Urgent carotid endarterectomy within the first 24 hours of the acute stroke period

Introduction. Acute cerebrovascular accident (stroke) is one of the primary causes of disability in the Russian Federation and worldwide. Approximately one-quarter of strokes are recurrent, with a higher likelihood of leading to disability and mortality. One method of surgical prevention for recurrent cerebrovascular accidents is carotid endarterectomy (CEA). For symptomatic stenosis of the internal carotid artery, surgical intervention should be performed within 14 days of the onset of acute stroke [1]. Currently, the necessity and safety of performing emergency CEA within the first 24 hours of stroke onset, especially in combination with thrombolytic therapy and/or thrombectomy, remains a debated issue. Clear criteria for selecting patients for surgical intervention have not been established.
Materials and methods. The study included 39 patients with ischemic stroke who were admitted to the KBC named after S.P. Botkin on the first day of their stroke and underwent carotid endarterectomy. All patients underwent neurological status evaluation using the NIHSS (National Institutes of Health Stroke Scale), modified Rankin Scale, modified Rivermead Mobility Index, brain CT, CT angiography, CT perfusion, duplex ultrasound scanning (DUS) of the brachiocephalic arteries, and lipid profile analysis.
Results. Hemorrhagic transformation of the stroke focus was observed in 5 (12.8%) patients; all patients with hemorrhagic transformation underwent reperfusion therapy – thrombolysis and/or thrombectomy. Upon admission, the severity of the stroke according to the NIHSS was 8.2±0.9 points, and at discharge, it was 5.4±0.8 points, p<0.05. The mobility index according to the Rivermead Scale at discharge was 8.6±0.8 points, and the degree of disability according to the Rankin Scale at discharge was 2.7±0.2 points. Among patients who underwent CEA within the first day of ischemic stroke, the mortality rate was 12.8% (n=5). Two clinical cases are presented, demonstrating successful carotid endarterectomy in the first day of stroke in combination with reperfusion therapy.
Conclusion. Carotid endarterectomy within the first day of ischemic stroke may be considered not only as a method for preventing recurrent ischemic stroke but also as a treatment method that reduces the degree of patient disability. Further studies are required to develop a patient selection algorithm for CEA within the first day of acute cerebrovascular accident (CVA) to improve the effectiveness of surgical treatment and minimize postoperative complications.

1. Клинические рекомендации. Ишемический инсульт и транзиторная ишемическая атака у взрослых. Год утверждения: 2021. IDКР171. Одобрено научно-практическим советом Минздрава РФ. Утверждено 01.09.2021. Clinical guidelines. Ischemic stroke and transient ischemic attack in adults. Year of approval: 2021. IDCR171. Approved by the Scientific and Practical Council of the Ministry of Health of the Russian Federation. Date of access 01.09.2021. (In Russ.).

2. Шишкова В., Адашева Т., Ременник А., Валяева В., Шкловский В. «Предикторы развития повторного ишемического инсульта» Врач, vol. 29, no. 2, 2018, pp. 38–44 Shishkova V., Adasheva T., Remennik A., Valyaeva V., Shklovsky V. «Predictors of the development of recurrent ischemic stroke» Doctor, vol. 29, No. 2, 2018, pp. 38–44. (In Russ.).

3. Trial of ORG 10172 in Acute Stroke Treatment. Adams H.P. et al, 1993.

4. European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease

5. Бокерия Л.А., Покровский А.В., Сокуренко Г.Ю. и др. Национальные рекомендации Клинические рекомендации поведению пациентов сзаболеваниями брахиоцефальных артерий. Москва,2013 г. Bokeriya L.A., Pokrovskii A.V., Sokurenko G. Yu. et al. Natsional’nye rekomendatsii po vedenie patsientov s zabolevaniyami brakhiotsefal’nykh arterii. [National guidelines for patient management with diseases of the brachiocephal arteries]. Moscow, 2013, 72 p. (In Russ.).

6. Хайрутдинов А.И., Тарасов Ю.В., Валиуллин Д.Х., Якубова В.Т. И др. Эффективность ибезопасность каротидной эндартерэктомии в остром периоде ишемического инсульта // МС. 2021. № 10. Khairutdinov A.I., Tarasov Yu. V., Valiullin D.H., Yakubova V.T. et al. Efficacy and safety of carotid endarterectomy in the acute period of ischemic stroke // MS. 2021. No.10. (In Russ.).

7. Jonsson, Magnus et al. Carotid Endarterectomy After Intracranial Endovascular Thrombectomy for Acute Ischaemic Stroke in Patients with Carotid Artery Stenosis. European Journal of Vascular and Endovascular Surgery, Volume 63, Issue 3, 371–378

8. Стаховская Л.В., Клочихина О.А., Богатырева М.Д., Чугунова С.А. Анализ эпидемиологических показателей повторных инсультов врегионах Российской Федерации (по итогам территориально-популяционного регистра 2009–2014 гг.). Consilium Medicum. 2016; 18 (9): 8–11. Stakhovskaya L. V., Klochikhina O. A., Bogatyreva M. D., Chugunova S.A. Analysis of epidemiological indicators of recurrent stroke in regions of Russian Federation (Onthe basis of and population registry 2009–2014). Consilium Medicum. 2016; 18 (9): 8–11. (In Russ.).

9. National Institutes of Health, National Institute of Neurological Disorders and Stroke. Stroke Scale. T. Brott et al, 1989, J. Biller et al, 1990.

10. Modified Rankin Scale. Rankin J. «Cerebral vascular accidents in patients over the age of 60». Scott Med J 1957; 2:200–15.

11. Rivermead mobility index. The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. F.M. Collen, D.T. Wade, G.F. Robb, C.M. Bradshaw. International Disability Studies. Apr-Jun 1991; 13(2): 50–4.

12. Alberta Stroke Program Early CT Score. Barber, P.A., Demchuk, A.M., Zhang, J., & Buchan, A.M. (2000). Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. The Lancet, 355(9216), 1670–1674.

13. Клинические рекомендации. Нарушения липидного обмена. Год утверждения: 2023. IDКР752. Одобрено научно-практическим советом Минздрава РФ. Утверждено 15.02.2023. Clinical guidelines. Disorders of lipid metabolism. Year of approval: 2023. IDCR752. Approved by the Scientific and Practical Council of the Ministry of Health of the Russian Federation. Date of access 15.02.2023. (In Russ.).