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Safety of Carotid Intervention Following Thrombolysis in Acute Ischaemic Stroke

Objectives Thrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid ath...

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Published in:	European journal of vascular and endovascular surgery 2014-11, Vol.48 (5), p.505-512
Main Authors:	Mandavia, R, Qureshi, M.I, Dharmarajah, B, Head, K, Davies, A.H
Format:	Article
Language:	English
Subjects:	Angioplasty Brain Ischemia - surgery Carotid arteries Carotid Artery, Internal - surgery Carotid Stenosis - surgery Endarterectomy Endarterectomy, Carotid - adverse effects Humans Safety Stroke Stroke - surgery Surgery Thrombolysis Thrombolytic Therapy - adverse effects
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creator	Mandavia, R Qureshi, M.I Dharmarajah, B Head, K Davies, A.H
description	Objectives Thrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke. Design Systematic review. Materials and methods MEDLINE and EMBASE were searched on 29 May 2014. Inclusion criteria were (i) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (ii) carotid intervention within 14 days of thrombolysis; and (iii) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman–Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CIs) were generated and heterogeneity was assessed. The strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system. Results Nine included publications recorded 114 carotid endarterectomy (CEA) and four angioplasty interventions. The point estimate of 30-day stroke or death for CEA was 4.93% (95% CI 1.83–9.44), representing four of 114. The strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4). Conclusions Early CEA post-thrombolysis appears safe, with stroke or death rates similar to that of the operation without thrombolysis. However, the wide CI obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis.
doi_str_mv	10.1016/j.ejvs.2014.08.012
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However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke. Design Systematic review. Materials and methods MEDLINE and EMBASE were searched on 29 May 2014. Inclusion criteria were (i) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (ii) carotid intervention within 14 days of thrombolysis; and (iii) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman–Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CIs) were generated and heterogeneity was assessed. The strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system. Results Nine included publications recorded 114 carotid endarterectomy (CEA) and four angioplasty interventions. The point estimate of 30-day stroke or death for CEA was 4.93% (95% CI 1.83–9.44), representing four of 114. The strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4). Conclusions Early CEA post-thrombolysis appears safe, with stroke or death rates similar to that of the operation without thrombolysis. However, the wide CI obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis.</description><identifier>ISSN: 1078-5884</identifier><identifier>EISSN: 1532-2165</identifier><identifier>DOI: 10.1016/j.ejvs.2014.08.012</identifier><identifier>PMID: 25216626</identifier><language>eng</language><publisher>England: Elsevier Ltd</publisher><subject>Angioplasty ; Brain Ischemia - surgery ; Carotid arteries ; Carotid Artery, Internal - surgery ; Carotid Stenosis - surgery ; Endarterectomy ; Endarterectomy, Carotid - adverse effects ; Humans ; Safety ; Stroke ; Stroke - surgery ; Surgery ; Thrombolysis ; Thrombolytic Therapy - adverse effects</subject><ispartof>European journal of vascular and endovascular surgery, 2014-11, Vol.48 (5), p.505-512</ispartof><rights>European Society for Vascular Surgery</rights><rights>2014 European Society for Vascular Surgery</rights><rights>Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c455t-c5f7f891d4c492900438ecd9a430039b665c5e00ce6f858b0a1e767517cf8a143</citedby><cites>FETCH-LOGICAL-c455t-c5f7f891d4c492900438ecd9a430039b665c5e00ce6f858b0a1e767517cf8a143</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>315,783,787,27936,27937</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/25216626$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Mandavia, R</creatorcontrib><creatorcontrib>Qureshi, M.I</creatorcontrib><creatorcontrib>Dharmarajah, B</creatorcontrib><creatorcontrib>Head, K</creatorcontrib><creatorcontrib>Davies, A.H</creatorcontrib><title>Safety of Carotid Intervention Following Thrombolysis in Acute Ischaemic Stroke</title><title>European journal of vascular and endovascular surgery</title><addtitle>Eur J Vasc Endovasc Surg</addtitle><description>Objectives Thrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke. Design Systematic review. Materials and methods MEDLINE and EMBASE were searched on 29 May 2014. Inclusion criteria were (i) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (ii) carotid intervention within 14 days of thrombolysis; and (iii) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman–Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CIs) were generated and heterogeneity was assessed. The strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system. Results Nine included publications recorded 114 carotid endarterectomy (CEA) and four angioplasty interventions. The point estimate of 30-day stroke or death for CEA was 4.93% (95% CI 1.83–9.44), representing four of 114. The strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4). Conclusions Early CEA post-thrombolysis appears safe, with stroke or death rates similar to that of the operation without thrombolysis. However, the wide CI obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis.