ISCHEMIC STROKE / ACUTE THERAPY

Surgical treatment of an acute ischemic stroke

Created 27/01/2022, last revision 16/09/2022

Emergency carotid endarterectomy (< 24h)

  • insufficient data on the effectiveness of the method in acute stroke  (AHA/ASA 2019 IIb/B-NR)
  • surgical risk in neurologically unstable patients is increased, but good results were reported in case series; no RCTs are available
  • can be considered in:
    • crescendo TIA/stroke with the initial mild deficit and small ischemic lesion on CT/MRI that is caused by significant stenosis or thrombotic ICA occlusion with presumed hypoperfusion mechanism  [Gorlitzer, 2009] [Gajin, 2013]
      • intracranial occlusion (above skull base) must be excluded; it is challenging to differentiate distal ICA thrombosis from blood stagnation without retrograde contrast agent filling
      • CEA indication is supported by the finding of low flows in the MCA and depleted VMR on TCCD and/or significant MR DWI/PWI mismatch
    • acute surgical revision of thrombosed ICA after recent CEA (in the absence of intracranial thromboembolic occlusion)
  • the acuteness of carotid occlusion can be assessed by CTP or ultrasound  [Herzig, 2011]
Carotid endarterectomy (CEA)

Tandem lesion

  • in case of simultaneous severe carotid stenosis/occlusion and intracranial occlusion, mechanical embolectomy should be performed (if the relevant criteria are met)
  • after a successful intracranial embolectomy, it is possible to proceed with:
    • emergency CAS (⇒ issue with antiplatelet therapy arises in the thrombolysed patients)
    • emergency carotid angioplasty to achieve recanalization with delayed stenting of the adequately medically prepared patient or early CEA
    • emergency CEA  (Slawski, 2018)

Emergency EC-IC bypass

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