Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery

Background and Purpose-Tissue plasminogen activator (tPA) has been shown to be effective for acute ischemic stroke. However, if a high-grade cervical carotid stenosis remains despite tPA therapy, patients are at risk for recu rrent stroke. Carotid endarterectomy (CEA) has been shown to be effective i n symptomatic patients with high-grade cervical carotid stenosis in reducin g the risk of stroke, but it is unknown whether CEA can be performed safely after tPA thrombolysis. We describe our experience with 5 patients who und erwent early (<48 hours) CEA for residual high-grade cervical carotid steno sis after thrombolytic therapy for acute ischemic stroke in the middle cere bral artery territory. Methods-All patients had a critical (>99%) carotid artery stenosis on the s ymptomatic side after tPA therapy. All patients received intravenous tPA; 3 patients also received intra-aortic tPA. Three patients received intraveno us heparin infusion immediately after administration of tPA. All patients s howed marked improvement in their National Institutes for Health Stroke Sca le scores after treatment with tPA. CEA was then performed within 45 hours (6 hours in 1 patient, 23 hours in 2, 26 hours in 1, and 45 hours in 1). Results-All 5 patients underwent successful CEA. There were no complication s related to surgery. At discharge, 2 patients had a normal examination, an d the remaining patients had mild deficits. In a long-term follow-up of 5 t o 22 months, no patient had a recurrent cerebrovascular event. Conclusions-Early CEA can be performed safely and successfully in patients after tPA treatment for acute ischemic stroke in appropriately selected pat ients.