Early versus delayed carotid endarterectomy after a nondisabling ischemic stroke: a prospective randomized study

Safety and Efficacy of Early Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Meta-Analysis

DESIGN

A systematic document retrieval of studies published in the past 10 years reporting periprocedural stroke/mortality/MI after carotid endarterectomy (CEA) related to the time between CEA and qualifying neurological symptoms. The application database has "PubMed, EMbase and Cochrane databases." RevMan5.3 software provided by the Cochrane collaboration was used for meta-analysis.

RESULTS

A systematic literature search was conducted in databases. A total of 10 articles were included in this study. They were divided into early CEA and delayed CEA with operation within 48 h, 1 w, or 2 w after onset of neurological symptoms. Incidence of the postoperative stroke in patients undergoing delayed CEA (≥48 h) was significantly higher than patients with delayed CEA (<48 h) (OR = 2.14, 95% CI: 1.43-3.21, P = 0.0002). The postoperative mortality of patients after delayed CEA (≥48 h) was significantly higher than patients after early CEA (<48 h) (OR = 1.35, 95% CI: 1.06-1.71, P = 0.02). The risk of postoperative mortality of patients treated with delayed CEA (≥7 d) was significantly higher than patients after the early CEA group (<7 d) (OR = 1.69, 95% CI: 1.21-2.32, P = 0.001).

CONCLUSION

Early CEA is safe and effective for a part of patients with symptomatic carotid stenosis, but a comprehensive preoperative evaluation of patients with carotid stenosis must be performed.

The benefit of deferred carotid revascularization in patients with moderate-severe disabling cerebral ischemic stroke

OBJECTIVE

Symptomatic carotid artery stenosis needs revascularization within 2 weeks by carotid endarterectomy (CEA) to reduce the risk of symptom recurrence; however, the optimal timing of intervention is yet to be defined in patients with large-volume cerebral ischemic lesion (LVCIL) and modified Rankin scale (mRS) score ≥3. The aim of this study was to determine the most appropriate timing for CEA in patients with a recent stroke and LVCIL.

METHODS

Data from patients with symptomatic carotid stenosis with LVCIL and mRS score of 3 or 4 from 2007 to 2017 were considered. Patients were submitted to CEA if they had a stable clinical condition and life expectancy >1 year. LVCIL was defined as a cerebral ischemic lesion of volume >4000 mm³. Perioperative stroke and death were evaluated by stratifying for timing of CEA by χ² test and multiple logistic regression. Patients with similar characteristics (LVCIL and mRS score of 3 or 4) unfit for CEA served as the control group for recurrence of stroke at 1-year follow-up.

RESULTS

In an 11-year period, of a total 4020 CEAs, 126 (2.9%) were performed in patients with a moderate stroke and LVCIL occurring in the same admission. The patients' median age was 69 years (interquartile range [IQR], 10 years); 72% (91) were male, with mRS score of 3 (IQR, 1) and LVCIL volume of 20,000 mm³ (IQR, 47,000 mm³). The median time elapsed from symptoms to CEA was 7 weeks (IQR, 8 weeks). Overall perioperative stroke/death was 7.3% (eight strokes and one death). By selective timing evaluation of the postoperative events, CEA performed within 4 weeks was associated with a significantly higher rate of stroke/death compared with patients operated on after 4 weeks: 11.9% (8/67) vs 1.7% (1/59; P = .03). By logistic regression, CEA within 4 weeks was an independent (from sex, cerebral ischemic lesion volume, dyslipidemia, and carotid stenosis) predictor of postoperative stroke/death (odds ratio, 8.2; 95% confidence interval, 1.01-73). In the same period, 101 patients were considered unfit for CEA for dementia (n = 22), severe comorbidities (n = 55), or short (<1-year) life expectancy (n = 24), and 43 (43%) survived at 1 year. At 1 year, the perioperative/recurrent stroke after CEA vs patients unfit for CEA was similar (6.2% vs 13.9%; P = .11), but CEA performed after 4 weeks led to significantly lower perioperative/recurrent stroke (1.7% vs 13.9%; P = .02).

CONCLUSIONS

The surgical risk of CEA in patients with a recent moderate-severe ischemic stroke and LVCIL is high. However, if the intervention is delayed >4 weeks, its benefit seems significant.

Carotid Endarterectomy with Autoarterial Remodeling of Bifurcation of the Common Carotid Artery and Carotid Endarterectomy with Patch Closure: Comparison of Methods

BACKGROUND

The objectives of our research were to identify whether the new method of carotid endarterectomy (CEA) with autoarterial remodeling of bifurcation of the common carotid artery (ARBCCA) influences daily parameters of blood pressure and heart rate (HR) while monitoring them on a daily basis and to assess the efficacy of the suggested method.

MATERIALS AND METHODS

It is a prospective randomized comparative study. The first group (n = 100) included patients that underwent ARBCCA, the second group (n = 100) included patients that underwent "classic" CEA with xenopericardial patch closure. Diurnal Holter recording of blood pressure and (HR) was performed before and after the surgical treatment in both groups.

RESULTS

Surgical treatment in both groups leads to an increase of HR, arterial hypertension time index by systolic blood pressure, and arterial hypertension time index by diastolic arterial blood pressure. The damage of carotid artery bulb increases sympathetic innervation and causes dysregulation of the baroreceptor mechanism.

CONCLUSIONS

In our study, we did not reveal a significant difference in the incidence of postoperative hypertension and the dependence of HR on the choice of surgical technique. Thus, the proposed ARBCCA method does not lead to an increased risk of pre-existing arterial hypertension development. A significant difference is found out on the parameter of the clamping time of carotid arteries in favor to ARBCCA group. Another advantage of the suggested technique is the number of restenosis greater than 50% during the 2-year follow-up (4 [4%] cases (ARBCCA group) versus 12 [12%] cases ["classic" CEA], respectively, P = .037).

Timing of carotid endarterectomy after recent minor to moderate stroke

OBJECTIVE

Early carotid endartectomy is generally favored by vascular surgeons in patients after a minor to moderate stroke. Herein, we compared the results of early versus delayed carotid endartectomy in patients presenting with similar National Institutes of Health Stroke Scale findings after a recent minor to moderate stroke.

METHODS

A retrospective analysis of 101 patients undergoing carotid endartectomy after a recent stroke in the distribution of the branches of the middle cerebral artery with >70% internal carotid artery stenosis from 2000 to February 2018 was performed.

RESULTS

Sixty patients had carotid endartectomy within 2 weeks (group A) and 41 had carotid endartectomy within 2-8 weeks of stroke (group B). Associated factors, such as coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, nicotine abuse, chronic obstructive pulmonary disease, and renal failure, were similar in both groups. However, there was preponderance of male patients in group B (0.01). In group A, 35 patients presented with minor stroke (National Institutes of Health Stroke Scale 1-4) and 25 had a moderate stroke (National Institutes of Health Stroke Scale 5-15). In group B, 21 had a minor stroke and 20 had a moderate stroke (P = .54). Perioperative stroke occurred in 4 patients in group A and none in group B (P = .14), with perioperative stroke and death rate of 4.0%. Postoperative seizures occurred in 1 patient in group A and three in group B (P = .30).

CONCLUSION

Early as well as delayed carotid endartectomy in patients with minor to moderate stroke results in a satisfactory outcome. To prevent recurrent stroke in the waiting period, early carotid endartectomy should be preferred.

Immediate versus delayed treatment for recently symptomatic carotid artery stenosis

BACKGROUND

The timing of surgery for recently symptomatic carotid artery stenosis remains controversial. Early cerebral revascularization may prevent a disabling or fatal ischemic recurrence, but it may also increase the risk of hemorrhagic transformation, or of dislodging a thrombus. This review examined the randomized controlled evidence that addressed whether the increased risk of recurrent events outweighed the increased benefit of an earlier intervention.

OBJECTIVES

To assess the risks and benefits of performing very early cerebral revascularization (within two days) compared with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register in January 2016, the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, Issue 1), MEDLINE (1948 to 26 January 2016), EMBASE (1974 to 26 January 2016), LILACS (1982 to 26 January 2016), and trial registers (from inception to 26 January 2016). We also handsearched conference proceedings and journals, and searched reference lists. There were no language restrictions. We contacted colleagues and pharmaceutical companies to identify further studies and unpublished trials.

SELECTION CRITERIA

All completed, truly randomized trials (RCT) that compared very early cerebral revascularization (within two days) with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis.

DATA COLLECTION AND ANALYSIS

We independently selected trials for inclusion according to the above criteria, assessed risk of bias for each trial, and performed data extraction. We utilized an intention-to-treat analysis strategy.

