Primary stroke-unit treatment followed by early CEA of high-grade ICA stenosis after minor stroke

Purpose/Aims: To assess the safety of early endarterectomy (CEA) in patients with high-grade symptomatic internal carotid artery (ICA) stenosis. Previous reservations regarding early CEA were proofed to be exaggerated. A close collaboration between vascular surgeons and neurologists is required to perform the operation as early as possible and therefore enhance the chance for rehabilitation.

Patients and methods: The course of treatment and outcome of patients with symptomatic high-grade ICA stenosis from 2000 until now are evaluated who underwent early CEA after being referred directly from the Stroke-Unit for carotid surgery. Additionally, we reviewed the patients for: age; duration of symptoms until admission; severity of ischemia-related symptoms; multimodal imaging (ultrasound, MRI, PET); duration until CEA; perioperative complications; duration of in-hospital care.

Results: 33 patients (age 65.0±10.0 [44–83] years) with the clinical and imaging signs of TIA (n=12), minor (n=15) and major stroke (n=6) were admitted. The duration of symptoms was 23.5±48.3 [0.8–240] hours. In 29 patients ipsilateral high-grade ICA stenosis was operated early (within 4.5±3.5 [1–12] days; n=23) or late (26.2±8.3 [20–41] days; n=6). Intra-stenotic flow-values were 396±101 and 303±117cm/s. In 4 patients an ipsilateral occlusion (0cm/s), contralateral high-grade stenosis (256±97cm/s) and imaging criteria of penumbra were found. In these patients a CEA was performed on the contra-lateral high-grade ICA stenosis 10.3±2.8 [7–13] days after onset of symptoms. Peri-operative morbidity with early as well as late CEA was 9%. The duration of in-hospital care was 15.3±8.3 [5–37] days with early CEA and 38.7±10.7 [25–48] days with late CEA.

Conclusions: After TIA or minor stroke CEA should be carried out as soon as possible as peri-operative morbidity is not increased and duration of in-hospital care is significantly shorter. After careful selection, these patients can undergo CEA under local anaesthesia with a low perioperative risk of neurological deterioration which is comparable to the risk of recurrent stroke while waiting for delayed surgery.