It is an emergency procedure. After a cerebral DWI to exclude a large ischemia and a diffusion through the barrier, the patient must be submitted to cervicotomy in locoregional anesthesia. After the preparation of carotid bifurcation and sistemic eparinization, it is necessary to clamp the internal carotid artery first. The following procedure is normal: arteriotomy, CEA, eventually shunting, closure of arteriotomy by patch.

Thank you very much.

Agree with Dr. Gossetti- emergency surgery, although we would operate under general anaesthesia. Postoperatively we would recommend transesophageal echocardiography to rule out intracardiac thrombus causing embolization.

I would agree - the patient should receive CEA. CAS and thrombolysis are the contraindications. The problem is deeper though - heparinization of patient during CEA, may result in haemorrhage and worsen the conditon. If the thrombus is not floating freely, it may be just a soft "unstable" plaque - conservative treatmen for 4-7 days; and subsequent CEA (after MRI) might be a safer option

By the way - I would always prefer a local anaesthesia (900 CEA's of personal experience, over 2500 assisted)

Intervention radiology

Is there any information about the EEG monitorization during cartoid stenting and cerebral embolic protection device usage during carotid stenting?

I think emergency surgery is mandatory, to avoid further embolization,whenever it is possible (small cerebral damage) . You are right, the detection of mobile thrombus located in the carotid bifurcation is not a rare event and early Duplex US represents a fundamental step to plan surgery as soon as possible:

A) Vicenzini E, Giannoni MF, Ricciardi MC, Toscano M, Sirimarco G,

Di Piero V, and Lenzi GL: Non Invasive Imaging of Carotid Arteries In Stroke:

Emerging Value of Real-time High-Resolution Sonography in Carotid

Occlusion Due to Cardiac Embolism.

Journal of Ultrasound in Medicine, 2010; 29: 1635-1641.

B) Giannoni, M.F., Vicenzini, E., Sbarigia, E., Piero, V.D., Lenzi, G.L., Speziale, F

Early ultrasound imaging of carotid arteries in the acute ischemic

cerebrovascular patients. Perspectives in Medicine 2012: 1;. 108-111.

C) Vicenzini, E.B., Giannoni, M.F., Ricciardi, M.C., Sirimarco, G., Toscano, M.,

Lenzi, G.L., Di Piero, V.

A horse, a horse, my kingdom for a horse- Saddle thrombosis of carotid

bifurcation in acute stroke. Perspectives in Medicine 2012; 1: 435-439

Urgent CEA in recently symptomatic patients and significant carotid artery stenosis is disputed option for many years. In last years popularity of this approach is increased and you can find many recent publication about it. The desision to operate urgently mainly based on severity of neurologic defecit and CT finding. Comlications of urgent surgery more common in patient with severe neurologic impairment and massive brain infarction.With same selection it is possible to get good results of surgery and to prevent reccurent stroke.Treatment of patient with floating thrombus or instable plack in carotid bifurcation and with recent neurologic event shuld be based on the same criterions. We have good expirience with urgent CEA in last 2 years, including cases of floating thrombus. Our expirience was presented in vascular forums, including last Veith's conference.

I would agree that it is easy to diffrentiate floating thrombus from an unstable plaque ( I am not sure if others understand us), i fa floating thrombus is there (such rare ...) CEA is than mandatory, even if the risk of haemorrhage from heparin is high. All the recent recommendations support CEA in every way, this is a showcase in supporting CEA over CAS.

P.S. It is my pity I wasn't at the Veith's...

Emergency carotid surgery for patient affected by Floating thrombus

I think treatment depends on the individual condition of the patient.. If there is prominent neurological symptomatology, rapid CEA may be dangerous. Heparin treatment could be initiated and after patient's condition improves, CEA can follow.

our experience:

The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack.

Capoccia L, Sbarigia E, Speziale F, Toni D, Biello A, Montelione N, Fiorani P.

J Vasc Surg. 2012 Jun;55(6):1611-7. Epub 2012 Feb 23.

i would also recomending the urgent CEA under local aneshesia by awake patient! you wouldnt need any kind of cerebral monitoring methods wich no one of them showed enough specivity and sensitivity accept by awake patient with direct motoric and nuerologic monıtoring possibility without any device using accept a plastic toy !

We have a good experience in Free-floating thrombus in the internal carotid artery. Our treatment is CEA.

Article Free-Floating Thrombus in the Internal Carotid Artery: Diagn...

no difference by local or general anaesthesia during CEA.

Article Carotid Endarterectomy: Comparison Between General and Local...

In our institution: immediate emergency CEA. Only exclusion: massive ipsilateral disabling stroke +/- intracranial hemorrhage.

Urgent CEA with very early distal ICA clamping before dissecting out the bulb

Urgent CEA - here's our series to help:

Diagnosis and surgical management of free-floating thrombus within the carotid artery.

Tristan R A Lane, Joseph Shalhoub, Ryan Perera, Amrish Mehta, Mary R Ellis, Ann Sandison, Alun H Davies, Ian J Franklin

Department of Vascular Surgery, Charing Cross Hospital, Imperial College NHS Trust, Imperial College London, London, UK.

Vascular and Endovascular Surgery (impact factor: 0.99). 10/2010; 44(7):586-93. DOI:10.1177/1538574410375312

Carotid Endarterectomy: Comparison Between General and Local Anesthesia. Revision of Our Experience With 428 Consecutive Cases

Tristan R A Lane, Joseph Shalhoub, Ryan Perera, Amrish Mehta, Mary R Ellis, Ann Sandison, Alun H Davies, Ian J Franklin

Department of Vascular Surgery, Charing Cross Hospital, Imperial College NHS Trust, Imperial College London, London, UK.

Vascular and Endovascular Surgery (impact factor: 0.99). 10/2010; 44(7):586-93. DOI:10.1177/1538574410375312

How can we manage patients with acute neurological symptoms and mobile thrombus in carotid bifurcation by Doppler ultrasonography?. Available from: https://www.researchgate.net/post/How_can_we_manage_patients_with_acute_neurological_symptoms_and_mobile_thrombus_in_carotid_bifurcation_by_Doppler_ultrasonography [accessed Apr 16, 2017].