Monmouth Stroke Service Success Story: Great outcome after emergent carotid endartercomy

Case presentation prepared by Drs N. Nachimuthu and M Chan, Residents, Dept of Internal Medicine, Monmouth Medical Center

Introduction:

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.

Case report:

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:
case1

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:

case4

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:

fig5

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:

case2

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.

Discussion:

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.

Click here to find out more about Monmouth’s Certified Stroke Center.

Hey Doctor, Leave That Asymptomatic Carotid Alone

pink-floyd-wall

If you are found to have a carotid artery blockage (stenosis), the chances are you can find a doctor who will want to operate or put a stent in to open it up for you, no matter whether you have had symptoms or not.

And, it it true that if you have had a recent TIA or a stroke and have a carotid stenosis, you should consider having surgery as soon as possible to prevent another cerebrovascular event.

However, we have already blogged about how the benefits of having surgery over medical therapy are much lower for patients who are found to have a carotid stenosis on a routine screening study, without ever having had any symptoms, i.e. asymptomatic carotid artery stenosis.

The scientific evidence for avoiding surgery on asymptomatic carotid disease just got a little stronger.

A recent study followed 4319 patients with a history of known arterial disease (coronary heart disease, abdominal aortic aneurysm, or peripheral arterial disease) or risk factors for atherosclerosis (diabetes mellitus, hypertension, and hyperlipidemia), but no previous TIA or stroke. All patients underwent carotid artery doppler, and 293 (about 7%) had a carotid stenosis (>50%). All patients underwent intensive medical management, and were followed for 5-6 years. The risk of stroke was 0.35%/yr overall and 0.4%/yr for patients with carotid stenosis (50-99%), not a statistically significantly difference.

The bottom line here is that if you have carotid stenosis, the first step is to determine if that stenosis is symptomatic or asymptomatic. If there is any doubt about this,  you should consult with a stroke expert to be sure.  If your carotid stenosis is asymptomatic, it is probably more important to quit smoking, treat blood pressure, treat high blood sugar and treat high cholesterol, and take an anti platelet agent like aspirin, than rush in to getting surgery.

Every case is different, get yourself checked out, don’t be just another brick  in the wall!

Find out more about TIA and stroke, carotid surgery, Monmouth’s innovative new TIA center, and Monmouth’s certified stroke centerClick here for a link to the full article.

Monmouth Stroke Awareness Month Event, May 15 2013, 12pm

125th-annv-logo-blue-and-gray

Join us for a FREE education event

WHEN – Wednesday May 15, 2013 12-1pm

WHERE – Long Branch Senior Center

Dr Neil Holland, Medical Director of the Stroke Program and Neuroscience Institute, Monmouth Medical Center

Nanette DeLeon, Registered Dietician, Monmouth Medical Center

stroke

Learn about:

The warning signs and symptoms of a stroke,

How urgent care is crucial in saving lives and preventing disability,

The telltale symptoms of transient ischemic attack, sometimes referred to as “mini-stroke”,

Nutrition for stroke prevention.

CALL 732 571 6542 To Register!

Click here for directions.

Find out more about: the Monmouth Stroke Center, Monmouth TIA center, Strokes and TIAs.

MMC Free Education Event, May 1

125th-annv-logo-blue-and-gray

Join us for a FREE education event

WHEN – Wednesday May 1, 2013 1-2pm

WHERE – SCAN Adult Learning Center

Dr Neil Holland, Chief of Neurology and Medical Director of the Neuroscience Institute

strokeTIA RAPID EVALUATION CENTER

Essential-tremor-is-characterized-by-sporadic-and-postural-tremor-on-handsTREMOR

CALL 732 542 1326 To Register!

Click here for directions

Monmouth TREC Featured on AHRQ Innovations Exchange

AHRQ

ahrq2

The U.S. Agency for Healthcare Research and Quality created the Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care.

The Innovations Exchange supports the Agency’s mission to improve the quality of health care and reduce disparities.

The AHRQ Health Care Innovations Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations.

ff

Monmouth’s innovative TIA Rapid Evaluation

Center (TREC) is featured in this month’s on-line

magazine!

ff

Click here for a link to the full article.

Click here for more information about TIA and stroke.

Click here for a patient story about Monmouth’s TREC.

Click here to view a TV interview with Dr Holland about Monmouth’s TREC.

American Academy of Neurology Identifies 5 Questionable Practices

rising-cost-of-healthcare

It’s no secret that health care costs are escalating.

Although physicians value their independence, part of the problem here is the unregulated use of costly tests, medications and procedures, many of which are unproven and of questionable benefit.

tumblr_ll6bvwxvjh1qeawdho1_500

xx

Evidence based medicine assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests in an attempt to help clinicians predict whether a treatment will do more good than harm.

However, less than 1 in 5 medical decisions in the USA are made based on evidence-based medicine.

xx

neurology

The American Academy of Neurology has recently taken a step in the right direction by publishing a list of 5 costly neurology practices which continue to be widely performed despite being of little proven benefit:

xx

1. Don’t perform electroencephalography (EEG) for headaches.

xx

2. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Syncope is caused by global cerebral hypoperfusion, not carotid artery disease, so even if a carotid stenosis is identified, it would be asymptomatic (see point number 5)

xx

3. Don’t use opioid or butalbital treatment for migraine except as a last resort.

Butalbital is effective short term treatment for migraine, but commonly leads to rebound, which ultimately exacerbates migraine.  Click here for more information about migraine.

xx

4. Don’t prescribe interferon-β or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of MS.

Interferon-β and glatiramer acetate, are effective for  relapsing phases of MS, but do not prevent the development of permanent disability in progressive forms of multiple sclerosis.  These medications cost more than $40,000 a year, and put a financial strain on the patients and their families to make the co-pays.  In some series as many as 10%-15% MS patients have progressive forms of the disease and yet are still taking one of these medications.

xx

5. Don’t recommend carotid endarterectomy (CEA) for all patients with asymptomatic carotid stenosis.

Surgery is of much less benefit for asymptomatic carotid stenosis, and should be reserved for those with a perioperative complication risk of less than 3% and a life expectancy of greater than 3 to 5 years. Click here for more information about surgery for carotid artery disease.

xx

Click here for more details.