carotid intervention within 14 days of thrombolysis; and (iii) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman-Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CIs) were generated and heterogeneity was assessed. The strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system.
  
  
  RESULTS
  Nine included publications recorded 114 carotid endarterectomy (CEA) and four angioplasty interventions. The point estimate of 30-day stroke or death for CEA was 4.93% (95% CI 1.83-9.44), representing four of 114. The strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4).
  
  
  CONCLUSIONS
  Early CEA post-thrombolysis appears safe, with stroke or death rates similar to that of the operation without thrombolysis. However, the wide CI obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis.
authors.affiliation: Academic Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. Electronic address: rishimandavia@gmail.com.
authors.forename: R
authors.initials: R
authors.lastname: Mandavia
authors.affiliation: Academic Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
authors.forename: M I
authors.initials: MI
authors.lastname: Qureshi
authors.affiliation: Academic Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
authors.forename: B
authors.initials: B
authors.lastname: Dharmarajah
authors.affiliation: Academic Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
authors.forename: K
authors.initials: K
authors.lastname: Head
authors.affiliation: Academic Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
authors.forename: A H
authors.initials: AH
authors.lastname: Davies
mesh_terms: D002545:Brain Ischemia / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000601:surgery; D016893:Carotid Stenosis / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D006801:Humans; D020521:Stroke / Q000601:surgery*; D015912:Thrombolytic Therapy / Q000009:adverse effects*
keywords: Angioplasty; Carotid arteries; Endarterectomy; Safety; Stroke; Thrombolysis