Immediate postoperative thrombolytic therapy: An aggressive strategy for neurologic salvage when cerebral thromboembolism complicates carotid endarterectomy

A 42-year-old man with a high-grade left internal carotid artery (ICA) sten osis demonstrated on a duplex scan was referred to us. A cerebral arteriogr am confirmed a greater than 90% left internal carotid stenosis, but with th e unexpected finding of a moderate amount of thrombus in the proximal ICA. He underwent emergent left carotid endarterectomy, but during the operation , only a small amount of thrombus was identified as adherent to the atheros clerotic plaque. He awakened in the operating room with a dense right hemip legia and aphasia. Immediate reexploration demonstrated a patent endarterec tomy site, a distal thromboembolectomy was performed without extraction of thrombus, and urokinase (250,000 units) was infused into the distal ICA. He reawakened with an unchanged right hemiplegia and aphasia. The patient the n under ii ent an urgent postoperative carotid and cerebral arteriogram tha t demonstrated an embolus to the middle cerebral artery. He was treated wit h the superselective infusion of urokinase (500,000 units), with almost com plete resolution of the clot. Over the course of the next 48 hours, the pat ient made a nearly complete neurologic recovery, and he was discharged from the hospital with only a slight facial droop. At 2 months' follow-up he wa s completely neurologically healthy To our knowledge this is the first repo rted case of urokinase administered in the immediate postoperative period i n the angiography suite to treat a thromboembolus complicating a carotid en darterectomy.