Intravenous tissue-type plasminogen activator therapy is an independent risk factor for symptomatic intracerebral hemorrhage after carotid endarterectomy

Abstract

Background: Carotid endarterectomy (CEA) for symptomatic carotid artery stenosis and intravenous tissue-type plasminogen activator (IV-tPA) for acute ischemic stroke are proven therapies; however, the safety of CEA in stroke patients who recently received IV-tPA has not been established.

Objective: To evaluate the safety of CEA in stroke patients who recently received IV-tPA.

Methods: A retrospective review of patients who underwent CEA for symptomatic carotid artery stenosis was performed. The primary end point was postoperative symptomatic intracerebral hemorrhage (sICH). A univariate analysis of potential risk factors for sICH, including IV-tPA therapy, timing of CEA, degree of stenosis, and stroke severity, was performed. Factors with a value of P < .1 on univariate analysis were tested further.

Results: Among 142 patients, 3 suffered sICH after CEA: 2 of 11 patients treated with IV-tPA (18.2%) and 1 of 131 patients not treated with IV-tPA (0.8%). Both IV-tPA patients suffering sICH underwent CEA within 3 days of tPA administration. On univariate analysis, IV-tPA (P = .02), female sex (P = .09), shorter time between ischemic event and CEA (P = .06), and lower mean arterial pressure during the first 48 hours of admission (P = .08) were identified as risk factors for sICH. On multivariate analysis, IV-tPA was the only significant risk factor (P = .002 by stepwise logistic regression; P = .03 by nominal logistic regression).

Conclusion: This study indicates that IV-tPA is an independent risk factor for sICH after CEA. This suggests that CEA should be pursued cautiously in patients who recently received IV-tPA. Early surgery may be associated with an increased risk for sICH.

Abbreviations: CEA, carotid endarterectomyIV-tPA, intravenous recombinant tissue-type plasminogen activatorMAP, mean arterial pressureNASCET, North American Symptomatic Carotid Endarterectomy TrialNIHSS, National Institutes of Health Stroke ScaleNINDS, National Institute of Neurological Disorders and StrokesICH, symptomatic intracerebral hemorrhageTIA, transient ischemic attack.

Figure 1

A 47-year old female presented with acute ischemic stroke in the left middle cerebral artery territory and an admission NIHSS of 10. There was no evidence of ICH at presentation (Figure 1A). She was subsequently administered tPA and post-thrombolysis NIHSS was 3. Digital subtraction angiography demonstrated 99% stenosis in the proximal left internal carotid artery, and she underwent carotid endarterectomy 2 days after presentation. The patient experienced acute worsening of her pre-operative aphasia on post-operative day 2, and head CT showed an ICH (Figure 1B). The patient’s aphasia had fully recovered in late follow up.

Figure 2

A 70-year old female presented with acute ischemic stroke in the right middle cerebral artery distribution and an admission NIHSS of 6. There was no evidence of ICH at presentation (Figure 2A). She underwent thrombolysis with tPA and post-thrombolysis NIHSS was 1. Digital subtraction angiography demonstrated 75% stenosis in the proximal right internal carotid artery, and she underwent carotid endarterectomy 3 days after presentation. The patient experienced acute mental status decline and left hemiparesis on post-operative day 1, and head CT showed an ICH (Figure 2B). A craniotomy and clot evacuation was emergently performed, resulting in improved neurological status. However, the patient developed additional complications following her craniotomy including repeat sICH as well as ventriculitis resulting in further deterioration of her neurological status. Ultimately, the family withdrew care and the patient died 38 days after presentation.