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• W2092505889 abstract "Surgical intervention for patients with neurologic deficits associated with extracranial cerebrovascular disease remains controversial, as reflected by conflicting and incomplete data available in the literature. Early experience with carotid endarterectomy for patients with acute stroke, including the report in 1964 by Wylie, Hein, and Adams,1Wylie EJ Hein MF Adams JE. Intracranial hemorrhage following surgical revascularization for treatment of acute strokes.J Neurosurg. 1964; 21: 212-218Crossref PubMed Scopus (250) Google Scholar argued convincingly against such intervention because of the substantially higher neurologic morbidity when compared with that associated with elective endarterectomy. However, these previous reports lacked consistency in several areas.2Blaisdell WF Clauss RH Gailbraith JG et al.Joint study of extracranial artery occlusion IV. Review of surgical considerations.JAMA. 1969; 209: 1889-1895Crossref PubMed Scopus (289) Google Scholar, 3Hunter JA Julian OC Dye WS Javid H. Emergency operation for acute cerebral ischemia due to carotid obstruction.Ann Surg. 1965; 162: 901Crossref PubMed Google Scholar, 4Thompson JE Austin DJ Patman RD. Endarterectomy of the totally occluded carotid artery for stroke.Arch Surg. 1967; 95: 791-801Crossref PubMed Scopus (58) Google Scholar Surgical populations studied were heterogeneous and included patients with dense infarcts or hemorrhagic strokes such that endarterectomy not infrequently produced disastrous results. The time interval between the onset of symptoms and endarterectomy varied considerably and surgical techniques differed markedly, particularly with regard to methods of cerebral protection. In addition, cerebrovascular angiography in patients with significant cartoid lesions was initially associated with an inordinately high incidence of neurologic morbidity, for the most part cause by cerebral emboli.5Faught E Trader SD Hanna GR. Cerebral complications of angiography for transient ischemia and stroke: prediction of risk.Neurology (Minneap). 1979; 29: 4-15Crossref PubMed Google Scholar From this early experience evolved the classical teaching that patients with acute neurologic deficits should await a 4- to 6-week period of stabilization before angiography and/or endarterectomy. However, more recent reports testify to the increasing safety with which cerebral angiography may be carried out, even in patients with acute stroke.6Eisenbert RL Bank WO Hedgcock MW. Neurologic complications of angiography in patients with cortical stenosis of the carotid artery.Neurology (NY). 1980; 30: 895-897Crossref PubMed Google Scholar, 7Buonanno F Toole JF. Management of patients with established (“completed”) cerebral infarction.Stroke. 1981; 12: 7-16Crossref PubMed Scopus (27) Google Scholar Safety has been further enhanced with the addition of digital subtraction techniques, which provide an increasingly adequate degree of resolution for most extracranial lesions without selective catheterization and, if intra-arterial, with a reduced volume of contrast medium.8Haykal HA Rumbaugh CL. Cerebrovascular accident: angiography/radionuclide brain scan/CT.Postgrad Radiol. 1984; 4: 181-201Google Scholar These studies have thus been obtained increasingly earlier during the course of patient evaluation and have identified a group of patients with high-grade, preocclusive carotid lesions. Such patients with limited or fluctuating neurologic deficits retain significant carotid territory cerebral tissue at risk for recurrent embolization or imminent occlusion.9Meyer FB Sundt Jr, TH Piepgras DG Sandok BA Forbes G. Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits.Ann Surg. 1985; 203: 82-89Crossref Scopus (199) Google Scholar, 10Dosick SM Whalen RC Gale SS Brown OW. Carotid endarterectomy in the stroke patient: computerized axial tomography to determine timing.J Vasc Surg. 1985; 2: 214-219PubMed Scopus (73) Google Scholar Our interest in early endarterectomy was prompted by several such patients whose initial infarction was extended during the 2 to 4 weeks after the onset of symptoms while they awaited endarterectomy. The criteria we currently use for selecting appropriate candidates for emergent or urgent carotid endarterectomy derive from a combination of clinical evaluation, CT scanning, and angiography. These criteria are outlined in Fig. 1, which represents an oversimplified but useful frame of reference.However, any such schematic algorithm must be individualized for a specific patient, a difficult task in the case of neurologic deficits since accurate assessment of the extent of infarction is unfeasible early in its course. Although this difficulty may well be overcome in the future with nuclear magnetic resonance, the