MAIN RESULTS

We identified one RCT that involved 40 participants, and addressed the timing of surgery for people with recently symptomatic carotid artery stenosis. It compared very early surgery with surgery performed after 14 days of the last symptomatic event. The overall quality of the evidence was very low, due to the small number of participants from only one trial, and missing outcome data. We found no statistically significant difference between the effects of very early or delayed surgery in reducing the combined risk of stroke and death within 30 days of surgery (risk ratio (RR) 3.32; confidence interval (CI) 0.38 to 29.23; very low-quality evidence), or the combined risk of perioperative death and stroke (RR 0.47; CI 0.14 to 1.58; very low-quality evidence). To date, no results are available to confirm the optimal timing for surgery.

AUTHORS' CONCLUSIONS

There is currently no high-quality evidence available to support either very early or delayed cerebral revascularization after a recent ischemic stroke. Hence, further randomized trials to identify which patients should undergo very urgent revascularization are needed. Future studies should stratify participants by age group, sex, grade of ischemia, and degree of stenosis. Currently, there is one ongoing RCT that is examining the timing of cerebral revascularization.

Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis

BACKGROUND

The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients.

METHODS

All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups.

RESULTS

During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups.

CONCLUSION

During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.

Very urgent carotid endarterectomy does not increase the procedural risk

OBJECTIVES

The timing of CEA for symptomatic internal carotid artery (ICA) stenosis remains a matter of controversy. Recent registry data showed a significantly increased risk, especially in the very early days after the onset of symptoms. In this study the outcome of CEA in the hyperacute phase has been investigated.

METHODS

The outcome of CEA for symptomatic ICA stenosis between January 2004 and December 2013 has been retrospectively analyzed. Patients were divided into four timing groups: surgery within 0 and 2 days, between 3 and 7 days, 8 and 14 days, and thereafter. The post-operative 30 day stroke and death rates were assessed.

RESULTS

A total of 761 symptomatic patients (40.1% with transient ischemic attack [TIA], 21.3% with amaurosis fugax, and 38.6% with ischemic stroke) were included, with an overall peri-operative stroke and death rate of 3.3%. A stroke and death rate of 4.4% (9/206) for surgery within 0 and 2 days, 1.8% (4/219) between 3 and 7 days, 4.4% (6/136) between 8 and 14 days, and 2.5% (5/200) in the period thereafter (p = .25 for the difference between the groups) was observed. The timing of surgery did not influence the peri-operative outcome in a multivariate regression analysis (OR 0.93 [0.63-1.36], p = .71).

CONCLUSIONS

These data show that very urgent surgery in symptomatic patients can be performed without increased procedural risk. Given the fact that ruptured plaques with neurological symptoms carry the highest risk of a recurrent ischemic event in the first 2 days, treating patients as soon as possible to offer the highest benefit in stroke prevention is recommended.

Urgent best medical therapy may obviate the need for urgent surgery in patients with symptomatic carotid stenosis

BACKGROUND AND PURPOSE

The purpose of this study was to analyze the 30-day outcome after introduction of a rapid carotid endarterectomy (CEA) program. Reasons for delay in CEA and the incidence of early recurrence neurological symptoms were recorded.

METHODS

This is a prospective population-based study of delays to CEA and 30-day outcome in patients with symptomatic carotid stenosis. Neurological recurrence (NR) rate was determined after initiation of urgent best medical treatment (loading dose aspirin/clopidogrel and duel therapy with aspirin plus clopidogrel with a statin) until CEA and compared with NR ≤90 days prior index event.

RESULTS

Of a total of 4905 (transient ischemic attack/ischemic stroke, and ocular events) patients, 115 symptomatic patients underwent CEA, 42% within 14 days of the index event and 99% within 14 days of surgical referral. The overall NR from index event to CEA in symptomatic carotid stenosis patients was significantly lower (2.5% [95% confidence interval, 1%-6%]) after best medical treatment when compared with NR ≤90 days in those before referral to a stroke clinic (29% [95% confidence interval, 22%-37%]; P<0.00001). There were no significant differences in outcomes among 48 early (<14 days), 46 intermediate (14-30 days), and 21 delayed (>30 days) CEAs.

CONCLUSIONS

CEA can be performed in the subacute period without significantly increasing the operative risk. The urgent best medical treatment was associated with significant reduction in the risk of early NR in CEA patients. It seems that urgent aggressive best medical treatment may obviate the need for urgent CEA.

Early versus delayed carotid endarterectomy in symptomatic patients

BACKGROUND

Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment.

