Outcomes of Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke in Evolution

Igor Gunka; Dagmar Krajickova; Michal Lesko; Ondrej Renc; Jan Raupach; Stanislav Jiska; Miroslav Lojik; Vendelin Chovanec; Alexander Hudak; Radovan Maly

doi:10.1016/j.avsg.2019.05.061

Outcomes of Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke in Evolution

Ann Vasc Surg. 2019 Nov:61:185-192. doi: 10.1016/j.avsg.2019.05.061. Epub 2019 Aug 5.

Authors

Affiliations

¹ Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic. Electronic address: gunka@email.cz.
² Department of Neurology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
³ Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
⁴ Department of Radiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
⁵ 1st Department of Internal Medicine - Cardioangiology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.

PMID: 31394223
DOI: 10.1016/j.avsg.2019.05.061

Abstract

Background: Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE).

Methods: A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE).

Results: A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2).

Conclusions: Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.

MeSH terms

Aged
Carotid Stenosis / complications
Carotid Stenosis / diagnosis
Carotid Stenosis / mortality
Carotid Stenosis / surgery*
Disability Evaluation
Endarterectomy, Carotid* / adverse effects
Endarterectomy, Carotid* / mortality
Female
Humans
Ischemic Attack, Transient / diagnosis
Ischemic Attack, Transient / etiology*
Ischemic Attack, Transient / mortality
Male
Middle Aged
Recovery of Function
Registries
Retrospective Studies
Risk Assessment
Risk Factors
Stroke / diagnosis
Stroke / etiology*
Stroke / mortality
Time Factors
Treatment Outcome