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The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack.
J Vasc Surg. 2012 Jun; 55(6):1611-7.JV

Abstract

OBJECTIVE

The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms.

METHODS

This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging.

RESULTS

Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%).

CONCLUSIONS

Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA.

Authors+Show Affiliations

Vascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy. lauracapoccia@yahoo.itNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

22364655

Citation

Capoccia, Laura, et al. "The Need for Emergency Surgical Treatment in Carotid-related Stroke in Evolution and Crescendo Transient Ischemic Attack." Journal of Vascular Surgery, vol. 55, no. 6, 2012, pp. 1611-7.
Capoccia L, Sbarigia E, Speziale F, et al. The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack. J Vasc Surg. 2012;55(6):1611-7.
Capoccia, L., Sbarigia, E., Speziale, F., Toni, D., Biello, A., Montelione, N., & Fiorani, P. (2012). The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack. Journal of Vascular Surgery, 55(6), 1611-7. https://doi.org/10.1016/j.jvs.2011.11.144
Capoccia L, et al. The Need for Emergency Surgical Treatment in Carotid-related Stroke in Evolution and Crescendo Transient Ischemic Attack. J Vasc Surg. 2012;55(6):1611-7. PubMed PMID: 22364655.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack. AU - Capoccia,Laura, AU - Sbarigia,Enrico, AU - Speziale,Francesco, AU - Toni,Danilo, AU - Biello,Antonella, AU - Montelione,Nunzio, AU - Fiorani,Paolo, Y1 - 2012/02/23/ PY - 2011/08/18/received PY - 2011/10/25/revised PY - 2011/11/12/accepted PY - 2012/2/28/entrez PY - 2012/3/1/pubmed PY - 2012/7/19/medline SP - 1611 EP - 7 JF - Journal of vascular surgery JO - J. Vasc. Surg. VL - 55 IS - 6 N2 - OBJECTIVE: The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms. METHODS: This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging. RESULTS: Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%). CONCLUSIONS: Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/22364655/The_need_for_emergency_surgical_treatment_in_carotid_related_stroke_in_evolution_and_crescendo_transient_ischemic_attack_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(11)03097-7 DB - PRIME DP - Unbound Medicine ER -