STUDY DESIGN

Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: group A (27 patients), within 7 days; group B (17), between 8 and 14 days; group C (12), between 15 and 21 days; and group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group.

RESULTS

Demographics and comorbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (P > .05 for all comparisons). Over the long term, the early group had one ipsilateral stroke at 17 months and the delayed group had two ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, P > .05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort.

CONCLUSIONS

There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotid endarterectomy can be safely performed and is preferred over delaying operative treatment.

Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients

Background

Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic (>50%) and asymptomatic (>60%) carotid artery stenosis. Here we report the midterm results of a microsurgical non-patch technique and compare these findings to those in the literature.

Methods

From 1998 to 2009 we treated 586 consecutive patients with CEA. CEA was performed, under general anesthesia, with a surgical microscope using a non-patch technique. Somatosensory evoked potential and transcranial Doppler were continuously monitored. Cross-clamping was performed under EEG burst suppression and adaptive blood pressure increase. Follow-up was performed by an independent neurologist. Mortality at 30 days and morbidity such as major and minor stroke, peripheral nerve palsy, hematoma and cardiac complications were recorded. The restenosis rate was assessed using duplex sonography 1 year after surgery.

Results

A total of 439 (75%) patients had symptomatic and 147 (25%) asymptomatic stenosis; 49.7% of the stenoses were on the right-side. Major perioperative strokes occurred in five (0.9%) patients [n = 4 (0.9%) symptomatic; n = 1 (0.7%) asymptomatic patients]. Minor stroke was recorded in six (1%) patients [n = 4 (0.9%) symptomatic; n = 2 (1.3%) asymptomatic patients]. Two patients with symptomatic stenoses died within 1 month after surgery. Nine patients (1.5%) had reversible peripheral nerve palsies, and nine patients (1.5%) suffered a perioperative myocardial infarction. High-grade (>70%) restenosis at 1 year was observed in 19 (3.2%) patients [n = 12 (2.7%) symptomatic; n = 7 (4.7%) asymptomatic patients].

Conclusions

The midterm rate of restenosis was low when using a microscope-assisted non-patch endarterectomy technique. The 30-day morbidity and mortality rate was comparable or lower than those in recently published surgical series.

Timing of carotid surgery after acute stroke

Carotid endarterectomy (CEA) has been proven to reduce the risk of stroke and death in both asymptomatic and symptomatic patients with carotid occlusive disease. Stroke is the third leading cause of death in the USA. Since up to one-third of stroke patients have a stroke secondary to carotid occlusive disease, it is important to offer CEA to this subgroup of patients that meet indications for surgery. Historically, literature has suggested that the optimal timing to perform CEA is approximately 6 weeks after an acute stroke. This was concluded owing to high perioperative morbidity and mortality if CEA was performed too early. However, data are increasingly showing that some patients do benefit from CEA earlier than 6 weeks after an acute stroke. This article discusses mid-20th Century literature and focuses on more recent 21st Century literature discussing the timing of CEA after acute stroke. Although there are data to support delayed CEA, it is reasonable to perform early CEA in select stroke patient populations. Candidates for early CEA should have complete or near resolution of symptoms, small infarcts on imaging and ipsilateral carotid stenosis.

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events

OBJECTIVES

This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event.

METHODS

The study involved patients with acute neurologic impairment, defined as ≥ 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis ≥ 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation ≥ 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or ≥ 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging.

RESULTS

Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 ± 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 ± 3.41 on admission and 3.11 ± 3.62 at discharge in the entire group (P < .01). Patients with an NIHSS score of ≥ 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 ± 1.03 preoperatively vs 1.31 ± 1.7 postoperatively, NIHSS ≥ 8 10.32 ± 1.94 vs 4.03 ± 3.67; P < .001).

CONCLUSIONS

In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis ≤ 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome.

RACE to protect brains

INTRODUCTION

Rapid-access carotid endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48 h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE.

SUBJECTS AND METHODS

A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CEAs) performed. Outcomes were compared between elective (ECE) and rapid-access operations.

RESULTS

In 1 year, 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. Twenty-three (30%) of ECE were for asymptomatic stenoses; no other significant differences in surgical indication were seen. Of symptomatic ECE, 43% were for completed stroke versus 55% for RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was one death following ECE (1.3%) and one stroke after RACE (5%), all not significant. Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time.

CONCLUSIONS

The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service, we have treated 50% of suitable patients within 48 h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.

Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery

Background and Purpose— Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke.

Methods— We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel–Haenszel meta-analysis.

Results— Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus ≥1 week, OR=1.2, 0.9 to 1.7, P =0.17; <2 weeks versus ≥2 weeks, OR=1.2, 0.9 to 1.6, P =0.13).

Conclusions— Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.

Urgency of Carotid Endarterectomy for Secondary Stroke Prevention

Background and Purpose— The benefit of carotid endarterectomy for preventing recurrent stroke is maximal when surgery is performed within 2 weeks after ischemic stroke or transient ischemic attack; the benefit is reduced when surgery is delayed >2 weeks and essentially lost if delayed >3 months. Guidelines recommend endarterectomy within 2 weeks poststroke/transient ischemic attack for patients with symptomatic carotid stenosis. This study examined time to endarterectomy at designated stroke centers as a measure of evidence-based best practices for stroke prevention.

Methods— From the Registry of the Canadian Stroke Network, we identified all consecutive patients presenting with acute ischemic stroke or transient ischemic attack at 12 provincial stroke centers (Ontario, Canada, 2003 to 2006) and selected those with unilateral symptomatic carotid stenosis of moderate (50% to 69%) or severe (70% to 99%) degree. Using linkages to administrative databases, we identified patients who underwent carotid endarterectomy within 6 months after the symptomatic event and calculated the time intervals between the index event and surgery. We compared the timing of surgery according to age, sex, degree of stenosis, index event, geographic region, and year. Logistic regression assessed variables associated with early surgery.

Results— One hundred five patients underwent endarterectomy for unilateral symptomatic carotid stenosis (50% to 99%) within 6 months of the index event. The median time from index event to surgery was 30 days (interquartile range, 10 to 81). Only one third (38 of 105) received endarterectomy within the recommended 2-week target timeframe, and in one fourth (26 of 105), surgery was delayed >3 months. Surgery within 2 weeks was more likely if the index event was a transient ischemic attack rather than a stroke. Access to early endarterectomy varied markedly between hospitals across the province and improved over time from 2003 to 2006.

Conclusions— In this hospital-based cohort, the majority of patients undergoing carotid endarterectomy after a transient ischemic attack or stroke had surgery delayed well beyond the period of maximum effectiveness. To enhance secondary stroke prevention, greater efforts are needed to minimize delays to diagnosis and surgical treatment for patients with symptomatic carotid stenosis.

The importance of early carotid endarterectomy in symptomatic patients

INTRODUCTION

Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients.

PATIENTS AND METHODS

A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan-Meier analysis and predictive factors identified using Cox regression analysis.

RESULTS

A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2-360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan-Meier survival analysis). Age (HR 1.059; 95% CI 1.014-1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7-621 days) after the first event. Eleven of 60 (18%) patients waiting < or = 97 days for surgery and 23 of 58 (40%) patients waiting > 97 days had repeat events. (P = 0.011, chi-squared test).

CONCLUSIONS

Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.

Carotid endarterectomy for stroke prevention revisited

Since its original description, more than 50 years ago, carotid endarterectomy (CEA) has been challenged in its success in achieving adequate stroke prevention among both symptomatic and asymptomatic patients with cervical carotid stenosis. CEA remains the most common vascular surgical operation performed today, however, its future has been called into question with the introduction of percutaneous carotid angioplasty and stenting, more effective antiplatelet agents (i.e., clopidogrel), cholesterol-lowering agents (i.e., statins) and angiotensin-converting enzyme inhibitors. The focus of this article is to review the notable trials substantiating the efficacy of CEA, indications for surgery and technical components that have refined expected favorable outcomes.

Urgent carotid surgery

Early intervention may be better

[Cerebral monitoring with somatosensory evoked potentials in carotid surgery. A review of 141 carotids]

OBJECTIVE

To evaluate postoperative and mid-term results of carotid surgery (CS) with somatosensory evoked potentials (SEP) monitoring.

METHODS

Between 1998 and 2006, 141 CS in 124 patients were performed under general anesthesia. Selective shunting was based on SEP abnormality. Shunting criteria were: reduction up to 50% of the amplitude or latency increasing up to 10%. Early results and follow-up data are analyzed retrospectively.

RESULTS

Shunting rate was 6%, 3 strokes (two transient strokes) occurred and one patient died of perioperative myocardial ischemia. The cumulative stroke and death rate at 30 days was 1.4%.

