Emergency carotid endarterectomy

Restricted access

✓ A retrospective review of carotid endarterectomies performed by the Neurosurgical Service at Massachusetts General Hospital from July, 1976, through December, 1985, disclosed 64 procedures that were performed on an emergency basis. The patients included 40 men and 24 women, with a mean age of 64 years (range 32 to 87 years). Correlation of angiographic findings with outcome revealed that of the 27 patients with severe stenosis, usually with delay in blood flow, 25 (93%) were the same or improved postoperatively; of the 11 patients with stenosis and an intraluminal filling defect (six of whom had an intraluminal clot), eight (73%) were the same or improved after surgery; of the 16 patients with complete occlusion, 14 (88%) were the same or improved (backflow was established in all cases); and of the 10 patients with moderate to severe stenosis and/or severe ulceration (including three with transient ischemic attacks who were receiving heparin), eight (80%) were the same or improved.

Pre- and postoperative clinical status were graded into five categories: intact; mild deficit; moderate deficit (significant impairment but able to perform activities of daily living); severe deficit (requiring assistance for daily activities); and death. Of the 36 patients who preoperatively were intact or had mild deficits, 33 (92%) were the same or improved postoperatively, three were worse, and there were no deaths. Among 15 patients presenting with moderate deficits, 12 (80%) were the same or improved, two were worse, and one died. Of the 13 patients with severe deficits, 10 (77%) were the same or improved and three died. Two patients with sudden severe deficits associated with loss of contralateral bruit were operated on without angiography and were intact postoperatively. Of the four deaths in the total series, two were attributed to cardiac causes and two to unrelated disease processes. The indications for emergency carotid endarterectomy are discussed.

Article Information

Address reprint requests to: Robert G. Ojemann, M.D., Neurosurgical Service, Massachusetts General Hospital, Boston, Massachusetts 02114.

© AANS, except where prohibited by US copyright law.

Headings

References

1.

Bauer RBMeyer JSFields WSet al: Joint Study of Extracranial Arterial Occlusion. III. Progress report of controlled study of long-term survival in patients with and without operation. JAMA 208:5095181969Bauer RB Meyer JS Fields WS et al: Joint Study of Extracranial Arterial Occlusion. III. Progress report of controlled study of long-term survival in patients with and without operation. JAMA 208:509–518 1969

2.

Biller JAdams HP JrBoarini Det al: Intraluminal clot of the carotid artery. A clinical-angiographic correlation of nine patients and literature review. Surg Neurol 25:4674771986Biller J Adams HP Jr Boarini D et al: Intraluminal clot of the carotid artery. A clinical-angiographic correlation of nine patients and literature review. Surg Neurol 25:467–477 1986

3.

Caplan LRSkillman JOjemann Ret al: Intracerebral hemorrhage following carotid endarterectomy: a hypertensive complication? Stroke 9:4574601978Caplan LR Skillman J Ojemann R et al: Intracerebral hemorrhage following carotid endarterectomy: a hypertensive complication? Stroke 9:457–460 1978

4.

Cote RBarnett HJMTaylor DW: Internal carotid occlusion: a prospective study. Stroke 14:8989021983Cote R Barnett HJM Taylor DW: Internal carotid occlusion: a prospective study. Stroke 14:898–902 1983

5.

Crowell RMOlsson YKlatzo Iet al: Temporary occlusion of the middle cerebral artery in the monkey: clinical and pathological observations. Stroke 1:4394481970Crowell RM Olsson Y Klatzo I et al: Temporary occlusion of the middle cerebral artery in the monkey: clinical and pathological observations. Stroke 1:439–448 1970

6.

Denny-Brown DMeyer JS: The cerebral collateral circulation. 2. Production of cerebral infarction by ischemic anoxia and its reversibility in early stages. Neurology 7:5675791957Denny-Brown D Meyer JS: The cerebral collateral circulation. 2. Production of cerebral infarction by ischemic anoxia and its reversibility in early stages. Neurology 7:567–579 1957

7.

