Introduction: Thrombolysis with intravenous tissue plasminogen activator (IV-tPA) has become a mainstay of treatment for acute ischemic stroke. As the evidence for aggressive stroke management has accumulated, authors have also reported neurologic decline associated with delays between identification of surgical carotid artery disease and carotid revascularization. However, the safety of early carotid revascularization in patients who have received tPA has not been established.
Methods: The Nationwide Inpatient Sample database was queried for patients admitted through the emergency room with a primary diagnosis of carotid stenosis and/or occlusion. Each patient was reviewed for administration of thrombolysis, carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS). Primary endpoints were intracerebral hemorrhage (ICH), post-procedural stroke (PPS), poor outcome, and in-hospital mortality. Potential risk factors were analysed using univariate and multivariate analyses.
Results: A total of 310,257 patients were analyzed. Patients who received tPA and underwent either CEA or CAS had a significantly higher risk of developing an ICH or PPS than patients who underwent either procedure without tPA administration. The increased risk of ICH or PPS in tPA treated patients who underwent carotid revascularization diminished with time, and became similar to patients who underwent carotid revascularization without tPA administration by 7 days after thrombolysis. Patients who received tPA and underwent CEA or CAS also had higher odds of poor outcome and in-hospital mortality.
Conclusions: Thrombolysis is a strong risk factor for ICH, PPS, poor outcome and in-hospital mortality in patients with carotid stenosis/occlusion who undergo revascularization. The increased risk of ICH or PPS due to tPA declines with time after thrombolysis. Delaying carotid revascularization in these patients may therefore be appropriate. This delay, however, will expose these patients to the risk of recurrent stroke Future studies are needed to determine the relative risks of these two adverse events.
Patient Care: Findings from this study will help reduce the incidence of adverse outcome in patients who undergo carotid revascularization procedures after receiving thrombolysis.
Learning Objectives: To understand that patients with ischemic stroke who receive intravenous thrombolyis have a higher risk of poor outcome after carotid revascularization.