Early acute hemispheric stroke after carotid endarterectomy. Pathogenesis and management

PURPOSE: A major stroke after carotid endareterectomy (CEA) is an event that should be managed according to a planned strategy. Literature data on this issue are not definitive. We reviewed our series in the attempt to define an algorithm of treatment if this complication occurs. METHODS: A consecutive series of 413 CEAs in 390 patients was considered. All operations were performed under general anaesthesia and EEG monitoring. An indwelling shunt was inserted only according to EEG changes. Direct closure of the arteriotomy was performed in all cases. Intraoperative ultrasound was not routinely employed before 2004. Patients who suffered from the new onset of an ischaemic hemispheric deficit or the worsening of a pre-existing deficit within 72 h after surgery were included in the present study. RESULTS: Sixteen patients (3.9%) suffered from perioperative stroke. Seven patients presented neurological deficits that rapidly and spontaneously resolved. In nine cases (2.2%) a major stroke occurred. Acute occlusion of the internal carotid artery (ICA), with or without embolic blocking of the omolateral M1 segment, occurred in eight cases; in one case a patent ICA was associated with the occlusion of two frontal branches of the omolateral middle cerebral artery. Seven cases were reoperated on. The ICA was reopened in all these cases except one. Among these seven cases, three (42%) had a good outcome. CONCLUSIONS: A major stroke after CEA is caused, in most of cases, by the acute ICA occlusion with or without intracerebral embolic occlusion. Reopening of the occluded ICA gives good results when intracerebral vessels are patent and when the occluded ICA is satisfactorily reopened. An algorithm of planned reactions in case of perioperative stroke is finally proposed.