Intracerebral hemorrhage after carotid endarterectomy: Incidence, contribution to neurologic morbidity, and predictive factors

Purpose: With a diminishing rate of cardiac and neurologic events after car otid endarterectomy, intracerebral hemorrhage is gaining increasing importa nce as a cause of perioperative morbidity and mortality. To date, informati on has been largely anecdotal, and there has been no comparison with a cont rol group of patients. Methods: The records of all patients experiencing symptomatic intracerebral hemorrhage after carotid endarterectomy were reviewed and compared with da ta from 50 randomly selected patients who did not experience intracranial b leeding. Univariate analyses were performed, using the Fisher exact test fo r dichotomous data and the Student t test for continuous data. Results: During a 6-year period, symptomatic intracranial hemorrhage develo ped in II (0.75%) of 1471 patients undergoing carotid endarterectomy; accou nting for 35% of the 31 total perioperative neurologic events. Hemorrhage o ccurred a median of 3 days postoperatively (range, 0 to 18 days). Signs and symptoms included hypertension in all 11 patients, headache in 7 conscious patients (64%), and bradycardia in 6 patients (55%). Massive hemorrhage wi th herniation and death occurred in 4 patients (36%). Moderate hemorrhage d eveloped in 5 patients (45%); 3 of these patients had partial recovery, and 2 had complete recovery. Petechial hemorrhage occurred in the remaining 2 patients (18%), 1 with partial and 1 with complete recovery. In comparison with the control group, there were no differences in respect to sex, indica tion for operation, smoking or diabetic history and antiplatelet therapy or perioperative heparin management. Patients with intracranial hemorrhage we re, however, younger, more frequently hypertensive, had a higher degree of ipsilateral and contralateral carotid stenosis, and had a higher rate of co ntralateral carotid occlusion. Conclusion: Intracranial hemorrhage occurs with notable frequency after car otid endarterectomy and accounts for a significant proportion of neurologic morbidity and mortality. Younger patients, hypertensive patients, and pati ents with severe cerebrovascular occlusive disease appear to be at greatest risk for the complication.