Asymptomatic carotid stenosis and unrelated operations: Should we be more aggressive?

BACKGROUND: Carotid lesions will often remain asymptomatic during the perioperative per iod, so prophylactic carotid endarterectomy (CEA) has not been advocated be fore other operations. The purpose of this study was to characterize the cl inical manifestations of new neurologic symptoms occurring in patients with previously asymptomatic carotid occlusive disease who have undergone recen t operations. STUDY DESIGN: We performed a retrospective review of patients developing neurologic sympt oms attributable to carotid occlusive disease after unrelated operations. RESULTS: Eleven patients (mean age 68 +/- 6.4 years, 8 men, 3 women) developed new n eurologic symptoms from previously asymptomatic extracranial carotid stenos es after 11 unrelated procedures. Neurologic events included hemispheric st roke (n = 10) and amaurosis fugax (n = 1). Two intraoperative strokes occur red (one mastectomy, one prostatectomy). Other events occurred a mean of 5. 8 +/- 5 (range 1 to 16) days after aortic surgery (n = 2), infrainguinal by pass (n = 3), contralateral CEA for symptomatic disease (n = 2), incisional herniorrhaphy (n = 1), and prostate surgery (n = 1). Responsible internal carotid artery lesions were all stenoses greater than 80%; seven were dearl y greater than 90%. Those suffering intraoperative stroke or stroke within 24 hours of operation (n = 3) were not receiving antithrombotic therapy. Al l other events (n = 8) occurred despite the use of antiplatelet or anticoag ulant agents. Four underwent emergent CEA. Four had elective CEA performed after reaching a neurological recovery plateau. CONCLUSIONS: Critical, asymptomatic internal carotid artery stenoses may cause neurologi c symptoms after unrelated surgical procedures. (J Am Coll Surg 2001;192:60 8-613. (C) 2001 by the American College of Surgeons).