Perioperative Stroke after

Carotid Endarterectomy

FAHC Vascular Surgery Case Study

2006
Daniel J Bertges, MD

Case History
70 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 ago
Meds: ASA 81 mg QD, atenolol, lipitor
SH: former 50 pk yr tobacco
ROS: no visual, speech or sensory changes
PE: HR 63, BP 140/80
RRR without murmur, CTA
bilateral carotid bruits
normal peripheral pulses
normal neurological exam

Case History
Labs normal
EKG: NSR with old anterior wall MI
Carotid Duplex:
severe 80-99 % L ICA stenosis
mild 1-50 % R ICA stenosis
patent, antegrade vertebrals bilateral

CEA
Elective 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 room

One hour later you are called to the RR
Patient is unable to move L arm
PE: HR 90, BP 150/85
Neck without hematoma
Neuro exam: slight L facial droop
L 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

Reoperation
Neck explored and carotid reopened
Acute thrombus in ICA
Carefully pull thrombus out
Good 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 CEA

1. 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 strokes

Most (60% to 80%) strokes are delayed
patient neurologically intact at end of case
Most 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
exploration
Decision 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 patients
prior CVA > prior TIA > asymptomatic
Stroke rates generally higher in patient with
contralateral carotid occlusion
Antiplatelet 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 -- controversial
but probably no difference

Prevention and detection of

CEA induced stroke

Awake under regional anesthesia

EEG and SSEP monitoring
Shunting
Completion study:
Intraoperative duplex
Completion angiography or angioscopy
Transcranial doppler: sensitive in detecting
cerebral emboli

Conclusions
Perioperative stroke after CEA is rare
Technical errors most common cause
Technical perfection and appropriate
perioperative antithrombotic therapy are keys
to preventing neurological deficits
Early recognition and timely re-exploration
important to minimize morbidity

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

Cerebral Hyperperfusion
Least common but most lethal complication
0.2% to 0.8% of all CEAs
Commonly peaks at 2 to 7 days following operation
Classically: unilateral headache, seizure activity, and
cerebral hemorrhage
Disturbed cerebral autoregulation
Regional cerebral hyperperfusion into
capillary bed with normally low blood flow
Cerebral edema and hemorrhage

References
Riles 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.

References

Taylor DW, Barnett HJ, Haynes RB, et al: Low-dose and highdose acetylsalicylic acid for patients undergoing carotid
endarterectomy: A randomised controlled trial. ASA and Carotid
Endarterectomy (ACE) Trial Collaborators. Lancet 353:21792184, 1999.
Lindblad B, Persson NH, Takolander R, Bergqvist D: Does lowdose 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.

References

Bond 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 29:8289, 1999.