Carotid endarterectomy and intracranial thrombolysis: Simultaneous and staged procedures in ischemic stroke Hans-Henning Eckstein, MD, Hardy Schumacher,

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Carotid endarterectomy and intracranial thrombolysis: Simultaneous and staged procedures in ischemic stroke Hans-Henning Eckstein, MD, Hardy Schumacher, MD, Arnd Dörfler, MD, Michael Forsting, MD, Olav Jansen, MD, Peter Ringleb, MD, Jens-Rainer Allenberg, MD Journal of Vascular Surgery Volume 29, Issue 3, Pages 459-471 (March 1999) DOI: 10.1016/S0741-5214(99)70274-0 Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig 1 A and B, Patient 1, a 41-year-old man, had acute left-sided hemiparesis caused by a more than 90% stenosis of the internal carotid artery on the right and an embolic occlusion of the intracranial carotid artery. He recovered after successful intravenous rt-PA lysis. No infarction was seen by means of CT (day 4). C, Six days later, he underwent an uneventful CEA, with evidence of recanalized intracranial internal carotid artery, middle cerebral artery, and anterior cerebral artery. Journal of Vascular Surgery 1999 29, 459-471DOI: (10.1016/S0741-5214(99)70274-0) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig 2 Patient 5, a 70-year-old man, had symptomatic high-grade internal carotid artery stenosis. On the ward, he sustained ischemic stroke with progressive hemiparesis. A, An acute occlusion of the internal carotid artery was revealed by means of an emergency carotid endarterectomy. B, Evidence of embolic occlusion of the middle cerebral artery was shown by means of completion angiography (M1). With a canula, 750,000 IU urokinase was locally administered via the internal carotid artery. Postoperatively, the patient recovered remarkably; only a minimal nonfunctional neurological deficit remained. C, On day 5, a patent middle cerebral artery was shown by means of computed tomographic angiography. D, Also on day 5, partial hemorrhagic transformation of an ischemic stroke was revealed by means of cerebral computed tomography. Journal of Vascular Surgery 1999 29, 459-471DOI: (10.1016/S0741-5214(99)70274-0) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig 3 Patient 7, a 55-year-old man with hypertension, had a progressive stroke with hemiparesis and aphasia. Acute internal carotid artery occlusion was diagnosed by means of Duplex sonography. An emergency carotid endarterectomy was performed after 12 hours. A, Occlusion of the middle cerebral artery was revealed by means of completion angiography. B, Selective thrombolysis with 600,000 IU urokinase was performed intraoperatively. C, Partial reestablishment of middle cerebral artery flow was shown by means of postoperative computed tomography angiography (still patent in transcranial Doppler ultrasound scan after 6 months). D, Despite major ischemic infarction shown by means of the cerebral computed tomography on day 3, the patient recovered partially (aphasia improved remarkably, was able to walk, Rankin 2). Journal of Vascular Surgery 1999 29, 459-471DOI: (10.1016/S0741-5214(99)70274-0) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions