Stroke Volume and Reperfusion Hemorrhage After Carotid Endarterectomy: A Single Center Retrospective Experience

Introduction: Patients who have had an ischemic stroke from high grade carotid stenosis are considered candidates for carotid endarterectomy (CEA). Reperfusion hemorrhage is a risk of revascularization and thought to be higher in patients with larger stroke volume, however, there is no existing literature to define this relationship.

Methods: We conducted a single-center retrospective study evaluating neurosurgery patients who underwent CEA for symptomatic carotid stenosis at our institution over a 10 year period. We excluded patients who did not have accessible preoperative brain imaging. We gathered baseline demographics, preoperative clinical characteristics, including stroke volume, and postoperative course and outcomes data. Preoperative stroke volume was measured on MRI Brain or CT Head using BrainLab software.

Results: 88 patients underwent CEA for symptomatic carotid stenosis by our neurosurgery department from 2014-2024. 3 patients were excluded because they did not have preoperative brain imaging. Average age at time of CEA was 67.9 years, 71.8% (61/85) were men. The majority of patients presented with evidence of ischemic stroke and measurable stroke volume on preoperative imaging; 35.3% (30/85) presented with transient ischemic attacks and/or 0 cm3 stroke volume on preoperative imaging. 20.9% (18/85) had large stroke volumes >30 cm3, with the largest volume being 186.1 cm3, and none of these patients had reperfusion hemorrhages after CEA. Only one patient suffered a reperfusion hemorrhage - she had a low volume stroke of 14.9 cm3, however, she did have evidence of some hemorrhage conversion prior to CEA and had difficult to control hypertension postoperatively. Among our patient cohort, there were no mortalities and a stroke rate of 3.5% (3/85), over an average follow-up of 101.1 days.

Conclusion : Our results suggest that stroke volume may not correlate with risk of reperfusion hemorrhage, and that patients with symptomatic carotid stenosis and larger stroke volumes may be candidates for CEA.