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Urgent carotid endarterectomy for acute cerebral ischemia

Bedi HS,1 Pandian JD,2 Gupta A3

Head CTVS,1 Professor & Head Neurology,2 Head Cardiac Anesthesia3

Department of Cardiovascular Endovascular & Thoracic Surgery,1 Department of Neurology,Department of Cardio Vascular Anesthesia3

1-3Christian Medical College & Hospital , Ludhiana, Punjab, India

ABSTRACT
Background

Carotid endarterectomy (CEA) is well established as the elective treatment for severe symptomatic carotid stenosis . In contrast, the merits of CEA performed  as an  emergency procedure in patients with acute stroke or fluctuating neurological deficit remain controversial.

Material Methods

CEA was performed as an emergency procedure on 16 patients within 4 to 48 hours after the onset of symptoms. Patients selected for urgent surgery fulfilled the following criteria: acute onset of fluctuating hemispheric neurological symptoms, significant carotid pathology, absence of cerebral hemorrhage, absence of massive cerebral damage and stable cardiopulmonary conditions. The patients presented with a crescendo-TIA in 7, evolving (stuttering) stroke in 3 and   fluctuating neurological deficits in  6 -  corresponding to a contralateral carotid stenosis.

Results

Following CEA, the neurological deficits improved instantaneously to complete recovery in 10 patients. The symptoms of 4 patients improved to non-disabling deficits, and remained unchanged in two patients. 14/16 patients were discharged within 8 days after admission. The neurologic status after discharge did not deteriorate in any of the patients during follow up – in fact it further improved in 4 of the patients (2 in whom there had been no change and 2 in whom there had been a partial improvement).

Conclusion

Emergency CEA may be beneficial for selected patients with stroke in evolution and fluctuating neurological deficits. Careful adherence to selection criteria, judicious intraoperative shunting, intensive unit care post surgery and an experienced team are recommended.

KEY WORDS
Carotid endarterectomy; Crescendo TIA; stroke in evolution

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