Early Postoperative Recognition and Management of Acute Stroke after Carotid Endarterectomy



Early Postoperative Recognition and Management of Acute Stroke After Carotid Endarterectomy



Mel J. Sharafuddin and Timothy F. Kresowik


Stroke complicating carotid endarterectomy (CEA) is broadly classified into intraoperative or postoperative. Such a classification has implications for the likely etiology and type of stroke and indication for exploration or neurorescue maneuvers; it also affects prognosis. An intraoperative stroke is defined as a major neurologic deficit recognized at the conclusion of surgery, whereas an early postoperative stroke is defined as a major neurologic deficit that develops within 3 days after the patient had awakened neurologically intact. More than one half of hemispheric strokes complicating CEA are associated with an underlying correctable lesion, and these patients typically present with a delayed-onset stroke.


Neurologic events occurring in a patient who awakens without neurologic deficits following CEA are distinct from intraoperative stroke. This time course is much more indicative of a thromboembolic event reflecting intraluminal thrombus formation at the endarterectomy site with or without embolization. This may be the result of any of numerous potential causes including luminal narrowing caused by longitudinal closure without a patch in a small artery; narrowing of the lumen of the internal carotid artery (ICA) at the apex of a patched closure; intimal damage of the ICA during insertion of a shunt; intimal flaps caused by poor termination point of the endarterectomy in the common, internal, or external carotid; or residual plaque.



Evaluation


It is important to keep in mind that an ischemic event, intracranial hemorrhage, or cerebral hyperperfusion may all be neurologically indistinguishable. One specific scenario that deserves mention is that of a neurologic deficit developing during the early postoperative period in a patient who awakened without a deficit following an otherwise uneventful CEA. This can indicate development of thrombosis at the area of repair and may be associated with a discrete technical defect. In that scenario, portable duplex ultrasound should be the initial step in evaluation. If complete thrombosis has occurred, the patient should proceed directly to reexploration, with fluoroscopic imaging available if possible. If the operative site is patent, further imaging with computed tomography (CT), magnetic resonance imaging (MRI), or intraarterial angiography should precede reexploration.






Surgical Reexploration


The goal of reexploration is to assess for and correct any technical or pathologic defects that are accessible from the endarterectomy site as expediently as possible. The first priority of the operation is to promptly reestablish cerebral perfusion. The wound is opened fully and control of the common, external, and internal carotid arteries is established. If the ICA is completely thrombosed it should not be clamped before the endarterectomy site is opened. The arteriotomy is reopened to allow removal of the thrombus. The thrombus is grasped and is carefully teased out of the vessel with an attempt to remove it in one piece. This often restores brisk retrograde flow from the ICA if the thrombus has been removed intact.


In the event of a propagated clot extending into the carotid siphon that is not removed using the previous maneuver, judicious use of a 2- to 3-Fr Fogarty embolectomy catheter may be attempted, but the catheter must not be advanced or inflated beyond even minimal resistance owing to the risk of a carotid–cavernous sinus fistula. We would favor using intraoperative fluoroscopic guidance for any mechanical attempts to remove distal thrombus. Endovascular rescue approaches can also be used to allow removal of downstream thrombus or correction of associated intimal or atheromatous occlusive downstream pathology (Figure 1). Such approaches have become much more available with the widespread availability of hybrid operating rooms.


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FIGURE 1 A 54-year-old woman underwent eversion carotid endarterectomy under locoregional anesthesia during which an indwelling shunt was used. Intraoperative duplex evaluation revealed intramural thickening of the internal carotid above the endarterectomy level but no intrinsic defect at the endarterectomy site, and the patient was neurologically intact at the conclusion of the procedure. While in the recovery suite she developed acute onset of dysphasia and contralateral weakness. She was brought back to the hybrid angiographic operating room. A, Selective carotid angiography shows a long dissection resulting in true lumen compression extending into the high cervical internal carotid artery (long arrow) with an associated pseudoaneurysm (arrowhead). This was thought to be a result of either clamp or shunt injury. No thromboembolic lesions were found. B, Management using stent-assisted angioplasty of the entire cervical segment using a 5 × 60 mm Xpert stent (Abbott, Abbott Park, IL) (short arrows) and flow diversion of the pseudoaneurysms using a 4.5 × 22 mm stent in a stent-within-stent technique (long arrows) was successful. After stenting, stenosis was abolished, with a small residual stagnant filling of the pseudoaneurysm. The patient’s neurologic deficits resolved completely, and she continues to do well 1 year later, with normal duplex and CT angiography follow-up.

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Aug 25, 2016 | Posted by in CARDIOLOGY | Comments Off on Early Postoperative Recognition and Management of Acute Stroke after Carotid Endarterectomy

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