PerioperativeStrokeafterCarotidEndarterectomy：颈动脉内膜切除术后围手术期脑卒中.pptVIP

Perioperative Stroke after Carotid Endarterectomy FAHC Vascular Surgery Case Study 2006 Daniel J Bertges, MD Case History 70 male h/o TIA presenting as L arm greater than leg paralysis lasting 12 hours, one week ago PMH: HTN, hypercholesterolemia, CAD s/p MI and CABG 2 years ago Meds: ASA 81 mg QD, atenolol, lipitor SH: former 50 pk yr tobacco ROS: no visual, speech or sensory changes PE: HR 63, BP 140/80 RRR without murmur, CTA bilateral carotid bruits normal peripheral pulses normal neurological exam Case History Labs normal EKG: NSR with old anterior wall MI Carotid Duplex: severe 80-99 % L ICA stenosis mild 1-50 % R ICA stenosis patent, antegrade vertebrals bilateral CEA Elective R CEA performed under GA with uncomplicated routine shunting Conventional endarterectomy with dacron patch angioplasty Systemic heparinization without protamine reversal No completion study Neurological exam after extubation grossly normal Neuro deficit in the recovery room One hour later you are called to the RR Patient is unable to move L arm PE: HR 90, BP 150/85 Neck without hematoma Neuro exam: slight L facial droop L arm flaccid, 0/5 motor Remainder of extremities within normal What would you do ? What are the possible etiologies ? What are your treatment options ? Should you return to OR ? What is your operative plan ? Should you obtain an angiogram ? What could have been done to potentially minimize risk of stroke ? Did the patient receive enough aspirin ? Should you reverse heparin with protamine after CEA ? Emergent ultrasound(done in RR or OR whichever is quicker) Reoperation Neck explored and carotid reopened Acute thrombus in ICA Carefully pull thrombus out Good back bleeding from ICA If no back bleeding options are controlled passage of Fogarty balloon catheter (remain aware of potential complication of carotid-cavernous sinus fistula) or thrombolytics Etiology of Perioperative stroke after CEA 1. ICA thrombosis (