Urgent carotid endarterectomy for stroke in evolution

Background: Carotid endarterectomy (CEA) is well established as the electiv e treatment for moderate or severe carotid stenoses with a history of neuro logic symptoms. In contrast, the merits of carotid revascularisation perfor med in emergency in patients with acute stroke or fluctuating neurological deficit remain controversial. Patients and methods: A total of 445 CEAs were performed on 424 patients fo r 212 (48%) asymptomatic and 233 (52%) symptomatic carotid stenoses within a 5 years period between January, 1995, and December 1999. Of the latter CE A was performed in emergency on 16 patients (3.8%) within 4 to 24 hours aft er the onset of symptoms. Patients selected for urgent surgery fulfilled th e following criteria: acute onset of fluctuating hemispheric neurological s ymptoms, significant carotid pathology: absence of cerebral hemorrhage, unc ompromised vigilance and stable cardiopulmonary conditions. Selected patien ts presented with a crescendo-TIA (n = 7) or fluctuating neurological defic its (n = 9) corresponding to a contralateral carotid stenosis. Results: Following CEA, the neurological deficits improved instantaneously to complete recovery in 9 patients. The symptoms of 4 patients improved to nondisabling deficits, remained unchanged in one and worsened in 2 patients from hemihypaesthesia to hemiparesis. 14/16 patients were discharged withi n 8 days after admission. The neurologic status after discharge did nor det eriorate in any of the patients during follow up of 19.3 +/- 13 months, but improved in 4 of the patients. Conclusion: Our retrospective study suggests that rescue CEA may be benefic ial for selected patients with stroke in evolution and fluctuating neurolog ical deficits. Careful adherence to selection criteria, intra-operative shu nting, intensive care post surgery surveillance and an experienced ream are recommended.