Reoperation for acute hemispheric stroke after carotid endarterectomy: is there any value?

OBJECTIVE: Because the clinical benefit of urgent investigation and carotid re-repair for acute stroke complicating carotid endarterectomy (CEA) is uncertain, the results of this approach were examined in a large series of patients.

METHODS: In a consecutive series of 700 CEAs, 24 patients (3.4%) had a postoperative stroke. Thirteen of these 24 patients experienced major hemispheric deficits (hemiplegia with or without aphasia, forced eye deviation, and decreased consciousness) that prompted either immediate surgical reexploration or cerebral angiography with reoperation on the basis of angiogram results; these 13 patients are the subject of this report. Neurological improvement was attributed to carotid reopening when affected muscle strength increased to antigravity power within 6 hours of reoperation.

RESULTS: Of the 13 patients with severe postoperative deficits, 5 (38%) had the deficits when they awakened, 7 deficits occurred within 12 hours of surgery, and the only intracerebral hemorrhage in this series occurred 8 days after surgery. Five patients underwent urgent reoperation without angiography, and carotid occlusions were found and repaired in two patients. In another patient, the carotid was patent, and an intra-arterial injection of tissue plasminogen activator (20 mg) was given. In the seven patients who underwent cerebral angiography as the first step, two carotid occlusions and one residual stenosis with thrombus were found and repaired on an urgent basis. Surgical reopening of occluded arteries was followed by improvement in two of four patients, and early improvement was noted in one patient with a stenosis correction as well as in the patient who received intraoperative tissue plasminogen activator. Four patients who underwent urgent reoperation did not demonstrate a benefit soon after surgery. Two patients died, two were left with major deficits and five with moderate deficits, and four patients eventually had good recovery at a minimum of 6 months of follow-up.

CONCLUSION: In this series, approximately one-half of hemispheric strokes complicating CEA had an underlying correctable lesion (occlusion or stenosis), and these patients typically had delayed-onset strokes. Approximately one-half of these patients improved early as a result of reopening, although computed tomography revealed new infarcts in most of them. Urgent carotid repair may benefit a minority of selected patients who have a major stroke after CEA.