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(Stroke. 1998;29:2667-2668.)
© 1998 American Heart Association, Inc.

Letters to the Editor

Timing of Carotid Endarterectomy After Stroke

Andrew P. Gasecki, MD, PhD

Division of Neurology, University of Nebraska Medical Center, Omaha, Nebraska

Michael Eliasziw, PhD

NASCET, John P. Robarts Research Institute, London, Canada

To the Editor:

We read the review article¹ on the timing of carotid endarterectomy after stroke with interest. We would like to emphasize several observations from the NASCET database. Although the article² on timing of endarterectomy may influence surgeons to perform early endarterectomy, it is important to recognize that all patients in the early-surgery group were operated on at least 3 days (misprinted as 2 days in the review article) after the initial stroke, with a median interval time of 16 days. Furthermore, the study did not enroll any patient with disabling stroke. In regard to delaying surgery in patients with high-grade stenosis, this practice may result in an increase in stroke recurrence (4.9% and 1.9% for nondisabling and disabling, respectively) during the first 30 days after the initial stroke, which may further postpone surgery. Thus, the combined risk associated with delaying surgery may be as high as 10.1% (4.9% recurrence in the first 30 days plus 5.2% delayed surgery perioperative risk) versus 4.8% perioperative risk related to the early endarterectomy. Given comparable perioperative complication rates between early (30 days) and delayed (>30 days) endarterectomy (4.8% versus 5.2%, respectively), the risk of recurrence during the first 30 days (4.9% in NASCET) adds a considerable risk and should be counted against delaying surgery. We suggest that future studies should compare the risk of early surgery with a combined estimate of risk during the waiting period and the perioperative risk of delayed surgery.

References

1. Pritz MB. Timing of carotid endarterectomy after stroke. Stroke.. 1997;28:2563–2567.[Abstract/Free Full Text]

2. Gasecki AP, Eliasziw M, Ferguson GG, Clagett GP, Hachinski VC, Barnett HJM. Early endarterectomy for severe carotid stenosis after a non-disabling stroke: results from the North American Symptomatic Carotid Endarterectomy Trial. J Vasc Surg.. 1994;20:288–295.[Medline] [Order article via Infotrieve]

Response

Michael B. Pritz, MD, PhD

Section of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana

I thank Drs Gasecki and Eliasziw for their interest in my recent review.¹ I look forward to their publication on this subject analyzing the data of the NASCET study for patients with 50% to 99% carotid stenosis. I agree that the risk of stroke recurrence while awaiting endarterectomy needs to be considered and factored into the delayed-surgery group. However, data from others^{2 3 4 5} indicate a risk of recurrent stroke that ranges from 2% to 21%. Furthermore, patients whose carotid artery has become occluded are no longer candidates for endarterectomy.

In addition, while awaiting surgery it is likely, as suggested in this review,¹ that patients with a fixed neurological deficit who are considered for carotid endarterectomy are not a homogeneous group. This review stratified stroke patients on the basis of the presence or absence of computed tomographic hypodensity, brain shift, level of consciousness, and vascular territory of the infarct.¹ These parameters, as well as others, may better define the risk of early carotid endarterectomy after recent stroke in patients with a fixed neurological deficit.

References

1. Pritz MB. Timing of carotid endarterectomy after stroke. Stroke.. 1997;28:2563–2567.

2. Dosick SM, Whalen RC, Gale SS, Brown OW. Carotid endarterectomy in the stroke patient: computerized axial tomography to determine timing. J Vasc Surg.. 1985;2:214–219.[Medline] [Order article via Infotrieve]

3. Khanna HL, Garg AG. 774 carotid endarterectomies for strokes and transient ischaemic attacks: comparison of early vs. late surgery. Acta Neurochir Suppl (Wien).. 1988;42:103–106.[Medline] [Order article via Infotrieve]

4. Sacco RL, Foulkes MA, Mohr JP, Wolf PA, Hier DB, Price TB. Determinants of early recurrence of cerebral infarction: the Stroke Data Bank. Stroke.. 1989;20:983–989.[Abstract/Free Full Text]

5. Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke.. 1996;27:415–420.[Abstract/Free Full Text]

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