PP5. Urgent Surgical Treatment of Carotid Stenosis in Patients with Acute Neurologic Deficits

Abstract

Late results from NASCET and ECST showed a greater benefit for surgery if performed within 4 weeks from symptoms. Recent studies have emphasized the risk of stroke after TIAs and of stroke recurrence after a first episode. Our aim is to describe our experience in treating symptomatic carotid stenosis in an emergency setting. All patients admitted for acute neurologic deficits to the Stroke Unit from 1/2002 to 9/2008 were considered possible candidates to surgery. Those treated within 36 hrs from positive carotid imaging studies were reviewed. All patients received a brain CT and an ABCD2 or NIHSS score, as appropriate. Surgery was not offered if NIHSS > 22. TIA was defined by deficits lasting < 24 hrs and negative CT for 72 hrs. Stroke was defined by symptoms lasting > 24 hrs or positive CT. Neurologic complications were defined by a worsening NIHSS or new area of brain ischemia at CT. End points were perioperative death / neurological morbidity as per NIHSS. Among 55 patients (40 male, mean age 69±9.8 yrs), 17 were admitted for TIA (3 amaurosis, 8 single TIA, 6 recurrent) with a mean ABCD2 score of 3.2±1.6 at admission; 38 had a stroke (34 minor, 4 stroke in evolution), with a median NIHSS of 3 (IQR 2-7.5); 14 of them had a positive CT. Median time from symptoms to observation was 4 hrs (2-7), from observation to surgery 34 hrs (9-115), with no difference between TIAs and strokes. We performed 54 endarterectomies (37 patch, 14 direct, 3 eversion) and 1 embolectomy. Local or regional anesthesia was used in 20 patients and general in 35. Among TIAs 1 patient died of an MI and 2 patients suffered a TIA postoperatively. In the stroke group 1 patient died of a cerebral hemorrhage arisen on 4th postop day, being symptoms free until then. 2 patients had a TIA (1 arm weakness and 1 amaurosis). 3 patients experienced a worsening NIHSS: 2 had a stroke while the third had a hyperperfusion syndrome (all CTs negative during hospital stay). Median NIHSS at discharge was 2 (1-3). Overall the death/stroke rate was 5.9% for TIA patients and 10.5% for stroke. Early surgery had higher perioperative mortality and stroke rates than expected. This can probably be acceptable for TIAs if compared to their risk of stroke. Stroke patients most likely need a better selection in order to pick up those who can benefit from early treatment.