Surgical treatment of acute carotid artery thrombosis

Aim. The efficacy of emergency carotid thromboendarterectomy (CTEA) for acute thrombosis of extracranial internal carotid artery (ICA) has been questioned related to complications. We evaluated the use of CTEA, based to selection of patients up the neurological status and the time of onset of symptoms, in recent ICA occlusion in stenosis aterosclerotic. Methods. From January 2001 to April 2009, patients who underwent urgent CTEA for recent acute thrombosis of ICA were retrospectively evaluated. Patient’s data included age, sex, comorbid factors, diagnostic management, time of onset of symptoms and admission in stroke unit (I/R), time of onset of symptoms and revascularization of ICA (I/F), operative procedure, long term follow-up with clinical assessment and carotid Duplex scan. Neurological status was evaluated with Modified Rankin Scale (MRS) in preoperatively and after one month, three months, six months and one year. Results. Eighteen patients (13 males and 5 females, mean age 69.5 years) were identified as having urgent CTEA due to acute symptomatic ICA. The mean I/F was 2.94 h (range 1-6) and the mean I/R was 6.44 h (range 4-10). Diagnostic work-up consisted of extracranial Duplex sonography, cerebral computed tomography with contrast, digital angiography, magnetic resonance angiography and intraoperative angiography. Exclusion criteria were: impaired level consciousness, infarction volume that exceeded more than one-third of middle cerebral artery (MCA) perfusion area, occlusion of intracranial ICA or ipsilateral MCA, intracranial hemorrhage or significant cerebral edema or hemispheric asymmetry. On admission the MRS score was: level 1 two cases (11%), level 2 two cases (11%), level three seven cases (39%), level 4 six cases (33%), level 5 one case (5%). Immediate postoperative morbidity including one case of non-fatal myocardial infarction (5%), one case of arrhytmia (5%), one neck hematoma required evacuation (5%), two transient cranial injuries (11%), one conversion to fatal hemmorrhagic stroke (5%), one stroke secondary to rethrombosis of IC (5%). Postoperative clinical course at discharge improved or deteriorated means change of one point or more in MRS at 12 months was: improved 11 (61%) patients, unchanged five (27%) patients, dead one (5%) patient at six months. Patency of ICA treated at 12 months was 94%. Conclusions. Restoration of blood flow in a acutely occluded ICA can only be achieved in the acute stage in selected patients who do not have major disturbances in level of consciousness, recent lesion of territory of MCA < one third, prompt revascularization with an I/F <10 hours.