Ahead of Print: tPA Increases ICH After CEA

Background: Carotid endarterectomy (CEA) for symptomatic carotid artery stenosis and intravenous tPA (IV-tPA) for acute ischemic stroke are proven therapies; however, the safety of CEA in stroke patients who recently received IV-tPA has not been established.

Objective: To evaluate the safety of CEA in stroke patients who recently received IV-tPA.

Methods: A retrospective review of patients who underwent CEA for symptomatic carotid artery stenosis was performed. The primary endpoint was post-operative symptomatic intracerebral hemorrhage (sICH). A univariate analysis of potential risk factors for sICH including IV-tPA therapy, timing of CEA, degree of stenosis, and stroke severity was performed. Factors with p<0.1 on univariate analysis were tested further.

Results: Among 142 patients, three suffered sICH following CEA – 2 of 11 patients treated with IV-tPA (18.2%) and 1 of 131 patients not treated with IV-tPA (0.8%). Both IV-tPA patients suffering sICH underwent CEA within 3 days of tPA administration. On univariate analysis, IV-tPA (p-value=0.02), female gender (p-value=0.09), shorter time between ischemic event and CEA (p-value=0.06), and lower mean arterial pressure during the first 48 hours of admission (p-value=0.08) were identified as risk factors for sICH. On multivariate analysis, IV-tPA was the only significant risk factor (p-value=0.002 by stepwise logistic regression; p-value=0.03 by nominal logistic regression).

Conclusion: Based on this study, IV-tPA is an independent risk factor for sICH following CEA. This suggests that CEA should be pursued cautiously in patients who recently received IV-tPA. Early surgery may be associated with an increased risk for sICH.

From: Intravenous tPA Therapy is an Independent Risk Factor for Symptomatic Intracerebral Hemorrhage Following Carotid Endarterectomy by Zipfel et al.

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