BLOOD-BRAIN-BARRIER BREAKING - IS STILL AN ABSOLUTE CONTRAINDICATION TO EARLY SURGICAL REPERFUSION OF THE BRAIN

In the early treatment of the patients with cerebrovascular insufficie ncy due to internal carotid artery stenosis, the presence of a cerebra l infarct and especially the blood brain barrier breaking (BBB) are co nsidered by many as a contraindication to early reperfusion by carotid endarterectomy (CEA). Generally, it has been recommended to differ th e operation at least for 4-6 weeks because of the high risk to convert an ischemic infarct into an hemorrhagic one. On the other hand, becau se unfavorable natural history has been reported as for the progressin g unstable neurological deficit as for the minor recent strokes, respe ctively by Millikan and Dosik, it seem to be justified a more aggressi ve management with the aim of : 1) eliminating the stenosis as embolic source of emboli ; 2) obtaining early brain reperfusion to increase t he probability of good recovery. Some previous experiences reported in the literature demonstrated satisfactory results of early reperfusion even in presence of BBB. The Authors present 4 cases of early CEA in patients with BBB. After the CT scan the patients have been submitted preoperatively to non invasive tests (duplex scanning and transcranial Doppler sonography) to assess the presence of the internal carotid ar tery stenosis and the viability of the intracranial cerebral arteries with special regard to the middle cerebral artery. All the patients un derwent CEA in loco-regional anesthesia and particularly systemic bloo d pressure was carefully monitored and any hypertensive status was ear ly corrected by prompt antihypertensive therapy (i.v. nitrates and or calcium blocking agents). None of them experienced a worsening of thei r neurological condition. On the basis of this preliminary experience, the authors believe that in some very selected cases (small cerebral infarct, good residual cerebral perfusion) and thanks to a careful int ra and perioperative monitoring of systemic blood pressure an early re perfusion of an acute or recent stroke is worthwhile (J Mal Vasc, 1993 , 18, pp. 238-242).