Case presentation prepared by Drs N. Nachimuthu and M Chan, Residents, Dept of Internal Medicine, Monmouth Medical Center
When feasible, administration of tissue plasminogen activator (tPA) is the standard of care for treatment of acute ischemic stroke to improve outcomes. Treated patents may be found on subsequent work up to have significant stenosis of one or both carotid arteries. Carotid endarterectomy (CEA) has been shown to be more effective than medical therapy for preventing subsequent strokes in patients with symptomatic stenosis. However, the timing of CEA after ischemic stroke with or without administration of tPA remains controversial, particularly in patients with critical stenosis or unstable symptoms.
To better illustrate this dilemma, we present the case of a 43 year old male who presented with symptoms of acute stroke, was given tPA within the recommended time frame, but was subsequently found to have high grade carotid stenosis and fluctuating symptoms. We follow with a review and discussion of recent literature showing that in select cases, CEA can be done early with no increase in perioperative complications or adverse events.
A 43 year old man presented to our Emergency Room after he was found to be restless in bed by his wife at 12:30am on the day of admission. He was also unable to express himself and was noted to have had a right sided facial droop. He was last observed to be asymptomatic 1 hour and 45 mins earlier when he was getting ready for bed at 10:45pm.
The patient arrived at the ER at 1:15am and a code stroke was immediately called. Initial examination revealed aphasia, disorientation, and right-sided facial droop, with a NIH stroke score of 5. There was no motor weakness and the rest of the neurologic exam was unremarkable. Vital signs were stable and within normal limits. A stat CT scan was done which did not show any hemorrhage or findings of ischemia:
After the CT scan, the patient initially showed some improvement in speech and orientation with the NIH stroke score dropping to 2. It seemed that treatment with tPA might not be necessary.
However, at 2am the patient’s symptoms again worsened acutely. Repeat NIH stroke score was 6 at 1:50am. tPA was given at 2:10am, 3 hours and 25 mins from last known normal.
Following tPA administration, the patient seemed to be improving again and was admitted to the ICU for close observation. However, a few hours later, at 6am, the patient again worsened. He had new right sided weakness and worsening of his aphasia and right facial droop. Given the fluctuating course of the patient’s symptoms he underwent a repeat stat CT of the head to rule out a bleed. This was negative. A CT angiogram of the head and neck was done at the same time, and this showed severe stenosis (almost total occlusion) of the left internal carotid artery:
At this point, our multidisciplinary stroke team suggested that he undergo emergent carotid endarterectomy to prevent further deterioration of his neurologic status. This was a controversial decision, but after discussing the risks and benefits of the procedure, the patient consented and a carotid endarterectomy was done urgently and completed at 12:05am on the second hospital day, or 21 hours and 55 mins from administration of tPA.
Intraoperatively, the patient was found to have left internal carotid artery narrowing secondary to hemorrhagic plaque and dissection:
The patient experienced no intraoperative complications. Post-operatively, he was started on Lovenox at 1mg/kg every 12 hours. He did develop a hematoma on the site of the CEA, and Lovenox and antiplatelets were immediately stopped. Aspirin at 325mg daily was resumed after a day and Plavix 75mg daily was resumed the next day, after the hematoma had shown signs of resolution. The patient experienced no further complications.
He underwent a repeat CT scan after surgery, more than a day from symptom onset, which did show an evolving left hemispheric stroke:
However, clinically, in the hours following CEA, his right sided weakness improved.
By the time the patient was discharged to a rehabilitation facility, he had only mild aphasia, a residual right facial droop, but no motor deficits.
Many vascular surgeons suggest waiting 6-8 weeks after acute stroke before considering CEA, because of fear or bleeding or extension of cerebral infarction during the surgery. However, this delay can lead to recurrent stroke or complete occlusion of the carotid artery. Moreover, more recent studies have shown that urgent early CEA can be performed on patients with evolving symptoms without additional risks.
We feel that our patient’s near complete recovery was the direct result of early CEA, done despite the recent stroke and potential hemorrhagic complications associated with the use of tPA.
These types of complicated medical decisions can only be made after discussion between neurologists, intensivists and vascular surgeons in a multidisciplinary stroke center.
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