First Week Appears to Be Critical Time for CEA After Stroke Event

CHICAGO — A newly published analysis suggests that the optimal timing of a carotid endarterectomy (CEA) is after 48 hours but within the first week after a major or minor stroke.

The decision for neurologists and surgeons alike concerns the balance between subjecting recently injured brain tissue to early carotid revascularization and risking recurrent stroke by delaying carotid endarterectomy. Carotid endarterectomy is an effective therapy for preventing stroke, but the timing is critical and controversial. 

Recent guidelines from the European Society for Vascular Surgery recommend that intervention with carotid endarterectomy be performed within 14 days after symptom development in most patients with a 50-99{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} carotid artery stenosis.

As reported in the December edition of the Journal of Vascular Surgery, researchers from the University of Pittsburgh and Boston Medical Centers, led by vascular surgeon Dr. Mohammad Eslami, addressed the issue of timing of CEA specifically following stroke. 

They retrospectively evaluated 989 patients registered in the Vascular Study Group of New England between 2003 and 2014 who suffered a stroke and subsequently underwent CEA. They divided the patients into four cohorts based on timing of CEA.

“CEA performed within two days of the index event carries a statistically significant higher risk of stroke compared to the other cohorts in this series of patients. Surgery performed within two to five days may be similar to a later CEA in neurologically stable stroke patients in terms of perioperative stroke,” Eslami noted. “Balancing the higher risk of postoperative stroke with the early risk of recurrent stroke, it appears prudent to avoid repair within the first two days but consider intervening during the index hospital stay in stable patients.”

It was additionally noted that endarterectomy is increasingly being offered during the same hospital stay as the index event. In 2003, more than 60{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of patients were discharged and readmitted for surgery, compared to 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} in 2014.

This study carries the limitations of a retrospective analysis as well exclusion of patients presenting with transient ischemic attack.

Overall, in carefully selected patients with non-disabling stroke, revascularization is recommended beyond two days but within the first week of the same hospital stay to decrease the risk of recurrent stroke.