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

6. 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

8. 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

9. 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)

10. 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

13. 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

14. Perioperative stroke and CEA: what doesn’t 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 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

16. 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

17. 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 ?

18. 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

19. 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.

20. 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 353:2179- 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 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.

21. 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 29:82- 89, 1999.