Carotid endarterectomy and intracranial thrombolysis: Simultaneous and staged procedures in ischemic stroke

Purpose: The feasibility and safety of combining carotid surgery and thromb olysis for occlusions of the internal carotid artery (ICA) and the middle c erebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. Methods: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusion s of the MCA, was performed between January 1994 and January 1998. Exclusio n criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the m odified Rankin scale. Results: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the RI CA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic str oke (n = 5) or surgical reexploration after elective CEA complicated by per ioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embo lic occlusions and 10 of 11 ICA occlusions were recanalized successfully (c onfirmed with angiography or transcranial Doppler studies). Pour patients r ecovered completely (Rankin 0), six patients sustained a minor stroke (Rank in 2/3), two patients had a major stroke (Rankin 4/5), and two patients die d. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. Conclusion: Combining carotid surgery with thrombolysis (simultaneous or st aged procedure) offers a new therapeutic approach in the emergency manageme nt of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.