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OUTCOMES OF URGENT CAROTID ENDARTERECTOMY FOR STABLE AND UNSTABLE ACUTE NEUROLOGICAL DEFICITS: A SINGLE-CENTRE RETROSPECTIVE ANALYSIS
Iacopo Barbetta, MD1, Michele Carmo, MD1, Alberto Settembrini, MD2, Lattuada Patrizia, MD3, Piergiorgio Settembrini, Professor4.
1Ospedale San Carlo Borromeo, UO Chirurgia Vascolare, Milano, Italy, 2Scuola di specialit di Chirurgia Vascolare, Universit degli studi di MIlano, Milano, Italy, 3Ospedale San Carlo Borromeo, UO Stroke Unit, Milano, Italy, 4Cattedra e scuola di specialit di Chirurgia Vascolare, Universit degli studi di Milano., Milano, Italy.
OBJECTIVES:
Urgent carotid endarterectomy (CEA performed within 2 weeks after the onset of acute neurological deficits) seems to yield better long-term results than if delayed or not performed.
We retrospectively analysed the results of all urgent CEAs performed in our institution since the establishment of an operative protocol with our Stroke Unit.
METHODS:
From January 2002 to July 2011 all the patients coming to our ER with acute neurological symptoms underwent a diagnostic work-up consisting of: neurologic evaluation , head computed tomography (CT), and carotid duplex scanning. Assessment of National Institute of Stroke Scale (NHISS) was performed at admission and discharge for neurologically stable patients.
88 patients with a carotid stenosis > 50% and no contraindication to surgery (NHISS > 15 or hemorrhagic infarction at CT scan) underwent urgent CEA.
The mean age was 70.8 years (range 37-89 years) with 63 (71.6%) men and 25 (28.4%) women.
Patients were grouped according to presentation: Group1 single transient ischemic attack (TIA), Group2 minor and moderate stroke, Group3 unstable symptoms (crescendo TIA or stroke in evolution).
We considered the timing of surgery as emergent (CEA<24h) or non emergent.
End points were NHISS score modification, postoperative morbidity and mortality.
RESULTS:
Urgent CEAs were performed at a median time of 50 hours (IQR 16-116 hours) from the onset of symptoms.
Median NHISS was 4 (IQR 2-6,2) on admission and 2 (IQR 0,7-3,2) on discharge with a median improvement of 2 points (IQR 0-4).
There was a total of 11 (12,5%) neurologic complications: 0/16 for GROUP1, 6/55 (10.9%) for GROUP2 and 5/17 (29.4%) for GROUP3.
In patients with minor to moderate stroke a timing of intervention >24h was significantly associated with a higher rate of complications (P<0,4), while in patients with unstable symptoms we we found no relation between timing of surgery and clinical outcomes.
Total mortality was 4 (4,5%): 3 deaths due to neurologic complications and 1 death do to myocardial infarction.
CONCLUSIONS:
Urgent CEA is a safe and effective therapeutic strategy for patients presenting with mild to moderate stable neurologic deficits, especially if performed in the very first hours of presentation. We need more accurate studies to identify that subset of patients presenting with unstable symptoms who may not benefit from early surgery.
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