Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht University, the Netherlands.
Julius Centre for Health Sciences and Primary Care, Utrecht University, the Netherlands.
Eur J Vasc Endovasc Surg. 2021 Sep;62(3):350-357. doi: 10.1016/j.ejvs.2021.05.033. Epub 2021 Jul 24.
No dedicated studies have been performed on the optimal management of patients with an acute stroke related to carotid intervention nor is there a solid recommendation given in the European Society for Vascular Surgery guideline. By implementation of an international expert Delphi panel, this study aimed to obtain expert consensus on the optimal management of in hospital stroke occurring during or following CEA and to provide a practical treatment decision tree.
A four round Delphi consensus study was performed including 31 experts. The aim of the first round was to investigate whether the conceptual model indicating the traditional division between intra- and post-procedural stroke in six phases was appropriate, and to identify relevant clinical responses during these six phases. In rounds 2, 3, and 4, the aim was to obtain consensus on the optimal response to stroke in each predefined setting. Consensus was reached in rounds 1, 3, and 4 when ≥ 70% of experts agreed on the preferred clinical response and in round 2 based on a Likert scale when a median of 7 - 9 (most adequate response) was given, IQR ≤ 2.
The experts agreed (> 80%) on the use of the conceptual model. Stroke laterality and type of anaesthesia were included in the treatment algorithm. Consensus was reached in 17 of 21 scenarios (> 80%). Perform diagnostics first for a contralateral stroke in any phase, and for an ipsilateral stroke during cross clamping, or apparent stroke after leaving the operation room. For an ipsilateral stroke during the wake up phase, no formal consensus was achieved, but 65% of the experts would perform diagnostics first. A CT brain combined with a CTA or duplex ultrasound of the carotid arteries should be performed. For an ipsilateral intra-operative stroke after flow restoration, the carotid artery should be re-explored immediately (75%).
In patients having a stroke following carotid endarterectomy, expedited diagnostics should be performed initially in most phases. In patients who experience an ipsilateral intra-operative stroke following carotid clamp release, immediate re-exploration of the index carotid artery is recommended.
尚无专门研究探讨与颈动脉介入相关的急性卒中患者的最佳治疗方法，欧洲血管外科学会指南也未对此提供确切建议。本研究通过实施国际专家德尔菲小组，旨在就颈动脉内膜切除术（CEA）术中或术后发生院内卒中的最佳治疗方法达成专家共识，并提供实用的治疗决策树。
进行了四轮德尔菲共识研究，共纳入 31 名专家。第一轮的目的是研究表明在六个阶段将术中及术后卒中进行传统划分的概念模型是否合适，并确定这六个阶段的相关临床反应。在第二轮、第三轮和第四轮中，目的是确定在每个预设情况下对卒中的最佳反应。在第一轮、第三轮和第四轮中，当≥70%的专家同意首选临床反应时达成共识；在第二轮中，当给出中位数为 7-9（最适当的反应）且 IQR≤2 时基于 Likert 量表达成共识。
专家们（>80%）一致同意使用概念模型。卒中侧和麻醉类型被纳入治疗算法。21 个场景中的 17 个（>80%）达成共识。在任何阶段对对侧卒中，或在夹闭期间对同侧卒中，或在离开手术室后对明显的卒中，应首先进行诊断。对于在苏醒阶段出现的同侧卒中，未达成正式共识，但 65%的专家将首先进行诊断。应进行 CT 脑和 CTA 或颈动脉双功超声检查。对于血流恢复后同侧术中卒中，应立即再次探查颈动脉（75%）。
在颈动脉内膜切除术后发生卒中的患者中，大多数阶段都应首先进行快速诊断。在颈动脉夹闭释放后同侧术中发生卒中的患者中，建议立即再次探查指数颈动脉。
