Surgical treatment of an acute ischemic stroke

David Goldemund M.D.
Updated on 21/12/2023, published on 27/01/2022

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, although good results have been reported in case series; no randomized controlled trials (RCTs) are available
  • can be considered in the following scenarios:
    • crescendo TIA/stroke with the initial mild deficit and small ischemic lesion on CT/MRI 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 filling
      • CEA indication is supported by the finding of low flows in the MCA and depleted vasomotor reactivity (CVR) 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 CT perfusion (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 EC-IC bypass

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Surgical treatment of an acute ischemic stroke