</description><subject>Angioplasty</subject><subject>Brain Ischemia - surgery</subject><subject>Carotid arteries</subject><subject>Carotid Artery, Internal - surgery</subject><subject>Carotid Stenosis - surgery</subject><subject>Endarterectomy</subject><subject>Endarterectomy, Carotid - adverse effects</subject><subject>Humans</subject><subject>Safety</subject><subject>Stroke</subject><subject>Stroke - surgery</subject><subject>Surgery</subject><subject>Thrombolysis</subject><subject>Thrombolytic Therapy - adverse effects</subject><issn>1078-5884</issn><issn>1532-2165</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2014</creationdate><recordtype>article</recordtype><recordid>eNp9kU1v1DAQhiMEoqXwBzigHLkkjD_jSAipWlG6UqUetpwtrzOhThO72MlW--9xtIVDD5xmDs_7SvNMUXwkUBMg8stQ43BINQXCa1A1EPqqOCeC0YoSKV7nHRpVCaX4WfEupQEABGHibXFGRSYklefF7c70OB_L0JcbE8PsunLrZ4wH9LMLvrwK4xienP9V3t3HMO3DeEwulc6Xl3aZsdwme29wcrbczTE84PviTW_GhB-e50Xx8-r73ea6urn9sd1c3lSWCzFXVvRNr1rScctb2gJwptB2reEMgLV7KYUVCGBR9kqoPRiCjWwEaWyvDOHsovh86n2M4feCadaTSxbH0XgMS9JZAGVKNpRklJ5QG0NKEXv9GN1k4lET0KtIPehVpF5FalA6i8yhT8_9y37C7l_kr7kMfD0BmK88OIw6WYfeYuci2ll3wf2__9uLuB2dd9aMD3jENIQl-uxPE52oBr1bX7l-kvDsSjLF_gAFUJi2</recordid><startdate>20141101</startdate><enddate>20141101</enddate><creator>Mandavia, R</creator><creator>Qureshi, M.I</creator><creator>Dharmarajah, B</creator><creator>Head, K</creator><creator>Davies, A.H</creator><general>Elsevier Ltd</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20141101</creationdate><title>Safety of Carotid Intervention Following Thrombolysis in Acute Ischaemic Stroke</title><author>Mandavia, R ; Qureshi, M.I ; Dharmarajah, B ; Head, K ; Davies, A.H</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c455t-c5f7f891d4c492900438ecd9a430039b665c5e00ce6f858b0a1e767517cf8a143</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2014</creationdate><topic>Angioplasty</topic><topic>Brain Ischemia - surgery</topic><topic>Carotid arteries</topic><topic>Carotid Artery, Internal - surgery</topic><topic>Carotid Stenosis - surgery</topic><topic>Endarterectomy</topic><topic>Endarterectomy, Carotid - adverse effects</topic><topic>Humans</topic><topic>Safety</topic><topic>Stroke</topic><topic>Stroke - surgery</topic><topic>Surgery</topic><topic>Thrombolysis</topic><topic>Thrombolytic Therapy - adverse effects</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Mandavia, R</creatorcontrib><creatorcontrib>Qureshi, M.I</creatorcontrib><creatorcontrib>Dharmarajah, B</creatorcontrib><creatorcontrib>Head, K</creatorcontrib><creatorcontrib>Davies, A.H</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>European journal of vascular and endovascular surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Mandavia, R</au><au>Qureshi, M.I</au><au>Dharmarajah, B</au><au>Head, K</au><au>Davies, A.H</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Safety of Carotid Intervention Following Thrombolysis in Acute Ischaemic Stroke</atitle><jtitle>European journal of vascular and endovascular surgery</jtitle><addtitle>Eur J Vasc Endovasc Surg</addtitle><date>2014-11-01</date><risdate>2014</risdate><volume>48</volume><issue>5</issue><spage>505</spage><epage>512</epage><pages>505-512</pages><issn>1078-5884</issn><eissn>1532-2165</eissn><abstract>Objectives Thrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke. Design Systematic review. Materials and methods MEDLINE and EMBASE were searched on 29 May 2014. Inclusion criteria were (i) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (ii) carotid intervention within 14 days of thrombolysis; and (iii) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman–Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CIs) were generated and heterogeneity was assessed. The strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system. Results Nine included publications recorded 114 carotid endarterectomy (CEA) and four angioplasty interventions. The point estimate of 30-day stroke or death for CEA was 4.93% (95% CI 1.83–9.44), representing four of 114. The strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4). Conclusions Early CEA post-thrombolysis appears safe, with stroke or death rates similar to that of the operation without thrombolysis. However, the wide CI obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis.</abstract><cop>England</cop><pub>Elsevier Ltd</pub><pmid>25216626</pmid><doi>10.1016/j.ejvs.2014.08.012</doi><tpages>8</tpages><oa>free_for_read</oa></addata></record>
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subjects	Angioplasty Brain Ischemia - surgery Carotid arteries Carotid Artery, Internal - surgery Carotid Stenosis - surgery Endarterectomy Endarterectomy, Carotid - adverse effects Humans Safety Stroke Stroke - surgery Surgery Thrombolysis Thrombolytic Therapy - adverse effects
title	Safety of Carotid Intervention Following Thrombolysis in Acute Ischaemic Stroke
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