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: firstname.lastname@example.org
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