Early Carotid Surgery for Recent Neurologic Deficit

Abstract

Early carotid endarterectomy after recent neurologic deficit is controversial. Traditionally, an interval of at least 4 to 6 weeks has been recommended based on poor historical results of early surgical intervention after recent strokes and fear of hemorrhagic transformation of the infarct. On the other hand, recurrent strokes have been observed in up to 9.5% of patients while awaiting carotid repair. Since 1996 we have adopted a more aggressive approach to a highly selected group of patients with fresh ischemic deficits, prolonged reversible ischemic neurologic deficit (PRIND), or crescendo transient ischemic attacks (TIAs). Of 2824 patients who underwent carotid endarterectomy between August 1996 and December 1998, 112 patients (3.9%) underwent 123 carotid operations within less than 30 days (median interval: 8 days) after a nondisabling stroke, PRIND, or TIA. Postoperatively five patients (4.4%) suffered a stroke, one patient a transient worsening of his preoperative deficit, and one patient a TIA. Six patients died, three of which were due to their stroke (mortality 5.3%). One of these fatal strokes was due to an intracerebral hemorrhage in a patient with normal preoperative computed tomography. The combined 30-day permanent neurologic stroke and death rate was 7.1%. Functional neurologic outcome was excellent with 74.1% of patients suffering no or minimal deficit (Rankin scale 0-1). Patients with unstable or progressing neurologic deficit were found to have a significantly increased postoperative stroke rate (25%). Early carotid endarterectomy after nondisabling neurologic deficit may be performed with acceptable risk in carefully selected patients. The benefit of early versus delayed surgery, however, can only be determined in a prospective randomized study.