Urgent carotid endarterectomy for stroke in evolution.

BACKGROUND: Carotid endarterectomy (CEA) is well established as the elective treatment for moderate or severe carotid stenoses with a history of neurologic symptoms. In contrast, the merits of carotid revascularisation performed 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 for 212 (48%) asymptomatic and 233 (52%) symptomatic carotid stenoses within a 5 years period between January, 1995, and December, 1999. Of the latter, CEA was performed in emergency on 16 patients (3.8%) within 4 to 24 hours after the onset of symptoms. Patients selected for urgent surgery fulfilled the following criteria: acute onset of fluctuating hemispheric neurological symptoms, significant carotid pathology, absence of cerebral hemorrhage, uncompromised vigilance and stable cardiopulmonary conditions. Selected patients presented with a crescendo-TIA (n = 7) or fluctuating neurological deficits (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 non-disabling deficits, remained unchanged in one and worsened in 2 patients from hemihypaesthesia to hemiparesis. 14/16 patients were discharged within 8 days after admission. The neurologic status after discharge did not deteriorate 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 beneficial for selected patients with stroke in evolution and fluctuating neurological deficits. Careful adherence to selection criteria, intraoperative shunting, intensive care post surgery surveillance and an experienced team are recommended.