Case Presentation

Sean David Johnson, MD

General Surgery Residency
Kendall Regional Medical
Center

CC/HPI
74y/o female presents with dizziness to KRMC
ED. She was recently admitted to Homestead
hospital for carotid surgery but desired surgery
to be done at KRMC by her previous Vascular
surgeon. Patient denies fever, chills, nausea,
vomiting, diarrhea or any other complaint.
PMH: HTN, DM, HLD, previous CVA, GERD
PSH: s/p R CEA (2013), cardiac cath/stents, csection
Meds: plavix, nifedipine, clonidine, insulin, folic
acid
Allergies NKDA
SH: No tobacco or alchol use
FH: heart disease

Physical examination

VS T 98.5 P 98R 14 BP 168/54 SpO2 100% R/A

General: NAD
Head/Eyes: atraumatic,
Neck: no JVD
Respiratory/Chest: CTAB
Cardiovascular: regular rate and rhythm, normal
heart sounds, normal cap refill,
Abdomen: soft, non-tender, no distention,
normal bowel sounds
Skin: no abrasions, warm, dry
Neurologic Gross sensation WNL, strength 5/5

Operative Note
Pre-operative diagnosis: L ICA Critical
Stenosis with ulcerated plaque
Post-op diagnosis: same
Procedure: L Carotid Endarterectomy
Anesthesia: Local block*
EBL: 100cc
Complications: intra operative CVA

PACU

Stroke Alert called

Critical Care team consulted
Patient intubated
STAT Brain MRI 10/20 :
Cortical restricted diffusion within the left frontal lobe, parietal
lobe, left temporal lobe, left superior occipital lobe and left
subinsular cortex from an acute infarct which is in the left
anterior
cerebral artery and middle cerebral artery distribution.
Old bilateral basal ganglia, left pontine and left cerebellar
infarcts.

 Neck CTA 10/20

Postsurgical changes of the left neck with multiple foci
of dissections involving the left carotid bulb, proximal and mid
cervical internal carotid artery.
Previous right endarterectomy.
Hypoplastic left vertebral artery with a non enhancement in the left
Occluded left intracranial vertebral artery which is
hypoplastic.
Left hemisphere sulcal effacement from acute ischemia.

Hospital Course
CT brain (10/21) ischemic changes
Neurology consulted (re: CVA, AMS)
GI consult (dysphagia) placed PEG
tube
Poor prognosis
Transferred to hospice care

LITERATURE REVIEW
Journal of Vascular Surgery
Volume 19, Issue 2, February 1994, Pages 206216
The cause of perioperative stroke after carotid
endarterectomy Presented at the Forty-seventh
Annual Meeting of the Society for Vascular Surgery,
Washington, D.C., June 8-9, 1993.
Thomas S. Riles, MD, Anthony M. Imparato, MD, Glenn
R. Jacobowitz, MD, Patrick J. Lamparello, MD, Gary
Giangola, MD, Mark A. Adelman, MD, Ronnie Landis, RN,
From the Division of Peripheral Vascular Surgery,
Department of Surgery, New York University Medical
Center, New York.

 Purpose: The purpose of this study was to

examine the cause of perioperative stroke
after carotid endarterectomy.
Methods: The records of 2365 patients
undergoing 3062 carotid endarterectomies
from 1965 through 1991 were reviewed. Sixtysix (2.2%) operations were associated with a
perioperative stroke. The mechanism of stroke
was determined in 63 of 66 cases. Patient risk
factors and surgeon-dependent factors were
analyzed.

 Results: More than 20 different mechanisms of

perioperative stroke were identified, but most could be
grouped into broad categories of ischemia during carotid
artery clamping (n = 10), postoperative thrombosis and
embolism (n = 25), intracerebral hemorrhage (n = 12),
strokes from other mechanisms associated with the surgery
(n = 8), and stroke unrelated to the reconstructed artery(n
= 8). Dividing the operative experience approximately into
thirds, during the years 1965 to 1979, 1980 to 1985, and
1986 to 1991 the perioperative stroke rates were 2.7%,
2.2%, and 1.5%, respectively. This, in part, is associated
with a better selection of patients (more symptom free,
fewer with neurologic deficits). There has been a notable
decrease in perioperative stroke caused by ischemia during
clamping and intracerebral hemorrhage, but postoperative
thrombosis and embolism remain the major cause of
neurologic complications.

 Conclusions: Although patient

selection seems to play a role, most
perioperative strokes were due to
technical errors made during carotid
endarterectomy or reconstruction
and were preventable.

 Br J Surg. 2005 Mar;92(3):316-21.

Sequential cohort study of
Dacron patch closure following
carotid endarterectomy
Ali T, Sabharwal T, Dourado RA,
Padayach TS, Hunt T, Burnand KG.

METHODS:
A cohort of 236 patients undergoing carotid
endarterectomy at a single centre was studied; 117
patients had primary closure of the arteriotomy and
119 patients in a sequential series had closure with a
Dacron patch. A standard endarterectomy with
completion intraoperative duplex imaging and digital
subtraction angiography was used throughout.
RESULTS:
Patch closure was associated with a significant
reduction in the 30-day combined death, stroke and
TIA rate: 10.3 per cent for primary closure versus 2.5
per cent for patch closure (P = 0.017). The risk of
any cerebral event (stroke or TIA) was also
significantly reduced (7.7 versus 1.7 per cent; P =
0.033). Residual stenosis on completion angiography
was more common after primary closure (24.6
versus 7.4 per cent; P = 0.003).
CONCLUSION:

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