Early Carotid Surgery in Acute Stroke: A Multicentre Randomised Pilot Study

Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis

OBJECTIVE

This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS).

RESULTS

Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50).

CONCLUSION

At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.

"Timing to carotid endarterectomy affects early and long term outcomes of symptomatic carotid stenosis."

OBJECTIVE

The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis.

METHODS

Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale(NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0-2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score vs. NIHSS score immediately before surgery.

RESULTS

500 CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of .2 (n=1) and stroke rate of 3.4% (n=17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR=2.6) in the 30-day neurological improvement vs. those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR=9.7).

CONCLUSIONS

The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hours) was associated with increased late stroke occurrence.

A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease

BACKGROUND

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.

METHODS

We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible.

RESULTS

Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes.

CONCLUSIONS

This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

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.

Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery

Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.

Editor's Choice - Systematic Review and Meta-Analysis of Very Urgent Carotid Intervention for Symptomatic Carotid Disease

BACKGROUND

The optimum timing of carotid intervention for symptomatic carotid stenosis remains unclear. The objective was to investigate outcomes of very urgent (< 48 h from neurological event) in comparison to urgent (≥ 48 h from neurological event) carotid intervention for symptomatic carotid disease.

METHODS

A systematic literature review was carried out of randomised control trials (RCTs) and observational studies reporting peri-procedural outcomes of carotid intervention in relation to the length of time since the neurological event (PROSPERO registration number: CRD 42017075766). Ipsilateral stroke and death were defined as the primary outcome endpoints. Transient ischaemic attack (TIA) and myocardial infarction (MI) were secondary outcome parameters. Comparative outcomes were calculated and reported as dichotomous outcome measures using the odds ratio (OR) and associated 95% confidence interval (CI) for very urgent (< 48 h since neurological event) versus urgent (≥ 48 h) intervention. The combined overall effect size was calculated using a random effects model.

RESULTS

Twelve observational studies and one RCT representing 5751 interventions, 5385 carotid endarterectomies (CEAs) and 366 carotid artery stenting (CAS) procedures, were included in quantitative synthesis. Very urgent carotid intervention was associated with increased risk of stroke within 30 days of treatment compared with urgent carotid intervention (OR 2.19, 95% CI 1.46-3.26, p < .001). No significant difference was found in mortality (OR 1.55, 95% CI 0.81-2.96, p = .19), TIA (OR 1.33, 95% CI 0.55-3.19, p = .52) or MI (OR 1.33, 95% CI 0.41-4.33, p = .64).

CONCLUSIONS

Very urgent carotid intervention was found to be associated with increased risk of stroke.

Carotid plaque volume in patients undergoing carotid endarterectomy

BACKGROUND

The main indication for carotid endarterectomy (CEA) is severity of carotid artery stenosis, even though most strokes in carotid disease are embolic. The relationship between carotid plaque volume (CPV) and symptoms of cerebral ischaemia, and the measurement of CPV by minimally invasive tomographic ultrasound imaging, were investigated.

METHODS

The volume of the endarterectomy specimen was measured using a validated saline suspension technique in patients undergoing CEA. Time from last symptom and severity of stenosis measured by duplex ultrasonography were recorded. Middle cerebral artery emboli were counted using transcranial Doppler imaging (TCD) in a subset of patients.

RESULTS

Some 339 patients were included, 270 with symptomatic and 69 with asymptomatic carotid stenosis. Mean(s.d.) CPV was higher in symptomatic than in asymptomatic patients (0·97(0·43) versus 0.74(0·41) cm³ ; P < 0·001). CPV did not correlate with severity of carotid stenosis (P = 0·770). Mean CPV was highest at 1·03(0·46) cm³ in the 4 weeks following cerebral symptoms, declining to 0·78(0·36) cm³ beyond 8 weeks. Among 33 patients who had TCD, mean CPV was 1·00(0·48) cm³ in the 27 patients with ipsilateral cerebral emboli compared with 0·67(0·16) cm³ in those without (P = 0·142). There was excellent correlation between CPV measured by tomographic ultrasound imaging and the endarterectomy specimen in 34 patients (r = 0·93, P < 0·001).

