Department of Vascular and Thoracic Surgery, Bichat-Claude Bernard University Hospital, Denis Diderot University and Medical School Paris VII, Assistance Publique-Hopitaux de Paris, Paris, France.
J Vasc Surg. 2012 Mar;55(3):701-7. doi: 10.1016/j.jvs.2011.09.054. Epub 2011 Nov 8.
This study documented with independent neurologic assessment the 30-day and 90-day outcomes in selected patients with severe internal carotid artery (ICA) stenosis who underwent carotid endarterectomy (CEA) in the acute phase of stroke-in-evolution (SIE).
From January 2003 to December 2010, data from patients who had surgery ≤2 weeks of an SIE with high-grade carotid stenosis were extracted from two prospectively collected databases. Clinical assessment was by the vascular neurologist using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale score. All patients had computed tomography or magnetic resonance brain imaging ≤3 hours of stroke onset. Those eligible received thrombolysis. Duplex ultrasound imaging was initially used for the diagnosis of severe (≥60%) ICA stenosis, and further assessment was by magnetic resonance or computed tomography angiography, or both. Perioperative medical treatment and operative techniques were standardized. Stroke, death, major cardiac events, and functional outcome were analyzed.
Twenty-seven patients underwent carotid revascularization in the acute phase of SIE. Fluctuating or progressive neurologic deficit was the presenting pattern in 20 patients and occurred after otherwise successful thrombolytic therapy in the remaining 7 (26%). Median NIHSS score at admission was 8. Median delay to surgery from the index event was 6 days. The mean degree of ICA stenosis was 87%. All patients received antiplatelet and statin therapy during the intervening period. Procedures were conventional CEA with patch angioplasty (polytetrafluoroethylene) in 26 patients (96.3%) and redo interposition bypass grafting in 1 patient. CEA was done under local anesthesia in 23 patients (85.2%), with selective shunting in 3 (13.0%), and under general anesthesia, with systematic shunting in 4. At discharge and at 1 and 3 months, no recurrent stroke or death, and one nonfatal myocardial infarction occurred in this series, with a 100% complete follow-up. At 3 months, all patients had a favorable functional outcome defined as a modified Rankin Scale score of ≤2.
This short series demonstrates that CEA in the acute phase of SIE with strict selection criteria and close blood pressure monitoring is safe, even after recent thrombolytic therapy, and is effective in functional outcome at 3 months. Larger series of patients are required to confirm the safety and efficacy of this management.
本研究通过独立的神经评估记录了在进展性卒中（SIE）的急性期接受颈动脉内膜切除术（CEA）的特定重度颈内动脉（ICA）狭窄患者的 30 天和 90 天结果。
从 2003 年 1 月至 2010 年 12 月，从两个前瞻性收集的数据库中提取了在 SIE 后 2 周内接受手术且存在重度颈动脉狭窄的患者的数据。临床评估由血管神经病学家使用国立卫生研究院卒中量表（NIHSS）和改良 Rankin 量表评分进行。所有患者在卒中发作后≤3 小时内均进行计算机断层扫描或磁共振脑成像。符合条件的患者接受溶栓治疗。双功能超声最初用于诊断重度（≥60%）ICA 狭窄，进一步的评估则通过磁共振或计算机断层血管造影或两者联合进行。围手术期的医疗和手术技术标准化。分析卒中、死亡、主要心脏事件和功能结局。
27 例患者在 SIE 的急性期接受了颈动脉血运重建。20 例患者的表现为波动或进行性神经功能缺损，其余 7 例（26%）在成功溶栓治疗后发生。入院时 NIHSS 中位数为 8。从首发事件到手术的中位延迟时间为 6 天。ICA 狭窄的平均程度为 87%。所有患者在干预期间均接受抗血小板和他汀类药物治疗。26 例患者（96.3%）采用常规 CEA 加补片血管成形术（聚四氟乙烯），1 例患者采用再重复置旁路移植术。23 例患者（85.2%）在局部麻醉下进行 CEA，3 例（13.0%）选择性转流，4 例在全身麻醉下系统转流。在出院时和 1 个月及 3 个月时，该系列患者无复发性卒中或死亡，1 例发生非致命性心肌梗死，随访率为 100%。在 3 个月时，所有患者的改良 Rankin 量表评分均≤2，功能结局良好。
本小系列研究表明，严格选择标准和密切血压监测下的 SIE 急性期 CEA 是安全的，即使在最近溶栓治疗后也是如此，并且在 3 个月时对功能结局有效。需要更大的患者系列来证实这种治疗方法的安全性和有效性。
