How are the neurologic complications of carotid endarterectomy (CEA) treated?

Updated: Oct 24, 2019
  • Author: Sonia Nhieu, MD; Chief Editor: Sheela Pai Cole, MD  more...
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Answer

Answer

Hypertension is the most prevalent and treatable risk factor for stroke, with isolated systolic hypertension further increasing the risk. [2, 12]  Patients who undergo CEA should be monitored for at least 24 hours, regardless of whether they require ICU admission or not. [2, 13]

Even after the critical stenosis is corrected, blood vessels in the region distal to the stenosis remain maximally dilated. The chronic vasodilation results in loss of cerebral autoregulation, and perfusion becomes pressure-dependent. Therefore, strict control of BP postoperatively is essential, and any elevation in BP must to be aggressively treated, especially in patients who demonstrate symptoms of cerebral hyperperfusion.

If the patient remains hemodynamically and neurologically stable during the first 24 hours after surgery, discharge from the hospital is reasonable. Otherwise, patients should remain under observation until they are clinically stable.

In patients who show signs of an acute postoperative stroke, urgent surgical reexploration or cerebral angiography is recommended, with the goal of reopening occluded vessels, correcting the arterial repair, or both. [3]  The efficacy of this invasive approach in reversing stroke is unclear. In NASCET, 10 patients underwent emergency reoperation for a major hemispheric stroke; although occluded arteries were reopened in eight of them, none of the eight benefited. [6]

On the other hand, a review examining 700 consecutive CEAs, in which 13 patients experienced major hemispheric defects, found that immediate surgical reexploration or cerebral angiography with reoperation based on the angiographic findings resulted in neurologic improvement in almost half of the 13. [14]  Despite neurologic improvement attributable to the reopening of the vessel, computed tomography (CT) still revealed new infarcts in almost all of them. Nevertheless, the authors concluded that urgent carotid repair may benefit a minority of selected patients who sustain a major stroke after CEA.


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