DeWeese JA: Management of acute strokes. Surg Clinic North Am 62:4674721982DeWeese JA: Management of acute strokes. Surg Clinic North Am 62:467–472 1982

8.

Donaldson MCDrezner AD: Surgery for acute carotid occlusion. Therapy in search of predictability. Arch Surg 118:126612681983Donaldson MC Drezner AD: Surgery for acute carotid occlusion. Therapy in search of predictability. Arch Surg 118:1266–1268 1983

9.

Dosick SMWhalen RCGale SSet al: Carotid endarterectomy in the stroke patient: computerized axialtomography to determine timing. J Vasc Surg 2:2142191985Dosick SM Whalen RC Gale SS et al: Carotid endarterectomy in the stroke patient: computerized axialtomography to determine timing. J Vasc Surg 2:214–219 1985

10.

Furlan AJWhisnant JPBaker HL Jr: Long-term prognosis after carotid artery occlusion. Neurology 30:9869881980Furlan AJ Whisnant JP Baker HL Jr: Long-term prognosis after carotid artery occlusion. Neurology 30:986–988 1980

11.

Goldstone JEffeney DJ: The role of carotid endarterectomy in the treatment of acute neurologic deficits. Prog Cardiovasc Dis 22:4154221980Goldstone J Effeney DJ: The role of carotid endarterectomy in the treatment of acute neurologic deficits. Prog Cardiovasc Dis 22:415–422 1980

12.

Grillo PPatterson RH Jr: Occlusion of the carotid artery: prognosis (natural history) and the possibilities of surgical revascularization. Stroke 6:17201975Grillo P Patterson RH Jr: Occlusion of the carotid artery: prognosis (natural history) and the possibilities of surgical revascularization. Stroke 6:17–20 1975

13.

Hafner CDTew JM: Surgical management of the totally occluded internal carotid artery: a ten-year study. Surgery 89:7107171981Hafner CD Tew JM: Surgical management of the totally occluded internal carotid artery: a ten-year study. Surgery 89:710–717 1981

14.

Hunter JAJulian OCDye WSet al: Emergency operation for acute cerebral ischemia due to carotid artery obstruction: review of 26 cases. Ann Surg 162:9019041965Hunter JA Julian OC Dye WS et al: Emergency operation for acute cerebral ischemia due to carotid artery obstruction: review of 26 cases. Ann Surg 162:901–904 1965

15.

Jones THMorawetz RBCrowell RMet al: Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg 54:7737821981Jones TH Morawetz RB Crowell RM et al: Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg 54:773–782 1981

16.

Kwaan JHMConnolly JESharefkin JB: Successful management of early stroke after carotid endarterectomy. Ann Surg 190:6766781979Kwaan JHM Connolly JE Sharefkin JB: Successful management of early stroke after carotid endarterectomy. Ann Surg 190:676–678 1979

17.

Lindberg B: Acute carotid occlusion. Indication for surgery? J Cardiovasc Surg 21:3153201980Lindberg B: Acute carotid occlusion. Indication for surgery? J Cardiovasc Surg 21:315–320 1980

18.

Mentzer RM JrFinkelmeier BACrosby IKet al: Emergency carotid endarterectomy for fluctuating neurologic deficits. Surgery 89:60661981Mentzer RM Jr Finkelmeier BA Crosby IK et al: Emergency carotid endarterectomy for fluctuating neurologic deficits. Surgery 89:60–66 1981

19.

Meyer FBSundt TM JrPiepgras DGet al: Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits. Ann Surg 203:82891986Meyer FB Sundt TM Jr Piepgras DG et al: Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits. Ann Surg 203:82–89 1986

20.

Morawetz RBDeGirolami UOjemann RGet al: Cerebral blood flow determined by hydrogen clearance during middle cerebral artery occlusion in unanesthetized monkeys. Stroke 9:1431491978Morawetz RB DeGirolami U Ojemann RG et al: Cerebral blood flow determined by hydrogen clearance during middle cerebral artery occlusion in unanesthetized monkeys. Stroke 9:143–149 1978

21.

