Selective shunting for carotid endarterectomy in patients with recent stroke

Abstract

Objective: Many surgeons favor routine shunting during carotid endarterectomy (CEA) in patients with recent stroke who otherwise prefer selective shunt placement for other indications of CEA. We analyzed the results of CEA in this group of patients with the strategy of selective shunting.

Methods: A retrospective review was performed of 59 patients (group A) undergoing CEA ≤8 weeks of a stroke (2000-2014) from two midsized teaching hospitals with stroke certification; of these, 38 patients had CEA ≤2 weeks and 21 other had CEA >2 weeks but <8 weeks. All patients sustained a middle cerebral artery stroke with ≥70% ipsilateral internal carotid artery stenosis. Cervical block anesthesia was used in 43 patients and general anesthesia in 16. During the same period, 1036 CEAs were performed for other indications (group B). All patients in group A were evaluated by stroke neurologist with a National Institutes of Health stroke scale score of 1 to 4 in 22 patients (minor stroke) and 5 to 15 in 37 patients (moderate stroke). A shunt was placed if neurologic changes (contralateral motor weakness, aphasia, loss of consciousness) occurred with the carotid cross-clamping or ischemic electroencephalogram changes under general anesthesia were observed.

Results: The study population consisted of 59 patients (36 males and 23 females) in group A with mean age of 70.5 ± 10.7 years. Carotid duplex imaging revealed contralateral internal carotid artery stenosis of <50% in 36 patients, 50% to 70% in 13, 71% to 99% in 9, and occlusion in 1. Ten patients (16.9%) required shunt placement, which was similar to the shunt in group B (11.8% for remote stroke, 10.2% for focal transient ischemic attack/monocular blindness, and 10.9% for asymptomatic carotid stenosis). Two patients in group A had perioperative stroke and died (3.4% stroke/mortality). There were no incidences of permanent cranial nerve palsy, myocardial infarction (MI), or hematoma requiring re-exploration in patients undergoing CEA in group A. Postoperative complications in group B included new neurologic deficits (postoperative stroke) in 16 (1.6%), MI in 2 (0.2%), permanent cranial nerve palsy in 3 (0.3%), and re-exploration for neck hematoma in 7 (0.7%). Six patients died after CEA in group B, for a combined stroke/death rate of 2.0%. Seizures after CEA for a recent stroke occurred in three patients (5.1%) in group A and in none in group B (P < .002). Postoperative complications (new neurologic deficits, MI, cranial nerve palsy, and re-exploration for neck hematoma) were similar in both groups (P > .05).

Conclusions: Shunt requirement during CEA for acute stroke is similar to other indications of CEA. Patients undergoing CEA for recent stroke had similar incidence of postoperative new neurologic deficit/mortality, MI, and cranial nerve palsy compared with other indications of CEA but had a higher incidence of perioperative seizures.