Mohammad Anadani, MD

Ijäs P, Aro E, Eriksson H, Vikatmaa P, Soinne L, Venermo M. Prior Intravenous Stroke Thrombolysis Does Not Increase Complications of Carotid Endarterectomy. Stroke. 2018

The benefit of carotid endarterectomy (CEA) for symptomatic carotid stenosis is well established; however, the optimal timing of procedure after stroke is still a matter of debate. Although few studies showed an increased risk of periprocedural stroke and death with early CEA (within 48 hours), others did not. In patients who receive intravenous thrombolysis (IVT), CEA is often delayed due to a concern of increased risk of intracerebral hemorrhage (ICH). However, this delay may result in a theoretical increase in risk of recurrent stroke while waiting for CEA.

In this study, Ijäs and colleagues underwent a retrospective registry study to investigate the safety and optimal timing of CEA after IV thrombolysis (IVT).

The authors used the HUSVASC and Helsinki Stroke Thrombolysis Registries to identify patients who underwent CEA after IVT. Data on recurrent cerebrovascular symptoms, peri- and postoperative ischemic and hemorrhagic strokes within 30 days after CEA, cardiac events, and hyperperfusion syndrome were collected. Hyperperfusion syndrome was defined as a triad of high blood pressure, headache, and confusion and neurological symptoms similar to the previous stroke that occurred within 1 month and could not be explained by other causes.

During the study period, 128 patients had both IVT and ipsilateral CEA. 73.4% of patients were male. Mean age was 68.9±9.2 years, median NIHSS was 6 (range, 0-20), and mean time from symptoms to IVT was 120 ±54 min. The rate of any intracerebral hemorrhage (ICH) was 3.9%.

While waiting for CEA, seven patients had recurrent stroke or progression of symptoms (crescendo TIA or stroke in evolution) with a median time from symptoms onset to the event of 4 days (range 0-8).

Peri/postoperative ischemic stroke occurred in 3.9% of patients, and there was no difference between early procedure (within 48 hours from IVT) and delayed procedure (>48 hours after IVT). Hyperperfusion syndrome and drug-resistant hypertension were more common in the early procedure group, but the difference was not statistically significant (Table 2).

Table 2. Complications and Outcomes According to the Timing of CEA

In multivariate analysis adjusting for multiple confounders, time between IVT and CEA was not associated with CEA-related stroke (peri-or postoperative ischemic stroke, or ICH related to hyperperfusion syndrome).

There was no difference in the rate of perioperative ischemic or hemorrhagic strokes or the mortality rate between patients who received IVT before CEA and those who did not receive IVT.

Study limitations include a small sample size and retrospective design. Moreover, this study included patients with minor ischemic stroke and TIA; therefore, its results may not apply to patients with large ischemic infarcts and/or ICH.

The abovementioned study demonstrated the safety of early CEA; however, it failed to show benefit from early CEA as the rate of recurrent stroke while waiting for CEA was low and similar between two groups. Moreover, early CEA was not associated with a decreased mortality rate or higher rate of functional independence (mRS 0-2).

The American Heart Association/American Stroke Association guidelines recommend revascularization between 48 hours and 7 days after ischemic stroke. Until further studies, neurologists should continue to follow the AHA/ASA guidelines.