Gunka Igor, Krajickova Dagmar, Lesko Michal, Renc Ondrej, Raupach Jan, Jiska Stanislav, Lojik Miroslav, Chovanec Vendelin, Hudak Alexander, Maly Radovan
Department of Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
Department of Neurology, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic.
Ann Vasc Surg. 2019 Nov;61:185-192. doi: 10.1016/j.avsg.2019.05.061. Epub 2019 Aug 5.
Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE).
A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE).
A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2).
Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.
在神经系统症状不稳定的情况下进行颈动脉内膜切除术（CEA）仍是一个有争议的问题。本研究的目的是评估在短暂性脑缺血发作（cTIA）或进展性卒中（SIE）患者中进行紧急（≤48小时）CEA的疗效。
对2013年1月至2018年11月期间所有连续接受紧急CEA的神经系统不稳定患者的前瞻性收集数据进行回顾性分析。终点指标包括30天内任何卒中及死亡率、症状性脑出血（ICH）、心肌梗死（MI）、需要干预的手术部位出血、美国国立卫生研究院卒中量表（NIHSS）评分变化以及90天时用改良Rankin量表（mRS）评估的功能结局。根据临床表现（cTIA或SIE）对患者进行评估。
共纳入46例神经系统不稳定患者，其中cTIA患者20例（43.5%），SIE患者26例（56.5%）。cTIA组30天内任何卒中或死亡风险为10.0%（20例中的2例），SIE组为7.7%（26例中的2例）。两个研究组术后均未检测到症状性ICH或MI。共有2例患者（4.3%；1例cTIA，1例SIE）因手术部位出血接受了再次手术。在SIE患者中，入院时NIHSS评分的平均值为9.85±5.12。术后，26例SIE患者中有22例（84.6%）神经功能缺损有临床改善，3例（11.5%）患者无变化，1例（3.8%）患者死亡。出院时，NIHSS评分的平均值为4.31±6.09分，与入院时的NIHSS评分相比有显著改善（P<0.001）。在3个月时，21例（80.8%）SIE患者有良好的临床结局（mRS≤2）。
对神经系统不稳定的患者进行紧急CEA，围手术期风险可接受。此外，在精心挑选的SIE患者中，紧急CEA可能与最终功能结局的显著改善相关。
