Early Postoperative Recognition and Management of Acute Stroke After Carotid Endarterectomy

Stroke complicating carotid endarterectomy (CEA) is broadly classified into intraoperative or postoperative. Such a classification has implications for the likely etiology and type of stroke and indication for exploration or neurorescue maneuvers; it also affects prognosis. An intraoperative stroke is defined as a major neurologic deficit recognized at the conclusion of surgery, whereas an early postoperative stroke is defined as a major neurologic deficit that develops within 3 days after the patient had awakened neurologically intact. More than one half of hemispheric strokes complicating CEA are associated with an underlying correctable lesion, and these patients typically present with a delayed-onset stroke.

Neurologic events occurring in a patient who awakens without neurologic deficits following CEA are distinct from intraoperative stroke. This time course is much more indicative of a thromboembolic event reflecting intraluminal thrombus formation at the endarterectomy site with or without embolization. This may be the result of any of numerous potential causes including luminal narrowing caused by longitudinal closure without a patch in a small artery; narrowing of the lumen of the internal carotid artery (ICA) at the apex of a patched closure; intimal damage of the ICA during insertion of a shunt; intimal flaps caused by poor termination point of the endarterectomy in the common, internal, or external carotid; or residual plaque.