Our Summary

This research paper discusses treatment strategies for acute ischemic stroke, a leading cause of illness and death worldwide. The paper focuses on strokes caused by blocked carotid arteries, which account for up to 20% of all strokes. It suggests that treating these strokes early with interventions on the carotid artery can improve outcomes for patients.

Intravenous thrombolysis (IVT), a technique that dissolves blood clots, has revolutionized stroke therapy. It uses a substance called tissue plasminogen activator (tPA) and is considered the main treatment for acute ischemic stroke if given within 3 to 4.5 hours of the onset of symptoms. There is, however, debate over when to perform carotid endarterectomy (CEA), a surgical procedure to remove blockages from the carotid artery, after IVT.

The researchers reviewed a range of published studies from 1998 to 2019. They found 21 reports involving 1165 patients. On average, the CEA was performed 7.1 days after IVT. The 30-day rate of stroke and death was 4.1%, and the average occurrence of brain bleeding was 2.6%. The combined data from these studies suggest that CEA can be safely performed within the first 14 days after stroke symptoms start in patients who previously received IVT. However, evidence is mixed regarding the safety of performing CEA urgently, within 48 to 72 hours of IVT.

The paper concludes that as more patients are quickly treated for stroke and then referred to specialized centers, vascular specialists will see more patients who may require urgent CEA after IVT. More research is needed to determine the best timing for CEA after IVT, particularly within the first 72 hours after administering tPA.

FAQs

  1. What is carotid endarterectomy (CEA) and when is it typically performed?
  2. What is the debate regarding the timing of CEA after intravenous thrombolysis (IVT)?
  3. What does the research suggest regarding the safety of performing CEA urgently, within 48 to 72 hours of IVT?

Doctor’s Tip

A doctor might advise a patient undergoing carotid endarterectomy to follow post-operative instructions carefully, including taking prescribed medications, monitoring for signs of infection or complications, and attending follow-up appointments to ensure proper healing and recovery. Additionally, the doctor may recommend lifestyle changes such as quitting smoking, maintaining a healthy diet, and regular exercise to reduce the risk of future blockages in the carotid artery.

Suitable For

Patients who are typically recommended for carotid endarterectomy include those who have had an acute ischemic stroke caused by a blocked carotid artery and have received intravenous thrombolysis (IVT) within 3 to 4.5 hours of symptom onset. These patients may benefit from CEA within the first 14 days after the stroke. However, there is ongoing debate and mixed evidence regarding the safety and timing of performing CEA urgently, within 48 to 72 hours of IVT. More research is needed to determine the best approach for treating these patients and improving outcomes.

Timeline

Before carotid endarterectomy, a patient may experience symptoms of carotid artery disease such as transient ischemic attacks (TIAs) or minor strokes. They may undergo diagnostic tests such as ultrasound or angiography to assess the severity of the blockage in the carotid artery. Once a decision is made to proceed with carotid endarterectomy, the patient will undergo preoperative evaluations and preparations.

During carotid endarterectomy, the surgeon makes an incision in the neck, removes the plaque buildup from the carotid artery, and then closes the incision. The procedure typically takes a few hours and is performed under general anesthesia. After the surgery, the patient is monitored in the hospital for complications such as bleeding, infection, or stroke.

After carotid endarterectomy, the patient may experience some pain, swelling, or bruising at the incision site. They will be given instructions for wound care, pain management, and activity restrictions. Follow-up appointments with the surgeon will be scheduled to monitor recovery and assess the effectiveness of the procedure in reducing the risk of future strokes. Physical therapy or rehabilitation may be recommended to help the patient regain strength and function in the neck and surrounding areas.

What to Ask Your Doctor

Some questions a patient should ask their doctor about carotid endarterectomy include:

  1. What is carotid endarterectomy and why is it recommended for me?
  2. What are the potential risks and complications associated with carotid endarterectomy?
  3. How long is the recovery period after carotid endarterectomy?
  4. What are the success rates of carotid endarterectomy in improving symptoms and reducing the risk of stroke?
  5. Will I need to make any lifestyle changes or take medications after the procedure?
  6. How soon after my stroke should carotid endarterectomy be performed?
  7. Are there any alternative treatments or procedures that I should consider?
  8. How many carotid endarterectomies have you performed, and what is your success rate?
  9. Will I need any follow-up appointments or tests after the procedure?
  10. Can you provide me with any additional information or resources about carotid endarterectomy?

Reference

Authors: Brinster CJ, Sternbergh WC 3rd. Journal: J Cardiovasc Surg (Torino). 2020 Apr;61(2):149-158. doi: 10.23736/S0021-9509.20.11179-0. PMID: 32225134