Urgent carotid endarterectomy for stroke: a case report

Sandeep Maharajh¹, Avidesh Panday¹, Dave Harnanan¹, Samara Hassranah¹, Vijay Naraynsingh¹

¹ Medical Associates Hospital, St Joseph, Trinidad and Tobago

Corresponding Author:
Sandeep Maharajh
Email: [email protected]

DOAJ: 133f2accda104f7f9b90d36507250906
DOI: https://doi.org/10.48107/CMJ.2024.03.003
Published Online: May 2, 2024

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2024 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association

ABSTRACT
Urgent carotid endarterectomy (CEA) is beneficial in patients with non-disabling stroke or transient ischemic attack and significant ipsilateral carotid artery stenosis. It is recommended to be performed within 2-4 weeks of the event; however, its safety when done within 48 hours is still under investigation with potential risks of recurrent ipsilateral stroke and death being reported. This case highlights that urgent CEA done within 48 hours can result in significant neurological improvement. NICE advises within 48 hours of diagnosis and <7 days of radiological imaging while some large studies- especially a Swedish study of >2000 patients concluded an increased risk of stroke and death when performed within 48 hours. Evidence is still developing. In selected cases, this timely intervention can be the standard of care in the Caribbean setting in keeping with international best practice.

INTRODUCTION
Carotid endarterectomy (CEA) is highly effective for stroke prevention in patients who have significant carotid stenosis and transient ischemic attack (TIA) or stroke in evolution. However, reluctance to do early CEA in patients with acute neurological symptoms was based on the risk of secondary hemorrhage on revascularization of the ischemic brain. There is much evidence on the safety of urgent CEA in symptomatic patients with early neurological events or non-disabling stroke. The main benefit of this procedure is to reduce the risk of recurrent ipsilateral ischemic stroke. A recent case stimulated this report and review of the literature.

Case Description
A 79-year-old previously well male presented to the Emergency Room with a 3-hour history of mild dysarthria and left upper and lower limb weakness. He had mild facial asymmetry with an upper motor neuron 7th nerve pattern along with 4/5 power in the left upper and 4+/5 power in the left lower limb. His cardiac examination was unremarkable with a regular pulse of 78/min and a blood pressure ranging from systolic of 190-210mmHg. His ECG and routine labs were normal. CT Brain was normal with an ASPECTS score of 10/10 (ASPECT Score aims to quantify CT changes in early middle cerebral artery stroke by subtracting from 10 based on pathologic topographic findings, lower the score the poorer the outcome). Given his mild disability, a decision was made not for intravenous thrombolysis. He was commenced on dual antiplatelet treatment (loading dose of Aspirin 325mg and Clopidogrel 300mg) as well as Rosuvastatin 40mg and allowed permissive hypertension with no medications for blood pressure unless a systolic greater than 220mmHg and diastolic greater than 110mmHg.

Over the next 24 hours his motor examination changed with worsening left hemiparesis, with 1/5 power in the right upper and 2/5 power in the right lower limb. There was prominent dysarthria and significant impairment of swallowing necessitating a nasogastric tube. At no point was there any loss of awareness or consciousness and his higher cognitive function was unaffected. Further testing at this time revealed a normal echocardiogram with no dilation of the left atrium or ventricle, no regional wall motion abnormalities, and an intact left ventricular ejection fraction. No valvular abnormalities or intramural thrombi was noted. His Carotid Duplex revealed an elevated peak systolic velocity (PSV) of the left internal carotid artery of 200 msec consistent with a 50-70% stenosis on the left and with normal parameters for the right internal carotid artery. In light of this, a CT Carotid Angiogram was done to accurately estimate the percentage stenosis as well as look for tandem lesions either intracranially or extracranially. This revealed a short segment 80% circumferential stenosis in the proximal left internal carotid artery (Figure 1). Additionally, on this scan we appreciated a lesion in the posterior limb of the left internal capsule and Centrum Semiovale.

In view of his worsening symptoms, new imaging findings on CT, significant ipsilateral carotid stenosis and lack of intracranial stenosis, the patient underwent successful carotid revascularization in the form of a CEA (Figure 2). This was performed in under 48 hours from the time of symptom onset. On day 1 post operation (day 3 post symptoms), the patient’s dysarthria and swallowing improved significantly so that the nasogastric tube was discontinued. On discharge on day 4, his power in the right upper limb was 2/5 and the lower limb 3/5. On clinical review two weeks later, he had grade 4/5 power in the upper limb and 4/5 power in the lower limb and was ambulating with a walker.

