Synopsis
Detect and distinguish perioperative cerebral ischaemia, haemorrhage and named cranial nerve injuries after carotid intervention, then escalate appropriately.
- Any new focal deficit after carotid intervention is an emergency: define whether it began intraoperatively or after an initially normal recovery and obtain urgent brain plus bilateral carotid imaging.
- Stridor or tracheal deviation with a postoperative neck haematoma requires immediate re-exploration; airway compromise can progress faster than routine imaging.
- Cranial nerve injury remains clinically distinct from stroke: examine tongue movement, voice and cords, swallowing, lower-lip symmetry and shoulder power while continuing full neurological assessment.
Key red flags
Any new ipsilateral or contralateral cerebral deficit after CEA or CAS requires urgent brain and bilateral carotid neurovascular imaging.
Stridor, tracheal deviation, rapidly expanding neck swelling or respiratory distress after CEA requires immediate airway and surgical re-exploration response.
Severe headache, seizure, hypertension, vomiting, confusion or reduced consciousness may indicate hyperperfusion syndrome or intracranial haemorrhage.
Hoarseness with stridor or known opposite vocal-cord palsy can represent bilateral recurrent-laryngeal dysfunction and threatens the airway.
Dense deficit immediately after clamp release under locoregional anaesthesia is a specific setting in which immediate carotid re-exploration is recommended.
New aphasia, neglect, visual-field loss or contralateral weakness appears during locoregional CEA or on recovery from anaesthesia.
A focal deficit after initially normal recovery, particularly within six hours, raises carotid thrombosis or embolism from the operated segment.
Ipsilateral headache, seizure, hypertension, nausea, confusion or reduced consciousness after flow restoration suggests vasogenic oedema or intracranial bleeding.
Hoarse or breathy voice, weak cough and impaired vocal-cord movement follow vagal or recurrent-laryngeal injury; bilateral dysfunction can cause stridor.
Investigation priorities
Identify intracranial haemorrhage, major infarction and other acute intracranial causes of deterioration.
Management branches
A new or worsened focal deficit occurs after CEA or CAS at any perioperative time.
- Call the stroke, vascular and anaesthetic teams, establish exact onset relative to clamp release, awakening and prior normal examinations, and check glucose and haemodynamics.
- Obtain urgent non-contrast brain CT and angiography of both carotids plus intracranial vessels unless the specific locoregional clamp-release scenario mandates immediate re-exploration.