Objective:

Report a perioperative large-vessel occlusive stroke immediately after carotid endarterectomy for severe left internal carotid artery stenosis with intraluminal thrombus, managed with emergent mechanical thrombectomy when thrombolysis was contraindicated.

Background:

A 68-year-old right-handed male with hypertension and prior cervical fusion presented with acute left eye pain, blurry vision, and diplopia. Ophthalmology noted intraocular pressure 40 OS, improving to 9 after Diamox/topicals; vision 20/50 OU. Neurologic exam showed NIHSS 0. CTA head/neck revealed 79–99% left ICA stenosis from the bifurcation through the petrous segment with thrombus. MRI brain showed chronic microvascular changes without acute infarct. Echocardiogram EF 55% without atrial fibrillation; thyroid studies, HbA1c, and lipid panel were unremarkable; platelets 238; no outpatient antiplatelets. He was started on heparin while awaiting elective left CEA with patch angioplasty and indwelling shunt. 

Design/Methods:

NA

Results:

Shortly after CEA, he developed right hemiparesis and global aphasia. Noncontrast CT showed hyperdense left MCA without hemorrhage. CTA/CTP demonstrated Left M1 and proximal MCA branch occlusions with perfusion mismatch (core with surrounding 80 mL penumbra). Additionally, localized dissection of the distal common carotid artery proximal to the bulb and a short proximal external carotid dissection, consistent with recent endarterectomy changes. He was ineligible for thrombolysis due to recent surgery and heparin and underwent MT achieving TICI 2C revascularization. MRI confirmed acute left MCA infarct. By discharge, right hemiparesis improved to 4/5, and global aphasia improved to predominantly transcortical motor aphasia.

Conclusions:

CEA reduces stroke risk in high-grade carotid stenosis but carries perioperative risks, including embolic events and carotid dissection. Evidence guiding acute reperfusion strategies immediately post-CEA—especially when IV thrombolysis is unsafe—is limited. Immediate post-CEA large-vessel occlusion can occur from thromboembolism or dissection. When thrombolysis is contraindicated, rapid imaging triage and MT can achieve substantial reperfusion and meaningful early recovery. Vigilant perioperative monitoring and expedited access to endovascular therapy are critical.