Emergency Stenting after Carotid Endarterectomy—A Case Report

Carotid disease is a cause of approximately 20% - 30% of all strokes, so the treatment of symptomatic carotid artery stenosis is an important method in secondary stroke prevention. The first-line treatment option for symptomatic carotid artery stenosis currently is a surgical procedure of carotid endarterectomy (CEA). While CEA is considered a safe and well-explored method of treatment, perioperative stroke has been reported in 3% - 4% of all CEA procedures. We report a case of a 75-year-old patient who was admitted to our department due to the recurrent transitory ischemic attacks, which presented as transitory weakness of right extremities. During initial work-up, MSCT angiography of head and neck vessels showed a subocclusive stenosis of the proximal part of left internal carotid artery (ICA) and two days after the symptom onset, the patient underwent an early CEA of left ICA. In immediate postprocedural period, the patient hyper-acutely developed right hemiplegia as well as sensomotor aphasia. MSCT perfusion showed hypoperfusion of most part of left cerebral hemisphere and MSCT angiography confirmed intraluminal thrombosis and subsequent subocclusion of the left ICA, due to the dissection of the treated part of the vessel and the patient underwent an urgent stenting procedure. Follow-up MSCT scan of the brain showed demarcation of acute ischemic lesion of left parietooccipital region, with small secondary hemorrhagic transition, while follow-up digital subtraction angiography (DSA) showed only marginal residual thrombosis, without significant stent stenosis. With continuous physical and logopedic therapy, satisfactory resolution of neurological deficit was achieved. The patient was discharged with only residual mild paresis of right arm and right homonymous hemianopsia. This case shows rare but possible complication of CEA, and while emergency CAS immediately after CEA may present additional risks and technical challenges, it offers an alternative yet efficient method in treating acute perioperative stroke.