Transcript Perioperative Stroke after CEA

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 ?
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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 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
Prevention and detection of
CEA induced stroke
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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.