Bilateral severe carotid stenosis or occlusion and computed tomographic scan positive hemispheric stroke with neurologic deficit: immediate contralateral carotid endarterectomy.

In the last 10 years, 13 patients presented with acute, hemispheric, computed tomographic scan-positive stroke; neurologic deficit; and bilateral carotid stenosis greater than 90% (N = 9) or ipsilateral occlusion with contralateral stenosis greater than 90% (N = 4). To improve ipsilateral flow without elevation of pressure to levels causing hemorrhagic infarction, all patients underwent carotid endarterectomy on the side contralateral to the hemispheric stroke from two to 10 days (average 6.6 days) from onset of symptoms. Those with fluctuating deficits stabilized to the initial fixed deficit and all 13 improved over the next six months. Four patients with ipsilateral internal carotid occlusion and one with ipsilateral severe siphon stenosis were discharged on antiplatelet therapy; of the remaining eight patients, seven underwent subsequent ipsilateral carotid endarterectomy from 42 to 111 days (average 58.4 days) from onset of symptoms. Mortality and stroke rate were 0. The four patients with internal carotid occlusion and the one with severe siphon stenosis filled both hemispheres from the contralateral carotid artery arteriographically in four and by oculoplethysmography in one. One patient demonstrated preferential flow from contralateral to the ipsilateral hemisphere, but not the reverse; one patient demonstrated pericallosal collaterals. Immediate endarterectomy of the severely diseased carotid artery contralateral to a hemisphere with a computed tomographic scan-positive stroke causing neurologic deficit resulting from a severe carotid stenosis is a safe treatment option and may be beneficial in those with fluctuating neurologic deficits.