- General
- Its rarely done as most has been superseded by interventional methods, such as thrombolysis and stenting, although there are no randomized controlled trial data to support that approach.
- Trial
- A recent meta-analysis of emergent CEA has shown that the pooled stroke and stroke/death rates after CEA for crescendo TIA in 176 patients were 6.5% and 9.0%, respectively.
- For those with stroke in evolution, the overall stroke and stroke/death rates in 114 patients were 16.9% and 20.0%, respectively.
- After retrospective analysis of 64 emergency endarterectomies the guidelines given below were suggested.
- However, the efficacy of immediate surgical removal of obstruction is controversial and unproven.
- In one early study, over 50% of patients suffered fatal intracranial haemorrhage within 72 hours of emergency carotid endarterectomy.
- Initial management of patient presenting with acute neuro deficit
- Obtain history directed at determining presence of previous stroke and other serious medical illness, and to try to differentiate from seizure
- Baseline neurological assessment including evaluation of STA pulses and carotid bruits
- During evaluation: close control of BP. O2 per NC. Labs+EKG; see Management of TIA or stroke. Consider hemodilution with LMD
- CT to R/O ICH or infarction (early stroke will not be visible) 5. when carotid disease is suspected, and CT is negative for ICH or acute infarct, emergency angiography, MRI/MRA or CTA is performed
- Indications for emergency carotid endarterectomy
- Stroke in evolution
- Crescendo TIAs: TIAs that abruptly increase in frequency to ≥ several per day
- Following intra-arterial thrombolysis, emergent/urgent CEA is indicated for residual critical carotid stenosis
- Contraindications
- Patients with depressed levels of consciousness or acute fixed deficits.
- Surgical management
- Again, most cases would now be managed initially with endovascular thrombolysis and stenting.
- Surgery would be considered if this is not an option.
- For emergency surgery, it is essential that blood pressure be stable
- In patients with complete occlusion, ICA is not occluded intra-op
- To avoid breaking up thrombus, if present
- If thrombus present
- Attempt spontaneous extrusion using back pressure
- If this fails, attempt to remove with smoothened suction catheter
- If this fails, pass balloon embolectomy catheter as far as base of skull (caution: avoid injury to distal ICA that could cause CCF)
- Obtain intra-op angiogram unless thrombus emerges and backflow is excellent
- Plicate ICA (avoid creating a blind pouch at origin) if there is good backflow or if satisfactory angiography cannot be obtained
- Surgical results
- Highest correlation was with presenting neurologic status
Presenting deficit | Same or improved | Deaths |
Intact or mild | 92% | 0 |
Moderate | 80% | 1 (7%) |
Severe | 77% | 3 (13%) |
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