Carotid endarterectomy in the stroke patient: Computerized axial tomography to determine timing

Abstract

Historically, patients with mild to moderate neurologic deficits lasting longer than 24 hours were believed to have sustained a completed stroke. They were followed up for 4 to 6 weeks and cerebral angiography was performed if indicated. CT scanning has identified a subset of these patients who have sustained a reversible ischemic neurologic deficit (RIND) rather than a completed stroke. The timing for angiography and surgery for this group has not been established. In an earlier study we found that 21% (4 of 19 patients) suffered a second stroke during the 4- to 6-week waiting period. To avoid this high rate of recurrence, we instituted an aggressive program of CT scan evaluation and surgical therapy for all "stroke patients" with negative CT scans. Two hundred forty-five patients were seen with a persistent neurologic deficit between July 1980 and December 1983. These patients underwent CT scans 1 and 5 days after the initial event. Of these 245 patients, 171 patients (70%) were found to have negative CT scans. Appropriate carotid lesions were found by arteriography in 110 (64%) of the negative CT scan group. There were 61 (55%) men and 49 (45%) women in this group. Eighty-five patients (77%) had previous neurologic symptoms or a cerebrovascular accident. Hypertension was present in 52% and diabetes mellitus in 30%. All 110 patients underwent carotid endarterectomy within 14 days (mean 10 days) of the initial onset of their neurologic deficit; these were all done with shunt protection. No patient suffered another neurologic deficit in the same territory within 30 days after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Early Carotid Surgery for Recent Neurologic Deficit

“…11 Sacco et al 12 reported a 14% recurrent stroke rate within 2 years in 1273 patients with acute cerebral infarction, 30% of which occurred in the first 30 days. Dosick et al 10 observed a 9.8% recurrence of neurologic events in 74 patients within 4 to 6 weeks after an ischemic stroke. In the ECST trial 71 patients randomized to medical care suffered an ipsilateral ischemic stroke, 24% of which were observed within 4 months of randomization.…”

“…22 Possibly patients with stroke and no ischemic lesions on CT are a favorable selection for early surgery. Dosick et al 10 reported one stroke (0.9%) and no death in 110 patients operated within 14 days of a nondisabling stroke who had negative CT scans on days 1 and 5.…”

“…Accordingly, in modern series these high-risk patients with large defects generally have been excluded. 10,11,16 The value of sequential CT scans however remains unclear. In our series as well as others the presence or absence of a new ipsilateral ischemic defect on CT did not appreciably influence outcome (Table 6).…”

“…2 Several authors have since reported favorable results with a more aggressive approach to selected patients with recent neurologic deficit reporting combined stroke/mortality rates between 0.9 and 7.4%. 10,11,[14][15][16][17][18][19] Although selection criteria have varied individually, several general principles are beginning to emerge.…”

“…[4][5][6][7][8][9] Subsequent recommendations to postpone surgery for at least 4 to 6 weeks have been called into question because a substantial rate of recurrent neurologic events has been observed to occur within this waiting period. [1][2][3][4][5][6][7][8][9][10][11][12] Recently we have adopted a more aggressive approach to these patients and have performed early carotid surgery after acute neurologic deficit in selected patients.…”