Intravenously Administered Abciximab in the Management of Early Cerebral Ischemia after Carotid Endarterectomy: Case Report

OBJECTIVE AND IMPORTANCE: Cerebral ischemia is the most worrisome perioperative complication of carotid endarterectomy (CEA). The stroke rate occurring with CEA is estimated to range from 2.3 to 6.3%. Numerous treatment options are available to the neurosurgeon in this scenario, although no "gold standard" exists. CLINICAL PRESENTATION: A 61-year-old woman presented with acute left arm weakness 40 minutes after an uneventful CEA for symptomatic carotid stenosis. Emergent angiography demonstrated vascular irregularities in a "moth-eaten" pattern along the arteriotomy closure, suggestive of platelet-fibrin aggregates ("white clot"). INTERVENTION: Abciximab was immediately administered intravenously in the angiography suite, with subsequent improvement of the visualized vascular irregularities on a second angiogram performed 12 minutes after infusion and complete resolution of the presumed platelet-fibrin aggregates on a third angiogram performed the next day. The patient had no further episodes of cerebral ischemia. She was discharged home on the fifth postoperative day with improving left arm weakness, which had completely resolved by her 2-month follow-up visit. CONCLUSION: To our knowledge, this is the first reported case of abciximab administered intravenously in the setting of acute thromboembolic brain ischemia after CEA. For the unique situation in which an acute thrombus, or white clot, is thought to be the cause of cerebral ischemia, we believe that abciximab may offer an effective and potentially safer alternative than fibrinolytics and may be a more appropriate drug to use from a physiological perspective.