A Retrospective Study on Early Carotid Endarterectomy within 48 Hours after Transient Ischemic Attack and Stroke in Evolution

Background: Large randomized controlled trials have shown that carotid endarterectomy (CEA) is beneficial in the treatment of recent severe symptomatic carotid stenosis. Data are lacking concerning the risks of early CEA (<48 hours) for stroke in evolution (SIE) or crescendo transient ischemic attack (CTIA). The primary end point of this retrospective study was to evaluate the incidence of stroke, major adverse cardiac events (MACEs), and death within the first 30 days after early CEA performed within 48 hours in patients presenting with transient ischemic attack (TIA)/SIE. Methods: Between 2001 and 2010, we treated 3,023 carotid artery stenoses, 29.5% (891/3,021) of which were in symptomatic patients. Early CEA within 48 hours after acute TIA/SIE was performed in 176 patients. Patients were divided into 3 groups for analysis of outcome after early CEA in symptomatic patients according to their initial neurologic deficit. Group 1 included 55 patients with TIA (single); group 2 included 55 patients with CTIA, and group 3 included 66 patients with SIE. Carotid artery stenosis was evaluated by duplex ultrasonography (DS). All patients were pre- and postoperatively visited by an experienced consultant neurologist who evaluated the neurologic status according to the modified Rankin Scale and the National Institutes of Health Stroke Scale (NIHSS). At admission, surgery was not performed on patients with disabling neurologic deficit (NIHSS score: >6) except for 4 selected cases (NIHSS score range: 8-14), patients with cerebral lesions >3 cm in diameter, patients with the presence or suspicion of parenchymal hemorrhage, patients with occlusion of the middle cerebral artery, and those who were deemed unfit for surgery. Clinical and DS follow-up examinations were performed after 6 and 12 months and annually thereafter. The mean duration of follow-up was 29.4 months (range: 0-120 months). Results: The cumulative TIA/stroke/myocardial infarction/death rate at 30 days was 3.9% (7/176). TIA and stroke rates were 0% (0/176) and 3.4% (6/176), respectively. The stroke rate in groups 1, 2, and 3 was 1.8% (1/55), 0% (0/55), and 7.6% (5/66), respectively. No hemorrhagic strokes, TIAs, or MACEs were detected after surgery. Stroke risk was higher in group 3 than in groups 1 or 2, but the differences in the 3 groups were not statistically significant (group 1 vs. group 2: 1/55 vs. 0/55 events [P = 0.3151]); group 1 vs. group 3: 1/55 vs. 5/66 events [P = 0.3020]; and group 2 vs. group 3: 0/55 vs. 5/66 events [P = 0.1039]. Thirty-day follow-up was available for all patients, while long-term follow-up (mean: 32.7 +/- 26.8 months) was available only for 158 patients (1 patient died and 17 were lost to follow-up). Conclusions: CEA can be performed with an acceptable risk in properly selected symptomatic patients within 48 hours after TIA or SIE. The benefits of early CEA in symptomatic patients include the prevention of recurrent stroke.