Carotid endarterectomy and intracranial thrombolysis: Simultaneous and staged procedures in ischemic stroke

• Published in: Journal of vascular surgery 1999-03, Vol.29 (3), p.459-471
• Main Authors: Eckstein, Hans-Henning, Schumacher, Hardy, Dörfler, Arnd, Forsting, Michael, Jansen, Olav, Ringleb, Peter, Allenberg, Jens-Rainer
• Format: Article
• Language: English
• Subjects: Acute Disease; Adult; Aged; Aged, 80 and over; Arterial Occlusive Diseases - drug therapy; Arterial Occlusive Diseases - surgery; Biological and medical sciences; Brain Ischemia - drug therapy; Brain Ischemia - surgery; Carotid Artery Diseases - drug therapy; Carotid Artery Diseases - surgery; Carotid Artery, Internal - drug effects; Carotid Artery, Internal - surgery; Cerebral Angiography; Cerebral Arteries - drug effects; Cerebral Arteries - surgery; Cerebral Infarction - etiology; Cerebrovascular Disorders - drug therapy; Cerebrovascular Disorders - surgery; Endarterectomy, Carotid; Feasibility Studies; Female; Humans; Intracranial Embolism and Thrombosis - drug therapy; Intraoperative Care; Intraoperative Complications - drug therapy; Male; Medical sciences; Middle Aged; Pilot Projects; Plasminogen Activators - therapeutic use; Safety; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Thrombolytic Therapy; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Transcranial; Urokinase-Type Plasminogen Activator - therapeutic use
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/S0741-5214(99)70274-0

Purpose: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. Methods: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. Results: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. Conclusion: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies. (J Vasc Surg 1999;29:459-71.)