title: Optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction.
abstract: OBJECTIVE
  There is debate concerning the optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction. Our intent was to stratify clinical and economic outcomes based on the timing of revascularization.
  
  
  METHODS
  We performed a retrospective cohort study using the Nationwide Inpatient Sample from 2002 to 2011. Patients were included if they were admitted non-electively with a primary diagnosis of carotid artery stenosis with infarction and subsequently treated with revascularization. Cases were stratified into four groups based upon the timing of revascularization: (1) within 48-h of admission, (2) between 48-h and day four of hospitalization, (3) between days five and seven, and (4) during the second week of admission.
  
  
  RESULTS
  27,839 cases met our inclusion criteria. The lowest odds of iatrogenic complications (OR=0.643, P<.001) and mortality (OR=0.631, P<.001) coincided with revascularization between days five and seven of hospitalization. Treatment with carotid artery stenting (CAS) and administration of recombinant tissue plasminogen activator (rtPA) increased the odds of complications and death. With regards to economic measures, administration of rtPA and utilization of CAS drove cost and length-of-stay up, while lower co-morbidity burden and earlier time to revascularization drove both measures down.
  
  
  CONCLUSIONS
  The present study suggests that the optimum timing of revascularization may be near the end of the first week of hospitalization following acute stroke. However, this study must be cautioned with limitations including its inability to control for critical disease specific variables including symptom severity and degree of stenosis. Prospective examination seems warranted.
authors.affiliation: Crouse Neuroscience Institute, Neurovascular and Stroke Center, Syracuse, USA.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Villwock
authors.affiliation: University of Florida, Department of Neurosurgery, Gainesville, USA.
authors.forename: Amit
authors.initials: A
authors.lastname: Singla
authors.affiliation: State University of New York Upstate Medical University, Department of Neurosurgery, Syracuse, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Padalino
authors.affiliation: State University of New York Upstate Medical University, Department of Neurosurgery, Syracuse, USA.
authors.forename: Raghu
authors.initials: R
authors.lastname: Ramaswamy
authors.affiliation: Crouse Neuroscience Institute, Neurovascular and Stroke Center, Syracuse, USA. Electronic address: ericdeshaies@crousemed.com.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Deshaies
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D002544:Cerebral Infarction / Q000150:complications / Q000401:mortality / Q000601:surgery*; D002548:Cerebral Revascularization / Q000191:economics / Q000379:methods*; D015331:Cohort Studies; D003365:Costs and Cost Analysis; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007348:Insurance, Health / Q000191:economics / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000191:economics / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D015607:Stents / Q000191:economics; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Carotid artery stenosis; Carotid endarterectomy; Carotid stent; Early medical intervention; Reperfusion