CONCLUSIONS

Intra-operative SEP monitoring with selective shunting may be safely performed in carotid surgery.

Cerebral Monitoring of Somatosensory Evoked Potentials during Carotid Surgery: A Review of 100 Cases

The purpose of this study was to evaluate immediate and middle-term results of surgical carotid artery revascularization (CAR) with cerebral monitoring of intraoperative somatosensory evoked potentials (SEPs). Between 1998 and 2004, a total of 100 CARs in 86 patients were performed under general anesthesia with SEP monitoring. A shunt was inserted if SEP amplitude decreased by 50% or latency time increased by 10%. Immediate and middle-term results were analyzed retrospectively. The shunt insertion rate was 5%. Two transient ischemic attacks were observed, and one patient died postoperatively due to myocardial infarction. The cumulative stroke and death rate was 1% at 30 days. Intraoperative SEP monitoring with selective shunt placement can be used safely for carotid surgery. Randomized studies will be necessary to determine the respective indications for various cerebral monitoring techniques.

The Timing of Carotid Endarterectomy Post Stroke

Despite the earlier accepted notion that CEA should be delayed 4 to 6 weeks after a stroke, current evidence suggests that CEA may be performed safely earlier than this in most patients who have mild to moderate deficits once symptoms stabilize. The gray areas, however, remain gray, as outlined. Crescendo TIAs are urgent cases in the authors' practice; others advocate a more moderate delayed approach in such cases. Almost everyone agrees that propagating intraluminal thrombus is treated best with a moderate delayed approach that allows the thrombus to resolve first with anticoagulants. Acute carotid occlusion must be assessed on an individual basis: cases that occlude under observation should be explored immediately; cases that come from the field with profound deficits have dismal outcomes, but even here surgery may be effective in salvaging a small group of good functional survivors, and the natural history without surgery is atrocious. Surgery for stroke in evolution is associated with higher morbidity and mortality rates; selected patients may benefit from emergency surgery. A final thought is that for patients who have routine TIA or small stroke, with minimal imaging evidence of infarction or mass effect, a stable deficit, and a normal level of consciousness, there is no reason to empirically delay carotid reconstruction, and patients are served best by a fast-track approach to surgical treatment.

Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes

OBJECTIVE

The optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients.

METHODS

A retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1,158 (45.6%) were in symptomatic patients. Patients who were operated on emergently <or=48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered "early" if performed <or=4 weeks of symptoms, and "delayed" if performed after a minimum of a 4-week interval following the most recent symptom.

RESULTS

Of nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1,046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA.

CONCLUSIONS

In a large institutional experience, patients who underwent CEA <or=4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA.

Primary Stroke Unit Treatment Followed by Very Early Carotid Endarterectomy for Carotid Artery Stenosis after Acute Stroke

BACKGROUND

Although it is recognized that carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery (ICA) stenosis, in the past, very early CEA has been shown to carry substantial risks. We assessed an interdisciplinary concept of very early CEA in patients with high-grade (>70%) symptomatic ICA stenosis at a single center.

PATIENTS AND METHODS

The course of treatment and outcomes of patients who underwent CEA as early as possible after being referred to the stroke unit for symptoms of transient ischemic attack and stroke were prospectively evaluated, including the following parameters: age, severity of ischemia-related symptoms according to the modified Rankin scale, duration of symptoms until admission, multimodal imaging findings (color-coded duplex, cranial computed tomography, magnetic resonance imaging, positron emission tomography), duration until CEA, perioperative course and complications, as well as duration of in-hospital care.

RESULTS

Fifty consecutive patients (median age 68 years, range 44-90) with clinical and imaging signs of transient ischemic attack (n = 19) or stroke (n = 31) were included from January 2000 until December 2004. All except 1 patient showed a preoperative Rankin < 4. There was a median time period of 6 h between the onset of symptoms and admission (range 1 h to 15 days) and a median duration of 4 days after admission until operation (range 1-21 days). Seven patients underwent CEA of the contralateral, severely stenosed ICA after symptomatic ipsilateral ICA occlusion. Four out of 5 patients who primarily underwent systemic thrombolysis recovered almost completely. Three patients (6%) experienced a clinical deterioration before surgery. In the majority of patients (43/50), CEA was performed under local anesthesia with selective shunt use which became necessary in 26%. Three patients (6%) had postoperative worsening due to new infarcts. In 2 cases, an intracerebral hemorrhage occurred, of which 1 remained asymptomatic. In 1 case, surgical revision was necessary because of an ICA thrombosis without permanent neurological decline. Patients were discharged after a median time of 14.5 days (range 4-44).

