Perioperative Stroke after Carotid Endarterectomy

1
Perioperative Stroke after Carotid Endarterectomy

• FAHC Vascular Surgery Case Study
• 2006
• Daniel J Bertges, MD

2
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

3
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

4
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

5
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

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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 ?

7
Emergent ultrasound(done in RR or OR whichever
is quicker)
Duplex intimal flap at distal endpoint of R ICA
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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

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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)

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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

11
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

12
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

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Perioperative stroke and CEA what matters ?

• Technique matters
• Stroke rates greater in symptomatic
  patients prior CVA gt prior TIA gt 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

14
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

15
Prevention and detection ofCEA 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

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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

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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 ?

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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

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References

• Riles TS, Imparato AM, Jacobowitz GR, et al The
  cause of perioperative stroke after carotid
  endarterectomy. J Vasc Surg 19206-216, 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 Surg134412-415, 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 21484-489, 2001.

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References

• Taylor 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 3532179-2184,
  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
  241125-1128, 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 13394-397, 1997.

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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 2982-89, 1999.