title: Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke.
abstract: OBJECTIVE
  Carotid intervention shortly after an acute neurologic ischemic event is being performed more frequently in stroke centers to reduce the risk of recurrent stroke. Thrombolysis with recombinant tissue plasminogen activator (tPA) is offered to select patients with ischemic stroke symptoms who present within 4.5 hours. However, there is a paucity of data as to whether tPA followed by urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS) has an increased risk of complications, particularly intracerebral hemorrhage (ICH). We sought to determine the periprocedural complications of urgently performed CEA or CAS following tPA.
  
  
  METHODS
  From January 2009 to January 2015, 762 patients underwent carotid interventions (CEA, n = 440; CAS, n = 322) at a tertiary referral center and 165 patients (21.6%) underwent an urgent CEA or CAS during the index hospitalization for an acute transient ischemic attack or stroke. We compared the effect of intravenous tPA on 30-day complications, including ICH. The χ(2) and Fisher exact tests were used to determine significance between groups.
  
  
  RESULTS
  During the 6-year period, 165 patients underwent urgent carotid interventions (CEA, n = 135; CAS, n = 30) for acute neurologic symptoms. Of these, 19% (31 patients [CEA, n = 25; CAS, n = 6]) had tPA for an acute stroke; the remaining (134 patients [CEA, n = 110; CAS, n = 24]) fell outside of the tPA time window. Most strokes were minor or moderate with a mean National Institutes of Health Stroke Scale (NIHSS) score of 6.6 (range, 0-19). The mean time to intervention for both groups was 2.4 days (0-15 days). The 30-day stroke, death, and myocardial infarction rates were 9.7% (3 of 31) for the tPA group compared with 4.5% (6 of 134) for the no-tPA group (P = .37). Including bleeding complications in these 30-day outcomes, there was no difference between the tPA (3 of 31) and the no-tPA cohorts (8 of 134; P = .43). In the tPA group, there were one ICH, one neck hematoma/death, and an additional death; in the no-tPA group, there were one ICH, two neck hematomas, one stroke, two myocardial infarctions, one ICH/death, and one additional death. No significant increased rates of bleeding were noted within the tPA group (2 of 31) compared with the no-tPA group (4 of 134; P = .32). Moreover, in the tPA cohort, more than half of the patients (17 of 31) underwent revascularization within 72 hours (CEA = 13; CAS = 4) with outcomes similar to those who underwent revascularization after 72 hours.
  
  
  CONCLUSIONS
  Thrombolysis followed by urgent CEA or CAS is not associated with an increased risk of complications in select patients who present with acute neurologic symptoms. Selection of patients is important; there was no ICH and only one death in each group for patients with minor to moderate ischemic stroke (NIHSS score <10).
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La. Electronic address: hbazan@ochsner.org.
authors.forename: Hernan A
authors.initials: HA
authors.lastname: Bazan
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Zea
authors.affiliation: Stroke/Vascular Neurology, Department of Neurology, Ochsner Clinic, New Orleans, La.
authors.forename: Bethany
authors.initials: B
authors.lastname: Jennings
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La.
authors.forename: Taylor A
authors.initials: TA
authors.lastname: Smith
authors.affiliation: Stroke/Vascular Neurology, Department of Neurology, Ochsner Clinic, New Orleans, La.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Vidal
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, La.
authors.forename: W Charles
authors.initials: WC
authors.lastname: Sternbergh
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia; D004632:Emergency Medical Services; D016894:Endarterectomy, Carotid; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D015607:Stents; D015912:Thrombolytic Therapy / Q000009:adverse effects; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator