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Intravenous Tissue-Type Plasminogen Activator Therapy Is an Independent Risk Factor for Symptomatic Intracerebral Hemorrhage After Carotid Endarterectomy

Vellimana, Ananth K. MD*; Yarbrough, Chester K. MD*; Blackburn, Spiros MD; Strom, Russell G. MD*; Pilgram, Thomas K. PhD; Lee, Jin-Moo MD, PhD§; Grubb, Robert L. Jr MD*; Rich, Keith M. MD*; Chicoine, Michael R. MD*; Dacey, Ralph G. Jr MD*; Derdeyn, Colin P. MD*,‡,§; Zipfel, Gregory J. MD*,‡,§

doi: 10.1227/NEU.0000000000000261
Research-Human-Clinical Studies

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 endarterectomy

IV-tPA, intravenous recombinant tissue-type plasminogen activator

MAP, mean arterial pressure

NASCET, North American Symptomatic Carotid Endarterectomy Trial

NIHSS, National Institutes of Health Stroke Scale

NINDS, National Institute of Neurological Disorders and Stroke

sICH, symptomatic intracerebral hemorrhage

TIA, transient ischemic attack

*Department of Neurological Surgery,

Mallinckrodt Institute of Radiology, and

§Department of Neurology, Washington University School of Medicine, St. Louis, Missouri;

Department of Neurosurgery, University of Florida, Gainesville, Florida

Correspondence: Gregory J. Zipfel, MD, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110. E-mail:

Portions of this work were presented in abstract form at the International Stroke Conference 2011; February 9, 2011; Los Angeles, California.

Received May 11, 2013

Accepted November 25, 2013

Copyright © by the Congress of Neurological Surgeons