Perioperative Stroke after Carotid Endarterectomy FAHC Vascular Surgery Case Study2006Daniel J Bertges, MD

Case History70 male h/o TIA presenting as L arm greater than leg paralysis lasting 12 hours, one week ago

PMH: HTN, hypercholesterolemia, CAD s/p MI and CABG 2 years agoMeds: ASA 81 mg QD, atenolol, lipitorSH: former 50 pk yr tobaccoROS: no visual, speech or sensory changes

PE: HR 63, BP 140/80RRR without murmur, CTAbilateral carotid bruitsnormal peripheral pulsesnormal neurological exam

Case HistoryLabs normalEKG: NSR with old anterior wall MI

Carotid Duplex:severe 80-99 % L ICA stenosis mild 1-50 % R ICA stenosis patent, antegrade vertebrals bilateral

CEAElective R CEA performed under GA with uncomplicated routine shunting

Conventional endarterectomy with dacron patch angioplasty

Systemic heparinization without protamine reversal

No completion study

Neurological exam after extubation grossly normal

Neuro deficit in the recovery roomOne hour later you are called to the RR Patient is unable to move L armPE: HR 90, BP 150/85Neck without hematomaNeuro exam: slight L facial droopL arm flaccid, 0/5 motor Remainder of extremities within normal

What would you do ?What are the possible etiologies ?What are your treatment options ?Should you return to OR ?What is your operative plan ?Should you obtain an angiogram ?What could have been done to potentially minimize risk of stroke ?Did the patient receive enough aspirin ?Should you reverse heparin with protamine after CEA ?

Emergent ultrasound(done in RR or OR whichever is quicker) Duplex: intimal flap at distal endpoint of R ICA

ReoperationNeck explored and carotid reopened

Acute thrombus in ICA

Carefully pull thrombus outGood back bleeding from ICA

If no back bleeding options are controlled passage of Fogarty balloon catheter (remain aware of potential complication of carotid-cavernous sinus fistula) or thrombolytics

Etiology of Perioperative stroke after CEA1. ICA thrombosis (most common)

2. Embolism (most common)

3. Cerebral hypoperfusion ischemia during clamping (less common)

4. Cerebral hyperperfusion with intracranial hemorrhage (rare)

Observations on post-CEA strokesMost (60% to 80%) strokes are delayedpatient neurologically intact at end of caseMost post-op events occur in first 24 hrs Most common cause is endarterectomy site thrombosis and/or embolism Technical defects are the most common cause of perioperative stroke

Management of perioperative stroke: who should be explored?Urgent duplex vs. angiography vs. neck explorationDecision to operate depends on severity and timing of symptoms and conduct of original operation Any decision not to operate on patient with delayed deficit must be supported by objective imaging test and improving or stable neuro exam

Management of perioperative stroke: who should be explored?Traditional approach is emergent reoperation with exploration of endarterectomy site

Thrombectomy for acute thrombosis of endarterectomy of effective with high percentage of reversal of the neurologic deficit

Perioperative stroke and CEA: what matters ?Technique matters Stroke rates greater in symptomatic patientsprior CVA > prior TIA > asymptomaticStroke rates generally higher in patient with contralateral carotid occlusionAntiplatelet therapy (ASA 75-325 mg)Patch angioplasty shown to reduce early stroke rate and late recurrent stenosis in metanalysis

Perioperative stroke and CEA: what doesnt seem to matter ?Type of anesthesia: general vs. regional

No definite evidence that completion study reduces stroke rate

Cerebral protection with shunt -- controversialbut probably no difference

Prevention and detection ofCEA induced strokeAwake under regional anesthesiaEEG and SSEP monitoringShuntingCompletion study:Intraoperative duplexCompletion angiography or angioscopyTranscranial doppler: sensitive in detecting cerebral emboli

ConclusionsPerioperative stroke after CEA is rare Technical errors most common cause

Technical perfection and appropriate perioperative antithrombotic therapy are keys to preventing neurological deficitsEarly recognition and timely re-exploration important to minimize morbidity

Scenario # 2Identical patient calls your office 5 days s/p CEA with severe R sided headache and nauseaWhat is your presumptive diagnosis ?What would you do ?

Cerebral HyperperfusionLeast common but most lethal complication 0.2% to 0.8% of all CEAsCommonly peaks at 2 to 7 days following operationClassically: unilateral headache, seizure activity, and cerebral hemorrhageDisturbed cerebral autoregulation Regional cerebral hyperperfusion into capillary bed with normally low blood flowCerebral edema and hemorrhage

ReferencesRiles TS, Imparato AM, Jacobowitz GR, et al: The cause of perioperative stroke after carotid endarterectomy. J Vasc Surg 19:206-216, 1994. Hamdan AD, Pomposelli FB Jr, Gibbons GW, et al: Perioperative strokes after 1001 consecutive carotid endarterectomy procedures without an electroencephalogram: Incidence, mechanism, and recovery. Arch Surg134:412-415, 1999. De Borst GJ, Moll FL, Van de Pavoordt HD, et al: Stroke from carotid endarterectomy: When and how to reduce perioperative stroke rate? Eur J Vasc Endovasc Surg 21:484-489, 2001.

ReferencesTaylor DW, Barnett HJ, Haynes RB, et al: Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: A randomised controlled trial. ASA and Carotid Endarterectomy (ACE) Trial Collaborators. Lancet 353:2179-2184, 1999. Lindblad B, Persson NH, Takolander R, Bergqvist D: Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial. Stroke 24:1125-1128, 1993. Fearn SJ, Parry AD, Picton AJ, et al: Should heparin be reversed after carotid endarterectomy? A randomised prospective trial. Eur J Vasc Endovasc Surg 13:394-397, 1997.

ReferencesBond R, Rerkasem K, Naylor AR et al: Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg 40(6):1126-1135, 2004. Ouriel K, Shortell CK, Illig KA, et al: Intracerebral hemorrhage after carotid endarterectomy: Incidence, contribution to neurologic morbidity, and predictive factors. J Vasc Surg 29:82-89, 1999.