Time is brain!

Carotid endarterectomy (CEA) is a proven treatment in the prevention of stroke, but its overall effectiveness is reduced by excessive delays from symptom to surgery. Specifically, delaying surgery in symptomatic patients with 50-99% NASCET stenoses (70-99% ECST) for >12 weeks prevents only eight strokes per 1000 CEAs in the long term. This is a very depressing observation as the 2004 Sentinel Audit observed that only 50% of stroke patients in the UK will have undergone a Duplex scan by 12 weeks. Excessive delays prior to surgery not only undermine professional confidence in the role of CEA, but they effectively mean that while every patient is exposed to the risks of surgery, many may gain little in the way of long-term stroke prevention. Many of the issues debated in this review will only be resolved by a paradigm shift in political emphasis, but surgeons too have a responsibility to recognise and correct important deficiencies within their own practice.