title: Standardized protocols enable stroke recognition and early treatment of carotid stenosis.
abstract: OBJECTIVE
  This study examined the effect of acute ischemic stroke (AIS) care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA).
  
  
  METHODS
  A standardized AIS protocol was instituted between vascular surgery and stroke neurology services in an academic hospital (group I) that included: (1) rapid patient evaluation and imaging inclusive of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound imaging or conventional arteriogram, or both; (2) patient admission to a dedicated stroke unit with minimum 1:2 intensive care nurse-to-patient staffing and a 24-hour available neurointensivist; (3) treatment of all patients with ipsilateral moderate or severe carotid stenosis by CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from undergoing expeditious CEA included (1) stroke in evolution, and (2) dense neurologic deficit or National Institutes of Health Stroke Scale score >15 (severe), or both. Comparisons of data were performed between group I patients and those treated in outlying hospitals (group II) for similar indications. All data were prospectively collected in a computerized database and outcomes evaluated retrospectively.
  
  
  RESULTS
  From November 2002 to November 2012, 369 patients underwent CEA for AIS ≤1 week of presentation. There were 192 patients in group I and 177 in group II. There were no differences in group I and II in mean stroke-to-CEA interval (3.4 vs 3.9 days) or in the performance of eversion CEA (94% vs 97%), respectively. Intraoperative shunt use was greater in group I (28%) than in group II (18%; P = .021). Fewer total neurologic events (stroke or transient ischemic attack) occurred in group I (6 [3.1%] vs 14 [7.3%]; P = .03). No patients died in either group. Postoperative National Institutes of Health Stroke Scale scores available in group I patients showed improvement from preoperative baseline in mild and moderate stroke patients (P < .001).
  
  
  CONCLUSIONS
  In patients with stable acute stroke, early CEA is feasible and relatively safe. Stroke or death occurs in only 1%, and most complications are of nonfatal cardiac origin. A standardized stroke team protocol that is inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of an acute stroke.
authors.affiliation: The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, NY. Electronic address: patyp@albanyvascular.com.
authors.forename: Philip S K
authors.initials: PS
authors.lastname: Paty
authors.affiliation: Department of Neurology and Neurosurgery, Albany Medical College, Albany, NY.
authors.forename: Gary L
authors.initials: GL
authors.lastname: Bernardini
authors.affiliation: The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, NY.
authors.forename: Manish
authors.initials: M
authors.lastname: Mehta
authors.affiliation: Department of Neuropharmacology and Neurosciences, Albany Medical College, Albany, NY.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Feustel
authors.affiliation: The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, NY.
authors.forename: Khusboo
authors.initials: K
authors.lastname: Desai
authors.affiliation: The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, NY.
authors.forename: Sean P
authors.initials: SP
authors.lastname: Roddy
authors.affiliation: The Institute for Vascular Health and Disease, Albany Medical College/Albany Medical Center Hospital, Albany, NY.
authors.forename: R Clement
authors.initials: RC
authors.lastname: Darling
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery / Q000628:therapy*; D002985:Clinical Protocols; D003299:Cooperative Behavior; D003422:Critical Care; D016894:Endarterectomy, Carotid; D005260:Female; D006757:Hospital Units; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis* / Q000209:etiology; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000209:etiology; D014057:Tomography, X-Ray Computed; D018616:Ultrasonography, Doppler, Duplex