From the Department of Neurology (P.I., H.E., L.S.).
Department of Clinical Neurosciences, Clinicum, University of Helsinki, Finland (P.I., L.S.).
Stroke. 2018 Aug;49(8):1843-1849. doi: 10.1161/STROKEAHA.118.021517.
Background and Purpose- Carotid endarterectomy (CEA) is recommended within 14 days after carotid artery stroke to prevent recurrence. However, the optimal timing of CEA after intravenous thrombolysis (IVT) remains unclear. We studied the safety of CEA after IVT while taking into account both stroke recurrence and CEA-related complications. Methods- Patients who underwent IVT followed by CEA in Helsinki University Hospital 2005 to 2016 were withdrawn from prospectively collected registers. The incidence of stroke recurrence during the time between IVT and CEA, peri/postoperative stroke, hyperperfusion syndrome or drug-resistant high blood pressure, and 3-month outcome measured by modified Rankin Scale was recorded. Stroke patients treated with CEA without preceding IVT were used as controls. Results- Altogether 128 CEAs with preceding IVT and 777 CEAs for stroke without IVT were identified. The median time from IVT to CEA was 9 days (range, 0-349 days; interquartile range, 16). Seven patients (5.5%) underwent CEA within 24 hours, 20 (15.6%) within 48 hours and 87 (68.0%) within 2 weeks from IVT. Stroke recurrence in IVT-CEA patients was 5.5% at median 4 days after IVT (range, 0-8 days). Outcome from CEAs performed within 48 hours from IVT did not differ from CEAs performed later with respect to peri/postoperative ischemic strokes (5.0% and 3.7%), hemorrhagic strokes (5.0% and 1.9%), neck hematomas (5.0% and 8.3%), myocardial infarctions (0.0% and 0.9%), or 3-month modified Rankin Scale. There was a tendency toward higher incidence of hyperperfusion syndrome in the patients operated within 48 hours from IVT (20.0% versus 6.5%; P=0.070). The CEA-related stroke rate was similar to that of the operation without thrombolysis. Only smoking was significantly associated with peri/postoperative stroke (odds ratio, 21.82; 95% confidence interval, 1.08-439.58). Conclusions- Time between IVT and CEA was not associated with CEA-related complications. The high rate of stroke recurrence during the waiting time for CEA underscores the importance of shortening surgery delays.
背景与目的-颈动脉内膜切除术（CEA）被推荐在颈动脉卒中后 14 天内进行，以预防复发。然而，静脉溶栓（IVT）后行 CEA 的最佳时机仍不清楚。我们研究了 IVT 后行 CEA 的安全性，同时考虑到卒中复发和 CEA 相关并发症。方法-2005 年至 2016 年，在赫尔辛基大学医院接受 IVT 后行 CEA 的患者从前瞻性收集的登记处中撤出。记录 IVT 和 CEA 之间时间内的卒中复发发生率、围手术期卒中、高灌注综合征或耐药性高血压以及 3 个月时改良 Rankin 量表测量的结果。未行 IVT 而接受 CEA 治疗的卒中患者作为对照组。结果-共纳入 128 例行 CEA 治疗且此前接受 IVT 的患者和 777 例行 CEA 治疗且此前未接受 IVT 的卒中患者。IVT 至 CEA 的中位时间为 9 天（范围，0-349 天；四分位距，16）。7 例（5.5%）在 IVT 后 24 小时内行 CEA，20 例（15.6%）在 48 小时内行 CEA，87 例（68.0%）在 2 周内行 CEA。IVT-CEA 患者在 IVT 后 4 天（范围，0-8 天）中位时间出现卒中复发，发生率为 5.5%。在 IVT 后 48 小时内行 CEA 与在 IVT 后更晚行 CEA 相比，围手术期缺血性卒中（5.0%与 3.7%）、出血性卒中（5.0%与 1.9%）、颈部血肿（5.0%与 8.3%）、心肌梗死（0.0%与 0.9%）或 3 个月时改良 Rankin 量表评分均无差异。在 IVT 后 48 小时内行 CEA 的患者中，高灌注综合征的发生率有增高趋势（20.0%比 6.5%；P=0.070）。CEA 相关卒中发生率与未溶栓手术相似。只有吸烟与围手术期卒中显著相关（比值比，21.82；95%置信区间，1.08-439.58）。结论-IVT 与 CEA 之间的时间间隔与 CEA 相关并发症无关。CEA 等待期间卒中复发率较高，强调了缩短手术延迟的重要性。