CONCLUSIONS

After careful selection and preparation in a stroke unit, patients with acute stroke due to carotid stenosis can undergo very early CEA under local anesthesia with a perioperative risk comparable with the risk of later endarterectomy, therefore preventing very early stroke recurrences.

SURGICAL MANAGEMENT OF EXTRACRANIAL INTERNAL CAROTID ANEURYSMS BY CERVICAL APPROACH

BACKGROUND

Extracranial internal carotid artery aneurysms (EICAA) are rare vascular problems with a great potential for lethal thromboembolic episodes.

METHODS

From 1994 to 2004, nine patients with EICAA, seven men and two women, were surgically treated for 10 aneurysms in our department. Aneurysm led to hemispheric symptoms in six cases (two hemispheric strokes and four hemispheric transient ischaemic attacks). The cause was fibrodysplasia in two cases, atherosclerosis in four cases, trauma in two cases and spontaneous dissection in two cases. All aneurysms were treated surgically by the cervical approach using shunting. Extended cervical approach was necessary in four patients with high-lying aneurysms. Nine aneurysms were totally resected and successful revascularization was carried out. Open aneurysmorrhaphy with vein patch angioplasty was carried out in one case of a saccular aneurysm.

RESULTS

There were no perioperative deaths or transient ischaemic attacks or strokes. Four patients developed cranial nerve deficits: one had hoarsness, two had partial facial paralysis (patients with extended cervical approach) and one had tongue deviation. These neurological symptoms were observed in large aneurysms (>4.5 cm) and disappeared within 14 months. No neurological complication was observed in a follow up that ranged from 6 months to 10 years.

CONCLUSIONS

Surgical repair of EICAA, especially with total resection and arterial reconstruction, is strongly recommended. Extended cervical approach has many technical difficulties but can allow treatment of high-lying aneurysms.

Carotid endarterectomy after ischemic stroke--is there a justification for delayed surgery?

PURPOSE

To assess the relationship between outcome of carotid surgery and wait after ischemic stroke.

METHODS

We retrospectively analysed data from patients undergoing carotid endarterectomy after ischemic stroke. We investigated the time interval between the event and endarterectomy in relation to surgical results and complications.

RESULTS

Between January 2000 and December 2003, 104 patients were scheduled to undergo carotid endarterectomy after a recent stroke. Endarterectomy was performed within 6 h in seven patients (6.7%); within 4 weeks in 29 (27.9%); 4 weeks or more in 62 (59.6%) and six (5.8%) patients received no further therapy. Perioperative complications among patients treated within 4 weeks were 3.4% and were comparable to those treated after 4 weeks (4.8%). However, more than 12% of the patients awaiting operation experienced a new cerebrovascular event (ischemic stroke or carotid occlusion), most of them occurred in the 3rd or 4th week after the initial event.

CONCLUSION

Our data indicates, that carotid endarterectomy can be performed with a comparable risk within a short delay after stroke. In addition severe cerebrovascular events occurring within the waiting period may be avoided.

Intracerebral Haemorrhage Following Carotid Endarterectomy

OBJECTIVES

To determine risk factors for the development of hyperperfusion and intra-cerebral haemorrhage following carotid endarterectomy and formulate potential protocols for prevention.

METHODS

MEDLINE database search of the English language literature (1966-2002) was performed using the words 'cerebral haemorrhage', 'intracranial haemorrhage' and 'carotid endarterectomy'. Other articles were cross-referenced by hand.

RESULTS

There are no data from randomised trials confirming the significance of any single risk factor. The evidence suggests that the following may have a role: pre-operative hypertension, recent ipsilateral non-haemorrhagic stroke, previous ischaemic cerebral infarction, surgery for a > 90% ipsilateral internal carotid artery (ICA) stenosis, impaired cerebrovascular reserve, intra-operative haemodynamic or embolic ischaemia, post-operative hypertension, an ipsilateral increase of > or =175% in peak middle cerebral artery velocity (MCAV) and/or a > or =100% increase in pulsatility index.

CONCLUSIONS

A critical ICA stenosis with impaired cerebrovascular reserve resulting in maximal intracerebral vasodilatation and post-operative hyperperfusion (impaired autoregulation) appear to be central to the development of ICH. Appropriate pre-operative screening and post-operative monitoring in high risk patients might identify those who would benefit from manipulation of the haemodynamic events that appear to promote ICH.

