Die notfallmäßige karotis-TEA bei neurologisch instabilen patienten

Background. Carotid endarterectomy (CEA) is well established as the elective treatment for moderate or severe carotid stenoses with a history of neurological symptoms. In contrast, the merits of carotid revascularization performed as an emergency procedure in patients with acute stroke or fluctuating neurological deficit remain controversial. Patients and methods. A total of 656 CEAs were performed on 621 patients for 330 (50.3%) symptomatic and 326 (49.7%) asymptomatic carotid stenoses within an 8-year period between January 1995 and June 2003. Of the latter, emergency CEA was performed on 30 patients (4.6%). Eleven patients presented with a crescendo TIA, and 19 patients presented with progressive neurological deficits corresponding to contralateral carotid stenosis within 4-24 h after the onset of symptoms. Patients selected for urgent surgery fulfilled the following criteria: acute onset of fluctuating hemispheric neurological symptoms, significant carotid pathology, absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions. Results. Following CEA, the neurological deficits improved instantaneously to complete recovery in 12 patients. The symptoms of nine patients improved to non-disabling deficits, remained unchanged in one, and worsened in three patients (one complete and two incomplete hemipareses). Of 30 patients, 24 were discharged within 8 days after admission. The neurological status after discharge deteriorated in only one of the patients during follow-up of 54 months, but improved in 7 of the patients. Conclusion. Our retrospective study suggests that rescue CEA may be beneficial for selected patients with stroke in evolution and fluctuating neurological deficits. Careful adherence to selection criteria, intraoperative shunting, and intensive care post surgery surveillance are recommended.