Vascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
J Vasc Surg. 2012 Jun;55(6):1611-7. doi: 10.1016/j.jvs.2011.11.144. Epub 2012 Feb 23.
The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms.
This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging.
Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%).
Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA.
本研究旨在探讨伴有不稳定神经症状的颈动脉狭窄患者行急诊颈动脉内膜切除术（CEA）的安全性。
本前瞻性单中心研究纳入了因狭窄程度≥50%的颈动脉狭窄而接受急诊手术的进展性卒（SIE）、波动性卒或渐强性短暂性脑缺血发作（cTIA）患者。术前检查包括入院时、术前即刻和出院时的国立卫生研究院卒中量表（NIHSS）神经评估、颈动脉双功能超声、脑增强 CT 或磁共振成像（MRI）。研究终点为围手术期（30 天）神经死亡率、NIHSS 评分变化，以及出血性或缺血性卒中复发。根据临床表现（SIE 或 cTIA）、手术时机以及神经影像学是否存在脑梗死对患者进行评估。
2005 年 1 月至 2009 年 12 月，48 例患者接受了急诊手术。从症状发作到手术的时间为 1 至 24 小时（平均 10.16±7.75 小时）。26 例患者出现 SIE，入院至手术时 NIHSS 评分恶化，22 例患者出现≥3 次 cTIA，术前 NIHSS 评分正常（=0）。4 例 SIE 患者和 8 例 cTIA 患者存在缺血性脑损伤。所有 cTIA 患者术前和术后 NIHSS 评分均正常。25 例 SIE 患者术后 NIHSS 评分改善。SIE 组术前 NIHSS 评分为 5.30±2.81，术后为 0.54±0.77（P＜0.0001）。1 例 SIE 患者术后出现未检出的脑缺血性病变的出血性转化，伴有进行性神经功能恶化和死亡（2%）。
由于目前尚无针对神经不稳定患者行 CEA 的随机对照试验，因此现有数据不支持对这些患者行急诊 CEA。我们的结果表明，对神经不稳定患者快速制定包括 CT 扫描和颈动脉双功能超声检查的方案，有助于确定可安全行急诊 CEA 的患者。