technique is not readily available at present.11Buonanno FS Kistler JP DeWitt LD Pykett IL Brady TJ. Proton (1H) nuclear magnetic resonance (NMR) imaging in stroke syndromes.in: Neurologic clinics— cerebrovascular disease. vol 1. WB Saunders Co, Philadelphia1983: 243-262Google Scholar Initial clinical neurologic history and examination allow most patients to be categorized as either stable or unstable with regard to their neurologic deficits. For patients with unstable deficits, those with steady, progressive clinical deterioration likely to result in a profound deficit are not appropriate candidates for endarterectomy. However, patients with unstable but fluctuating deficits remain potential candidates for early endarterectomy prior to the onset of irreversible ischemia. Patients with clinically stable deficits may also be divided into limited or extensive categories on the basis of the functional anatomy involved. The patient with a limited deficit and residual ipsilateral carotid territory at risk, in whom recurrent emboli or infarct extension would produce a more profound or disabling deficit, is considered an appropriate candidate for a prompt endarterectomy. In contrast, the patient with an established dense hemiplegia and aphasia would have little to gain by early endarterectomy. Should appropriate recovery ensue, however, delayed endarterectomy may ultimately prove appropriate.12Kistler JP Ropper AH Heros RC. Therapy of ischemic cerebral vascular disease due to atherothrombosis.N Engl J Med. 1984; 311: 27-34-100-35PubMed Google Scholar After the initial clinical evaluation, CT scanning allows further differentiation of the patient population. Mass lesions, such as arteriovenous malformations, subdural hematomas, or neoplasms, are excluded, as are infarcts associated with hemorrhage. In the case of a documented ischemic infarct, some estimate as to the magnitude of the infarct may be ascertained, although timing of the study in relationship to the onset of symptoms remains a critical variable. Enhanced CT scanning may demonstrate an infarct earlier, but recent evidence suggests that infarcted cerebral tissue is more susceptible to extravasation of contrast material and resultant neurotoxicity.13Pullicino P Kendall B. Contrast enhancement in ischemic lesion. 1. Relationship to prognosis.Neuroradiology. 1980; 19: 235-239PubMed Google Scholar Noninvasive evaluation is usually obtained, but patients with established neurologic deficits require angiography regardless of the noninvasive findings since a nonhemodynamically significant lesion may be the source of major embolic strokes. Nevertheless, in most patients noninvasive evaluation accurately demonstrates a lesion's hemodynamic significance, which may offer helpful correlation in the event of equivocal radiographic findings. In addition, appropriate examination with high-resolution duplex scanning frequently allows documentation of intraplaque hemorrhage, a situation that may argue against anticoagulation and for prompt endarterectomy. Although noninvasive evaluation is not necessarily critical at present, the information gained may prove useful, provided it can be obtained expeditiously. Patients with limited or fluctuating deficits, without mass lesion, hemorrhagic infarct, or massive ischemia seen on CT scanning, should undergo angiography as rapidly as possible. Direct visualization allows differentiation of those candidates requiring urgent endarterectomy from those more appropriately managed medically or with delayed surgery. With digital subtraction angiography, the presence of a lesion and the degree of stenosis can be rapidly determined. Those patients with total occlusion or a noncritical stenosis are not subjected to early endarterectomy, nor are those with smooth shallow plaques. On the other hand, patients with a critical stenotic lesion or a complex multiulcerated plaque are systemically anticoagulated and operated on urgently, usually the following day. However, patients with preocclusive stenoses represent those at highest risk for extension of the initial infarct because of recurrent emboli or subsequent total occlusion. This is more likely to occur within the first 12 hours after angiography than at any other time.5Faught E Trader SD Hanna GR. Cerebral complications of angiography for transient ischemia and stroke: prediction of risk.Neurology (Minneap). 