Objective

No dedicated studies have been performed on the optimal management of patients with an acute stroke related to carotid intervention nor is there a solid recommendation given in the European Society for Vascular Surgery guideline. By implementation of an international expert Delphi panel, this study aimed to obtain expert consensus on the optimal management of in hospital stroke occurring during or following CEA and to provide a practical treatment decision tree.

Methods

A four round Delphi consensus study was performed including 31 experts. The aim of the first round was to investigate whether the conceptual model indicating the traditional division between intra- and post-procedural stroke in six phases was appropriate, and to identify relevant clinical responses during these six phases. In rounds 2, 3, and 4, the aim was to obtain consensus on the optimal response to stroke in each predefined setting. Consensus was reached in rounds 1, 3, and 4 when ≥ 70% of experts agreed on the preferred clinical response and in round 2 based on a Likert scale when a median of 7 – 9 (most adequate response) was given, IQR ≤ 2.

Results

The experts agreed (> 80%) on the use of the conceptual model. Stroke laterality and type of anaesthesia were included in the treatment algorithm. Consensus was reached in 17 of 21 scenarios (> 80%). Perform diagnostics first for a contralateral stroke in any phase, and for an ipsilateral stroke during cross clamping, or apparent stroke after leaving the operation room. For an ipsilateral stroke during the wake up phase, no formal consensus was achieved, but 65% of the experts would perform diagnostics first. A CT brain combined with a CTA or duplex ultrasound of the carotid arteries should be performed. For an ipsilateral intra-operative stroke after flow restoration, the carotid artery should be re-explored immediately (75%).

Conclusion

In patients having a stroke following carotid endarterectomy, expedited diagnostics should be performed initially in most phases. In patients who experience an ipsilateral intra-operative stroke following carotid clamp release, immediate re-exploration of the index carotid artery is recommended.

中文翻译：

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颈动脉内膜切除术后程序性卒中的临床反应：德尔菲共识研究

客观的

尚未对与颈动脉介入相关的急性卒中患者的最佳管理进行专门的研究，欧洲血管外科学会指南中也没有给出可靠的建议。通过国际德尔福专家小组的实施，本研究旨在就 CEA 期间或之后发生的住院卒中的最佳管理达成专家共识，并提供实用的治疗决策树。

方法

进行了包括 31 位专家在内的四轮德尔福共识研究。第一轮的目的是调查表明传统划分六个阶段的术中和术后卒中的概念模型是否合适，并确定这六个阶段的相关临床反应。在第 2、3 和 4 轮中，目的是在每个预定义设置中就对中风的最佳反应达成共识。当 ≥ 70% 的专家同意首选临床反应时，在第 1、3 和 4 轮达成共识；在第 2 轮基于李克特量表，给出中位数为 7 – 9（最充分的反应），IQR ≤ 2 .

结果

专家们同意 (> 80%) 使用概念模型。中风偏侧性和麻醉类型包括在治疗算法中。在 21 个场景中的 17 个（> 80%）中达成了共识。对任何阶段的对侧中风，交叉夹紧期间的同侧中风，或离开手术室后的明显中风，首先进行诊断。对于苏醒期的同侧卒中，尚未达成正式共识，但 65% 的专家会首先进行诊断。应进行脑 CT 联合 CTA 或颈动脉双重超声检查。对于血流恢复后的同侧术中卒中，应立即重新探查颈动脉 (75%)。

结论

对于颈动脉内膜切除术后中风的患者，在大多数阶段最初应进行快速诊断。对于在颈动脉钳松开后出现同侧术中卒中的患者，建议立即重新探查索引颈动脉。