Figure 1: CT Angiogram showing significant left extracranial common carotid stenosis (yellow arrow).

Figure 2: Intraoperative CEA photo showing successful removal of atheromatous plaque (white arrow) and smooth lumen of endarterectomized carotid (blue arrow).

DISCUSSION
The restoration of cerebral blood flow in patients with acute stroke is time dependent to limit neuronal cell death. Emergent CEA has been shown by the NASCET and the European Carotid Surgery Trial (ECST) to be beneficial in providing neurological improvement and secondary prevention of future strokes in patients with symptomatic carotid stenosis [1] [2]. These trials showed clear benefit in patients with high grade ipsilateral carotid stenosis of >70% diameter while no benefit was shown in stenoses <50%. The NASCET 2-year follow up showed an ipsilateral stroke risk of 26% with best medical treatment (BMT) versus 9% risk with BMT and CEA.

Urgent CEA restores blood flow to ischemic areas of the brain and aims to eradicate thromboembolic extracranial carotid sources for secondary prevention of stroke. The above trials initially advised for delayed CEA after the neurological event due to initial reports of increased risk of intracranial hemorrhage. However, subsequent trials have studied the risk vs benefits of urgent vs delayed/elective CEA for ischemic strokes and transient ischemic attacks with varying results. Rothwell et al analyzed 5893 patients from both the NASCET and ECST and deduced greatest benefit from CEA was in male patients, patients older than 75 years of age and those randomized within 2 weeks of their last ischemic event [3].

Most importantly – is CEA within 48 hours safe? In our case, urgent CEA was performed at less than 48 hours and early significant improvement in motor function and dysarthria resulted.  A meta-analysis by Chen et al of 10 studies of 29,457 patients studied specific outcomes. This paper reported urgent CEA within 48 hours after onset of stroke resulted in a decreased risk of postoperative stroke. Notably CEA performed after 1 and 2 weeks of event showed an increased incidence of post operative stroke when compared to those who had intervention before this time[4]. Further evidence in support of CEA in less than 48 hours was provided, as this meta-analysis concluded that the perioperative mortality risk was less when CEA was performed within 48 hours of symptom onset.

The safety of CEA within 48 hours is further supported by Ranter et al in studying 761 patients; there was no evidence of increased risk of stroke or death with CEA performed in less than 48 hours compared to 2- 7 days or less than 14 days [5]. Bruls et al smaller study of 31 patients purports CEA can be safely performed within 24 hours [6]. Contrastingly, a national review of the Swedish vascular registry of 2596 patients, stated a combined mortality and stroke post operative risk of 11.6% when urgent CEA was performed within 48 hours versus a 3.6% to 4.0% risk in those operated on between 2 to 14 days [7].

With the use of objective scoring such as the NIH Stroke Scale/Score (NIHSS), clinicians are able to rapidly and reproducibly stratify the severity of stroke in the emergent setting. Data suggest that higher scores can predict worse outcomes after urgent CEA. When NIHSS scores were correlated with outcomes in patients receiving CEA within 48 hours, Mihindu et al. found that patients with an NIHSS score >10 had a significantly higher risk of worsened strokes, intracranial hemorrhage and death [8].

The standard of care is the provision of intravenous recombinant-tissue plasminogen activator for ischemic strokes within the 4.5-hour window. Risk factors for carotid artery stenosis and strokes are similar and therefore these patients may be candidates for urgent CEA. Data regarding the safety of urgent CEA post thrombolysis is developing. In a review of 21 reports on 1165 patients, Brinster et al. data suggest that CEA can be safely performed within the first 14 days of receiving intravenous thrombolysis [9]. Notably, Bazan et al. found increased risk of intracranial hemorrhage in patients with moderate to severe scoring on National Institutes of Health Stroke Scale (NIHSS) >16 [10]. Therefore, the importance of appropriate patient selection for the acute management of stroke is emphasized.

Early revascularization after ischemic non-disabling stroke or TIA with urgent carotid endarterectomy within 14 days has been proven to provide neurological improvement and secondary prevention of stroke. The complications of intracranial hemorrhage, myocardial infarction and death cited early on have been shown to be non-significant and appropriate selection of patients minimizes these risks. A major risk factor associated with this procedure is delay of surgery from the time of diagnosis with higher risks of complications. Therefore, increased familiarity with the benefits of surgery by clinicians is useful to include in the management of suitable patients and the relevant organizational structures should be instituted to provide timely diagnosis, further imaging investigations, operative management and post-operative rehabilitation.

Conclusion
From this case, it is shown that urgent CEA done within 48 hours can result in significant neurological improvement. Urgent CEA is now the standard of care worldwide in the emergent treatment of strokes in patients with significant extra-cranial carotid artery stenosis who meet strict selection criteria. With the increasing incidence of stroke, readily available CT imaging modality and patients presenting within the appropriate window for emergent treatment, early CEA should be considered.

Acknowledgements: None.
Ethical approval statement: This paper has been given ethical approval by the local ethics committee.
Financial disclosure or funding: Not Applicable.
Conflict of interest: Not Applicable.
Informed consent: Informed consent was provided by patient for this case report.
Author contributions: Sandeep Maharajh – literature review and contributions to writing of manuscript; Avidesh Panday – critical review and contributions to writing of the manuscript, neurologist for case; Dave Harnanan – critical review, vascular surgeon for case; Samara Hassranah – contributions to writing the manuscript; Vijay Naraynsingh – critical review, contributions to writing of the manuscript, final approval, senior surgeon for case.

 REFERENCES

1. North American Symptomatic Carotid Endarterectomy Trial Collaborators, Barnett, H., Taylor, D. W., Haynes, R. B., Sackett, D. L., Peerless, S. J., Ferguson, G. G., Fox, A. J., Rankin, R. N., Hachinski, V. C., Wiebers, D. O., & Eliasziw, M. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. The New England journal of medicine 1991, 325(7), 445–453. DOI: 10.1056/NEJM199108153250701
2. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet (London, England) 1998, 351(9113), 1379–1387.
3. Rothwell, P. M., Eliasziw, M., Gutnikov, S. A., Warlow, C. P., Barnett, H. J., & Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet (London, England) 2004, 363(9413), 915–924.DOI: 10.1016/S0140-6736(04)15785-1
4. Chen, X., Su, J., Wang, G., Zhao, H., Zhang, S., Liu, T., Su, X., & Zhou, N. Safety and Efficacy of Early Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Meta-Analysis. BioMed research international, 2021, 6623426. DOI: 10.1155/2021/6623426
5. Rantner, B., Schmidauer, C., Knoflach, M., & Fraedrich, G. Very urgent carotid endarterectomy does not increase the procedural risk. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 2015, 49(2), 129–136.  DOI: 10.1016/j.ejvs.2014.09.006
6. Bruls, S., Desfontaines, P., Defraigne, J. O., & Sakalihasan, N. Urgent Carotid Endarterectomy in Patients with Acute Neurological Symptoms: The Results of a Single Center Prospective Nonrandomized Study. Aorta (Stamford, Conn.) 2013, 1(2), 110–116. doi: 10.12945/j.aorta.2013.13-008
7. Strömberg, S., Gelin, J., Osterberg, T., Bergström, G. M., Karlström, L., Osterberg, K., & Swedish Vascular Registry (Swedvasc) Steering Committee. Very urgent carotid endarterectomy confers increased procedural risk. Stroke 2012, 43(5), 1331–1335. DOI: 10.1161/STROKEAHA.111.639344
8. Mihindu, E., Mohammed, A., Smith, T., Brinster, C., Sternbergh, W. C., 3rd, & Bazan, H. A. Patients with moderate to severe strokes (NIHSS score >10) undergoing urgent carotid interventions within 48 hours have worse functional outcomes. Journal of vascular surgery 2019, 69(5), 1471–1481. DOI: 10.1016/j.jvs.2018.07.079
9. Brinster, C. J., & Sternbergh, W. C. Safety of urgent carotid endarterectomy following thrombolysis. The Journal of cardiovascular surgery 2020, 61(2), 149–158. DOI: 10.23736/S0021-9509.20.11179-0
10. Bazan, H. A., Zea, N., Jennings, B., Smith, T. A., Vidal, G., & Sternbergh, W. C. Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke. Journal of vascular surgery 2015, 62(6), 1529–1538. DOI: 1016/j.jvs.2015.07.082