Najafi HJavid HDye WSet al: Emergency carotid endarterectomy. Surgical indications and results. Arch Surg 103:6106141971Najafi H Javid H Dye WS et al: Emergency carotid endarterectomy. Surgical indications and results. Arch Surg 103:610–614 1971

22.

Ojemann RGCrowell RM: Surgical Management of Cerebrovascular Disease. Baltimore: Williams & Wilkins1983Ojemann RG Crowell RM: Surgical Management of Cerebrovascular Disease. Baltimore: Williams & Wilkins 1983

23.

Ojemann RGCrowell RMRoberson GHet al: Surgical treatment of extracranial carotid occlusive disease. Clin Neurosurg 22:2142631975Ojemann RG Crowell RM Roberson GH et al: Surgical treatment of extracranial carotid occlusive disease. Clin Neurosurg 22:214–263 1975

24.

Pistolese GRVentura MSpeziale Fet al: Emergency carotid surgery. Int Surg 69:2312341984Pistolese GR Ventura M Speziale F et al: Emergency carotid surgery. Int Surg 69:231–234 1984

25.

Rob CG: Operation for acute completed stroke due to thrombosis of the internal carotid artery. Surgery 65:8628651969Rob CG: Operation for acute completed stroke due to thrombosis of the internal carotid artery. Surgery 65:862–865 1969

26.

Sekhar LNHeros RCLotz PRet al: Atheromatous pseudo-occlusion of the internal carotid artery. J Neurosurg 52:7827891980Sekhar LN Heros RC Lotz PR et al: Atheromatous pseudo-occlusion of the internal carotid artery. J Neurosurg 52:782–789 1980

27.

Strand TAsplund KEriksson Set al: A randomized controlled trial of hemodilution therapy in acute ischemic stroke. Stroke 15:9809891984Strand T Asplund K Eriksson S et al: A randomized controlled trial of hemodilution therapy in acute ischemic stroke. Stroke 15:980–989 1984

28.

Sundt TM Jr: The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy. Stroke 14:93981983Sundt TM Jr: The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy. Stroke 14:93–98 1983

29.

Sundt TM JrGrant WCGarcia HJ: Restoration of middle cerebral artery flow in experimental infarction. J Neurosurg 31:3113221969Sundt TM Jr Grant WC Garcia HJ: Restoration of middle cerebral artery flow in experimental infarction. J Neurosurg 31:311–322 1969

30.

Sundt TM JrSharbrough FWAnderson REet al: Cerebral blood flow measurements and electroencephalograms during carotid endarterectomy. J Neurosurg 41:3103201974Sundt TM Jr Sharbrough FW Anderson RE et al: Cerebral blood flow measurements and electroencephalograms during carotid endarterectomy. J Neurosurg 41:310–320 1974

31.

Thompson JE: Protection of the brain during carotid endarterectomy. I. Routine shunting. Int Anesthesiol Clin 22:1231281984Thompson JE: Protection of the brain during carotid endarterectomy. I. Routine shunting. Int Anesthesiol Clin 22:123–128 1984

32.

Treiman RLCossman DVCohen JLet al: Management of postoperative stroke after carotid endarterectomy. Am J Surg 142:2362381981Treiman RL Cossman DV Cohen JL et al: Management of postoperative stroke after carotid endarterectomy. Am J Surg 142:236–238 1981

33.

Whisnant JPSandok BASundt TM Jr: Carotid endarterectomy for unilateral carotid system transient cerebral ischemia. Mayo Clin Proc 58:1711751983Whisnant JP Sandok BA Sundt TM Jr: Carotid endarterectomy for unilateral carotid system transient cerebral ischemia. Mayo Clin Proc 58:171–175 1983

34.

Wood JHKee DB Jr: Hemorheology of the cerebral circulation in stroke. Stroke 16:7657721985Wood JH Kee DB Jr: Hemorheology of the cerebral circulation in stroke. Stroke 16:765–772 1985

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 322 322 201
Full Text Views 623 623 10
PDF Downloads 92 92 5
EPUB Downloads 0 0 0

PubMed

Google Scholar