Immediate reexploration for the perioperative neurologic event after carotid endarterectomy: Is it worthwhile?

Purpose: When managing a new neurologic deficit after carotid endarterectom y (CEA), the surgeon is often preoccupied with determining the cause of the problem, requesting diagnostics tests, and deciding whether the patient sh ould be surgically reexplored. The goal of this study was to analyze a seri es of perioperative neurologic events and to determine if careful analysis of their timing and mechanisms can predict which cases are likely to improv e with reoperation. Methods: A review of 2024 CEAs performed from 1985 to 1997 revealed 38 pati ents who manifested a neurologic deficit in the perioperative period (1.9%) . These cases form the focus of this analysis. Results: The causes of the events included intraoperative clamping ischemia in 5 patients (13.2%); thromboembolic events in 24 (63.2%); intracerebral hemorrhage in 5 (13.2%); and deficits unrelated to the operated artery in 4 (10.5%). Neurologic events manifesting in the first 24 hours after surgery were significantly more Likely to be caused by thromboembolic events than by other causes of stroke (88.0% vs 12.0%, P < .002); deficits manifesting after the first 24 hours were significantly more likely to be related to ot her causes. Of 25 deficits manifesting in the first 24 hours after surgery, 18 underwent immediate surgical reexploration. Intraluminal thrombus was n oted in 15 of the 18 reexplorations (83.3%); any technical defects were cor rected. After the 18 reexplorations, in 12 cases there was either complete resolution of or significant improvement in the neurologic deficit that had been present (66.7%). Conclusions: Careful analysis of the timing and presentation of perioperati ve neurologic events after CEA can predict which cases are likely to improv e with reoperation. Neurologic deficits that present during the first 24 ho urs after CEA are likely to be related to intraluminal thrombus formation a nd embolization. Unless another etiology for stroke has clearly been establ ished, we think immediate reexploration of the artery without other confirm atory tests is mandatory to remove the embolic source and correct any techn ical problems. This will Likely improve the neurologic outcome in these pat ients, because an uncorrected situation would lead to continued embolizatio n and compromise.