1979; 29: 4-15Crossref PubMed Google Scholar In our institution, operative management of patients with acute neurologic deficits does not differ from that used for patients undergoing elective endarterectomy. We routinely use general anesthesia with intraoperative electroencephalographic (EEG) monitoring.14Whittemore AD Kauffman JL Kohler TR Mannick JA. Routine electroencephalographic (EEG) monitoring during carotid endarterectomy.Ann Surg. 1983; 197: 707-713Crossref PubMed Scopus (74) Google Scholar The necessity for an indwelling shunt is determined on a selective basis by the occurrence of significant EEG changes attendant to carotid clamping. In our initial series of 28 patients operated on who had neurologic deficits, a shunt was required in 40%, a significantly higher requirement than the 18% found in our larger elective group.15Whittemore AD Ruby ST Couch NP Mannick JA. Early carotid endarterectomy in patients with small, fixed neurologic deficits.J Vasc Surg. 1984; 1: 795-798PubMed Scopus (62) Google Scholar In the current study, of the 44 patients undergoing urgent carotid endarterectomy, 41% required shunting. The carotid arteriotomy is closed primarily without a vein patch and completion arteriography is routinely obtained. Particular attention is paid to the maintenance of systemic arterial pressure at normotensive levels in the recovery room, yet the use of the intensive care unit postoperatively is only rarely necessary. In 1984 we reported our results with emergent or urgent carotid endarterectomy in a small group of 28 patients with stable limited neurologic deficits.15Whittemore AD Ruby ST Couch NP Mannick JA. Early carotid endarterectomy in patients with small, fixed neurologic deficits.J Vasc Surg. 1984; 1: 795-798PubMed Scopus (62) Google Scholar This group underwent endarterectomy an average of 11 days (range 2 to 30 days) after the onset of symptoms, most occurring within the first week. Clinical symptoms ranged from isolated speech deficits through minor weakness of either upper or lower extremity, and various combinations thereof. Seventy-five percent of patients underwent CT scans preoperatively and of those, 62% demonstrated evidence of recent infarction. Subsequent arteriography demonstrated greater than 75% stenosis in all patients and 90% stenosis in half of the patients. Since 1984, we have added 16 patients with either limited stable deficits or fluctuating deficits for a total of 44 patients. As indicated in Table I, our experience with urgent and emergent carotid endarterectomy in this selective group has not differed significantly from that achieved with elective endarterectomy in more than 600 patients.Table IResults with emergent/urgent carotid endarterectomy in patients with limited stable or fluctuating neurologic deficitsNeurologic morbidityNo. of patientsDeathsFixedTransientElective6077 (1.2%)5 (0.8%)8 (1.3%)Urgent441 (2.3%)00 Open table in a new tab The only observed death in this small group of 44 patients occurred in a single patient who sustained a fatal pulmonary embolus on the second postoperative day. There were no new neurologic deficits nor any apparent extension of the infarct. The condition of patients with an improving fixed deficit, however, may deteriorate slightly during the first 48 hours after surgery before their preoperative status is recovered. Our experience with urgent and emergent carotid endarterectomy in selected patients with neurologic deficits is in agreement with other recent reports that document acceptable results obtained with proper patient selection and surgical technique.16Najafi H Javid H Dye WE Hunter JA Wideman FE Julian OC. Emergency carotid thromboendarterectomy: surgical indications and results.Arch Surg. 1971; 103: 610Crossref PubMed Scopus (39) Google Scholar, 17Ojemann RG Crowell RM Roberson GH Fisher CM. Surgical treatment of extracranial carotid occlusive disease.Clin Neurosurg. 1975; 22: 214PubMed Google Scholar, 18Goldstone J Moore WS. Emergency carotid artery surgery in neurologically unstable patients.Arch Surg. 1976; 111: 1284-1291Crossref PubMed Scopus (58) Google Scholar, 19Goldstone J Moore WS. A new look at emergency carotid artery operations for the treatment of cerebrovascular insufficiency. Current concepts of cerebrovascular disease.Stroke. 1978; 9: 599Crossref Scopus (50) Google Scholar, 20Mentzer Jr, RM Finkelmeier BA Crosby IK Wellons Jr., HA Emergency carotid endarterectomy for fluctuating neurologic deficits.Surgery. 1981; 89: 60-66PubMed Google Scholar Although these results appear to represent an improvement over the natural history, a randomized prospective series is required for accurate critical analysis. Accumulating such a series represents a formidable undertaking because of the relatively small group of patients at risk and because of the necessarily varied and inconsistent criteria used for patient selection. With the advent of newer techniques that may allow more precise assessment of the extent of cerebral infarction early in the clinical course, we may be able to more accurately select those patients most likely to benefit from urgent or emergent endarterectomy." @default.
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