CONCLUSION

CPV correlated with symptoms of cerebral ischaemia, but not carotid stenosis. It could be a potential indicator for CEA.

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.

Early carotid artery stenting for symptomatic carotid artery stenosis

BACKGROUND

The aim of present study was to assess safety and efficacy of early carotid artery stent (CAS) in patients with symptomatic carotid artery stenosis compared with delayed CAS.

METHODS

This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Outcomes of 206 patients with symptomatic carotid stenosis who were treated by CAS were analyzed. According to CAS timing from last symptom, patients were divided into early (within 2 weeks, 74 [35.0 %]) and delayed (after 2 weeks, 112 [64.1 %]) group by CAS timing from the last symptom. Procedural complication and early (≤30 days of CAS) event (ipsilateral stroke or any death) for safety, and late (31 days to 1 year of CAS) event for efficacy of CAS preventing further stroke were evaluated. The two groups were compared using Cox proportional hazard analysis.

RESULTS

No difference was found in procedural complication between the groups (early 2 [2.7 %] vs. delayed group 7 [5.3 %], hazard ratio [HR] 0.61, 95 % confidence interval [CI] 0.123-2.979, p = 0.537). In the early group, however, early event developed more frequently than in the late group (9 [12.2 %] vs. 1 [0.8 %], HR 16.05, 95 % CI 1.991-129.438, p = 0.009). The late event rate showed no difference between the two groups (4 [5.4 %] vs. 4 [3.0 %], HR 2.09, 95 % CI 0.484-8.989, p = 0.324).

CONCLUSIONS

Early CAS is not safe during periprocedural period, compared with late CAS. In CAS for symptomatic carotid stenosis, delayed CAS should be considered.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

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.

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.

Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis

There is still considerable uncertainty about the place of carotid stenting in patients with recently symptomatic carotid bifurcation stenosis. Most reviews of carotid endarterectomy versus carotid stenting concentrate on technical aspects and advances in stenting, but the techniques involved in both carotid endarterectomy and stenting are evolving. In addition to reviewing the results of the various randomised controlled trials of carotid endarterectomy versus stenting for symptomatic carotid stenosis, this review considers recent advances and current best practice for endarterectomy. Ongoing randomized trials will determine whether or not the procedural risk of stroke and death is definitely lower with endarterectomy than with stenting, but the key issue that remains to be determined reliably is how the procedural risks of stenting vary with patient characteristics - perhaps the most important question being not whether endarterectomy is better than stenting or vice versa, but for whom is one technique likely to be better than the other.

Prevalence of and risk factors for extracranial internal carotid artery stenosis in Korean Type 2 diabetic patients

AIMS

The objectives of this study were to evaluate the prevalence of and risk factors for extracranial internal carotid artery stenosis in Type 2 diabetic patients.

METHODS

This study included 406 patients aged 40-79 years with Type 2 diabetes (male 55.4%, female 44.6%). Both carotid arteries of each patient were examined by carotid duplex scanning. The duplex ultrasound criteria based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) measurement method were used for the identification of carotid stenosis.

RESULTS

Extracranial internal carotid artery stenosis >or= 40% by velocity criteria was detected in 5.2% of the patients. The prevalence of carotid stenosis increased with advancing age: 1.0% at 40-49 years of age, 5.0% at 50-59 years, 7.3% at 60-69 years and 9.5% at 70-79 years. The degree of stenosis was > 70% in 42.9% of patients with stenosis, Bilateral stenosis was detected in 14% of patients. Of the patients with >or= 40% carotid stenosis, 33% had a decreased ankle-brachial index, 38% had a previous history of stroke, and only one patient (5%) had a documented history of coronary artery disease. Multivariate analysis, including variables determined to be significantly different by univariate analysis between patients with or without >or= 40% stenosis, indicated that age, systolic blood pressure and high-density lipoprotein (HDL)-cholesterol (inverse correlation) were independent risk factors associated with carotid stenosis.

CONCLUSIONS

Carotid duplex scanning is a useful strategy in identifying carotid stenosis in older Type 2 diabetic patients with high systolic blood pressure, or low levels of HDL cholesterol. The early identification and subsequent appropriate management of carotid stenosis, particularly in this group of patients, may facilitate efforts to reduce the incidence of macrovascular complications.

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.