Time is brain: an update

Abstract

The '6-month' threshold for treating symptomatic patients is obsolete. There is compelling evidence that the highest-risk period for stroke (after suffering a transient ischemic attack) is the first 2 weeks, especially the first few days, and that carotid endarterectomy (CEA) confers maximal benefit when performed early. Despite well-documented anxieties, there is increasing evidence that CEA can be performed safely within the first 7 days after onset of symptoms, although risks may be higher when performed within 48 h. The role for carotid artery stenting in the hyperacute period remains uncertain. Centers performing carotid artery stenting within 14 days of symptom onset with risks equivalent to CEA should be encouraged to continue and help others to achieve similar outcomes. For the majority, however, CEA will probably remain the safer option. 'Best medical therapy' and risk factor modification should be started as soon as a transient ischemic attack is suspected, while the early introduction of dual antiplatelet therapy may reduce recurrent events prior to CEA, without increasing perioperative bleeding complications.

Safety of Early Carotid Artery Stenting for Symptomatic Stenosis in Daily Practice

“…CEA has been shown to confer maximum benefit if performed as soon as possible after symptom onset. 2 In the earlier years included in this study, the majority of patients were treated late. This is probably owing to the lack of an early treatment recommendation in the guidelines until 2006, when the AHA guideline for the prevention of stroke recommended that revascularisation of symptomatic carotid artery stenosis should be performed within 14 days of event onset.…”

“…Some recently published papers have reported a significant decrease in stroke recurrence in symptomatic carotid stenosis: Shahidi reported an overall risk of neurological symptom recurrence of 1.6% from the index event to CEA in symptomatic patients, 30 and Naylor reported a 30 day death/ stroke rate of 1% when dual antiplatelet therapy was started shortly before CEA. 2 The routine use of statins in previous years can be of influence in the low complication rates of CAS. Unfortunately, medical treatment, excluding antiplatelet agents, was not recorded in the present study and this is one of the limitations.…”

“…The risk of recurrent stroke in patients with symptomatic severe carotid stenosis has been calculated at 11e25% in the first 14 days. 1,2 Although carotid endarterectomy (CEA) has been established as the gold standard treatment for symptomatic severe carotid stenosis with the highest evidence level, 3e5 carotid artery stenting (CAS) has emerged as an alternative to CEA in the management of carotid stenosis. 6 The treatment interval with the two techniques after the index ischaemic event has changed in recent years.…”

“…8,9 Nowadays, it has been well established that treatment must be undertaken as soon as possible after non-disabling carotid artery stenosis symptoms to prevent a new ischaemic event. 2,10,11 The aim of this study was to evaluate safety (30 day morbidity and mortality) of CAS in the early phase in daily practice according to such recommendations. To this end, trends in the timing of carotid stenting performed at the authors' centre were reviewed and differences analysed between early (first 14 days) and delayed (15e180 days) CAS after non-disabling carotid artery stenosis symptoms.…”

Integrated diagnostics

“…The paradigm of ischemic stroke management lies in the straightforward concept that “time is brain”, so that treatment shall be started as soon as possible, preferably within 3 hours according to the AHA/ASA guidelines ( 23 , 27 ). Universal agreement has been reached that thrombolytic therapy ( i.e.…”