Objectives: Delaying carotid endarterectomy (CE) for at least
6 weeks after an acute non-disabling stroke has been recommended.
This prolonged interval may place the patient with high-grade carotid
stenosis at risk for a recurrent stroke before surgery.
Design: To know if this waiting period was warranted, we have
done a prospective study with inclusions extending from January 1990
to December 1997 involving 72 consecutive patients having a
non-disabling hemispheric stroke with severe (70-99%) ipsilateral
carotid stenosis. In all these patients, CE was performed within 15
days after stroke.
Materials: A non-disabling hemispheric stroke was defined as
the persistence of symptoms of hemispheric ischemia for more than 24
hours, which resulted in no significant impairment in the activities
of everyday life.
Methods: All patients were seen by a neurologist before
performing carotid angiography and contrast CT scan. Magnetic
resonance imaging (MRI) was done in all patients with a negative CT
scan. All CE were performed under general anesthesia with
intraluminal shunting. All patients had a postoperative duplex scan,
and were followed yearly by a neurologist and by a surgeon with a
duplex scan. The mean follow-up was 30 months.
Results: Among the 72 patients, 28 (39%) had a normal
preoperative CT-contrast scan, and 44 patients (61%) had a hypodense
area with contrast enhancement in 6 (8%). Among the 28 patients with
negative initial CT scan, 13 patients (18%) had positive MRI with
bright signals on T2-weighted images. The postoperative mortality
and stroke rate was 2.8%; two patients occluded the operated internal
carotid artery and died. At the end of a five-year period, the
cumulative survival rate was 83 ± 12%, and the cumulative
stroke-free rate was 97.2 ± 2.8% at one year and 91.7 ± 7%
at five years. In this study, the sensitivity of CT scan in
detecting infarction rapidly increases after 5 days, but no
association was found between abnormal preoperative CT scan and
postoperative or subsequent risk of stroke.
Conclusions: We conclude that early CE (<15 days) after an
acute non-disabling stroke can be performed with no increase in
mortality or morbidity. An arbitrary time limit of 6 weeks for CE
exposes these patients with high-grade stenosis to carotid occlusion
with a recurrent stroke, which may be avoidable by earlier
surgery
