The Timing of Carotid Endarterectomy Post Stroke

Benefits of using dexmedetomidine during carotid endarterectomy: A review

As per current recommendation, patients with acute ischemic stroke should be offered carotid endarterectomy (CEA) within 24-72 hours. The same applies to patients with recurrent transient ischemic attacks (TIA). This time is usually less for hemodynamic optimization of patients who’ve suffered acute ischemic stroke. Hence’ they are hemodynamically labile and can have accelerated hypertension on induction/extubation. This can have disastrous outcomes. It is a common practice among anesthesiologists to avoid angiotensin converting enzyme(ACE) inhibitors or angiotensin receptor blockers on the day of surgery. This also adds to hypertensive issues perioperatively. Dexmedetomidine is a wonderful drug which can be used during CEA. Due to its centrally mediated sympatholytic effect, it confers good hemodynamic control during induction, intraoperatively, and during extubation. We did a search on PubMed and Google for carotid endarterectomies done under general and locoregional anesthesia during which dexmedetomidine was used. The keywords used by us during the search were as follows: anesthesia, carotid endarterectomy, anesthesia. We also searched for use of dexmedetomidine infusion to attenuate hypertensive response to intubation and for providing stability in major surgeries like CABG, craniotomies, bariatric surgeries, and valve replacements.

Carotid stenting in acute ischemic stroke patients with intraluminal thrombus

INTRODUCTION

Carotid stenosis with intraluminal thrombus is associated with a high risk of early recurrent stroke. We evaluated the feasibility and outcome of carotid stenting in acute ischemic stroke patients with carotid stenosis and intraluminal thrombus.

METHODS

Among 295 consecutive acute ischemic stroke patients who were referred for intra-arterial thrombolytic (IAT) therapy, six patients with carotid stenosis and intraluminal thrombus were treated by stent assisted angioplasty. The clinical characteristics, feasibility, and clinical outcomes were assessed.

RESULTS

All patients had severe stenosis of the underlying carotid bulb (mean, 86.8%; range, 71-99%) with adjacent intraluminal thrombus. Stent assisted angioplasty resulted in successful recanalization in all six patients. Thrombus was captured with the filter device in four patients. Three patients with tandem occlusion of the ipsilateral proximal middle cerebral artery were successfully recanalized with intra-arterial urokinase. No patients suffered procedure related complications or symptomatic hemorrhage. Four patients showed good long-term outcome (3 month mRS; 0-2).

CONCLUSIONS

Stent assisted angioplasty is a feasible treatment option for acute ischemic stroke patients caused by carotid stenosis with intraluminal thrombus and may be effective in preventing early recurrent stroke.

Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.