Timing of carotid endarterectomy after acute stroke Joseph J. Piotrowski, M D , Victor M. Bernhard, M D , Jeffrey R. R u b i n , M D , K e n n e t h E. M c I n t y r e , M D , James M. Malone, M D , F. N o e l P a r e n t III, M D , and G l e n n C. H u n t e r , M D , Tucson, Ariz. An arbitrary delay o f at least 6 weeks before performing carotid endarterectomy after acute stroke has been recommended based on anecdotal reports. This prolonged interval may increase the danger of recurrent neurologic deficit before surgery. From September 1978 to September 1988, carotid endarterectomy was performed on 140 patients at variable intervals after stroke. Eleven patients had temporary stroke, which left 129 patients with neurologic symptoms that persisted for 3 weeks or had a cortical infarct on CT scanning. A prospective therapeutic protocol was applied to 82 patients admitted with acute stroke. They were observed until neurologic recovery reached a plateau, based on clinical observation by a neurologist, before performing angiography and carotid endarterectomy (group I). Forty-seven patients were not seen until after recovery from stroke was established (group II). At initial presentation, the severity of neurologic deficit was classified as mild, moderate, or severe in 31%, 58%, and 11%, respectively. Recovery before operation was registered as complete in 11%, mild residual in 66%, moderate residual in 21%, and severe residual in 2%. Group I patients (n = 82, 64%) were operated on within 6 weeks of stroke and group II (n = 47, 36%) were operated on at varying times after 6 weeks. No significant difference was found in the incidence ofcerebrovascular events (1.2% vs 4.2%) and deaths (1.3% vs 2.1%) between groups I and II with respect to the timing o f carotid endarterectomy, and no significant difference was found between patients operated on at 2, 4, 6, or more than 6 weeks after stroke. We conclude that carotid endarterectomy after acute stroke can be performed with no increase in morbidity or mortality as long as neurologic recovery has reached a plateau. An arbitrary delay of 6 weeks is not required to prevent perioperative neurologic complications. (J VASe SuRG 1990;11:45-52.) An arbitrary delay o f 6 weeks before performing carotid endarterectomy (CEA) after acute stroke was initially recommended to prevent the development o f a hemorrhage infarct. Initial reports by Wylie et ~ " l H u n t e r et al.,2 Rob,3 and Bruetman et al.4 on ]3atients with acute progressive neurologic symptoms -who subsequently underwent operation revealed an ~arming incidence o f this complication, which led to death in most cases. These case reports, as well as the randomized trial, the Joint Study o f Extracranial Arterial Occlusion, s from this era include patients with occluded internal carotid arteries. In addition,

From the Universityof Arizona Health SciencesCenter, Section of Vascular Surgery. Presented at the Thirty-seventhScientificMeeting of the North American Chapter, International Society for Cardiovascular Surgery, New York, N.Y., June 19-20, 1989. Reprint requests: Victor M. Bernhard,MD, Professorof Surgery, Chief, Section of Vascular Surgery, University of Arizona - Health SciencesCenter, 1501 N. CampbellAve., Tucson, AZ 85724. 24(~,¢16966

computerized tomography (CT) was not available, and therefore patients with alternate causes o f cerebral disease may have been selected for CEA. In the last 10 years 129 patients have undergone CEA at varying intervals after stroke. A prospective therapeutic protocol has been observed in 82 o f these patients after acute stroke; they were observed until neurologic recovery reached a plateau before they had angiography and CEA. The purpose o f this retrospective study was to compare the operative complication rate o f those 82 patients with a concurrent group o f 47 patients from the same institution who were first encountered after neurologic stabilization and were operated on more than 6 weeks after onset o f cerebrovascular symptoms. METHODS From 1978 to 1988, 140 patients underwent CEA after stroke on the combined vascular surgery service o f the University o f Arizona Health Sciences Center and the Veterans Administration Medical Center in Tucson, Ariz. Ninety patients o f this group 45

Journal of VASCULAR SURGERY

46 Piotrowski et al.

Table I. Patient demographics and neurologic findings

Age in years Demographics

Diabetes Hypertension Heart disease Smoking Sex (men) Initial presentation Mild stroke Moderate Severestroke After stabilization Full recovery Mild residual Moderate Severe

Group I

Group 11

6 weeks (n = 47)

Total (n = 129)

65.7 (44-89)

n (%)

n (%)

18 (21.9) 53 (64.6) 27 (32.9) 40 (48.8) 66 (80.5)

13 (27.7) 35 (74.5) 15 (31.9) 16 (34.0) 42 (89.4)

31 (24.0) 88 (68.2) 42 (32.6) 56 (43.4) 108 (83.7)

25 (30.5) 47 (57.3) 10 (12.2)

15 (31.9) 28 (59.6) 4 (8,5)

40 (31.0) 75 (58.1) 14 (10.9)

8 56 16 2

6 29 11 1

14 85 27 3

(9.8) (68.3) (19.5) (2.4)

(12.8) (61.7) (23.4) (2.13)

(10.9) (65.9) (20.9) (2.3)

Separate chi-square analysis of each of these parameters in the group of patients operated on within 6 weeks of stroke compared to these parameters in patients operated on after 6 weeks did not reveal a statistically significant difference at thep