Early carotid endarterectomy after acute stroke

PURPOSE

Carotid endarterectomy (CEA) after acute stroke is generally delayed 6 to 8 weeks because of fear of stroke progression. This delay can result in an interval stroke rate of 9% to 15%. We analyzed our results with CEA performed within 1 to 4 weeks of stroke.

METHODS

Records for all patients undergoing CEA after stroke between 1980 and 2001 were analyzed. Perioperative evaluation included carotid duplex scanning or angiography, and head computed tomography or magnetic resonance imaging. All patients with nonworsening neurologic status, additional brain territory at risk for recurrent stroke, and severe ipsilateral carotid stenosis underwent CEA. Patients were grouped according to time of CEA after stroke: group 1, first week; group 2, second week; group 3, third week; group 4, fourth week. Statistical analysis was performed with the chi(2) test, logistic regression, and analysis of variance.

RESULTS

Two hundred twenty-eight patients underwent CEA within 1 to 4 weeks of stroke. Perioperative permanent neurologic deficits occurred in 2.8% of patients in group 1 (72 procedures), 3.4% of patients in group 2 (59 procedures), 3.4% of patients in group 3 (29 procedures), and 2.6% of patients in group 4 (78 procedures). There was no relationship between location or size of preoperative infarct and time of surgery. Only preoperative infarct size correlated with probability of neurologic deficit after CEA (P <.05).

CONCLUSION

Incidence of postoperative stroke exacerbation is similar at all intervals. The results are within acceptable limits for treatment of symptomatic carotid stenosis. CEA may be performed within 1 month of stroke with similar results at all intervals during this period.

Ultrasound and Arterial Wall Disease

Rapid progress in non-invasive ultrasound techniques has resulted in a wide variety of clinical applications for the assessment of cerebrovascular diseases. Recent highlights in ultrasound research include the evaluation of vascular ageing as a degenerative process, the demonstration of plaque development, motion and vulnerability in atherosclerosis and multi-dimensional as well as innovative imaging techniques (e.g., compound imaging) to depict early and small vascular lesions. In addition, echo-contrast agents have been used to compensate for difficulties in visualising late, severe or subtotal obstructive plaques, but failed to be really superior to conventional techniques as evidenced in a prospective, multi-centre trial (Contrast Enhanced Duplex sonography versus Arteriography Studies - CEDAS). With increasing sophistication of ultrasound methodology, it becomes essential to establish standards for data acquisition and interpretation: three consensus meetings have provided detailed recommendations on quantification of carotid atherosclerosis, characterisation of carotid artery plaques and detection of microembolism by transcranial Doppler as a potential indicator of stroke risk.

Carotid artery revascularization

Stroke is the third leading cause of death in the United States, and up to one third of patients have a stroke secondary to carotid occlusive disease. Surgical management has firmly established itself as an important modality in treating this disease. Several prospective randomized trials have defined the patients that would have the most benefit from carotid endarterectomy (CEA). These patient populations include asymptomatic patients with a >or= 60% stenosis and symptomatic patients with a >or= 50% stenosis. The timing of CEA after stroke remains controversial, but recent studies advocate early CEA in a select group of patients. During the CEA, the method of closing of the arteriotomy has an overall effect on the safety of the procedure as well as long-term outcome. As compared with primary repair of the arteriotomy, patch closure has been shown to decrease the frequency of restenosis. In addition, carotid eversion endarterectomy (CEE) is an alternative method to remove the plaque that has a similar efficacy to standard CEA. The role of carotid angioplasty and stenting (CAS) continues to evolve and offers the patient a less invasive method of treating the carotid plaque.

Cerebrovascular cases

Five cases are presented illustrating some of the investigative and therapeutic dilemmas faced when treating patients with cerebrovascular disease in the outpatient clinic. The results of some recent major randomized controlled trials are applied to assist the decision-making process for individual patients. The investigation and management of patients with minor stroke or transient ischemic attack, and symptomatic or asymptomatic carotid stenosis are discussed. Issues raised include the role of angiography versus noninvasive imaging, carotid endarterectomy versus carotid stenting, and how to apply new evidence regarding antihypertensive and lipid-lowering therapy to patient management. The role of thrombolysis for acute stroke is discussed, and the work-up of a patient with attacks of dizziness and a patient with atypical headache are also presented.