title: The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack.
abstract: OBJECTIVE
  The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms.
  
  
  METHODS
  This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging.
  
  
  RESULTS
  Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%).
  
  
  CONCLUSIONS
  Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA.
authors.affiliation: Vascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy. lauracapoccia@yahoo.it
authors.forename: Laura
authors.initials: L
authors.lastname: Capoccia
authors.forename: Enrico
authors.initials: E
authors.lastname: Sbarigia
authors.forename: Francesco
authors.initials: F
authors.lastname: Speziale
authors.forename: Danilo
authors.initials: D
authors.lastname: Toni
authors.forename: Antonella
authors.initials: A
authors.lastname: Biello
authors.forename: Nunzio
authors.initials: N
authors.lastname: Montelione
authors.forename: Paolo
authors.initials: P
authors.lastname: Fiorani
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002533:Cerebral Angiography / Q000379:methods; D016009:Chi-Square Distribution; D004185:Disability Evaluation; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D018579:Patient Selection; D011237:Predictive Value of Tests; D011300:Preoperative Care; D011446:Prospective Studies; D020127:Recovery of Function; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D012384:Rome; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex