Association between index symptom and timing on perioperative stroke rate in patients undergoing carotid endarterectomy

Abstract

Background and Purpose

Carotid endarterectomy (CEA) in symptomatic carotid stenosis (SCS) may have a higher risk of perioperative stroke due to disease severity or hemorrhagic conversion. This study aimed to evaluate CEA outcomes for SCS and examine causes of post-operative stroke based on intervention timing and preoperative symptoms.

Methods

All CEAs performed for SCS from 2012 to 2023 across two metropolitan hospitals were analyzed. CEAs were performed with general anesthesia, patching, and shunting. Post-operative (30-day) strokes were classified as technical, hemorrhagic, or embolic and were evaluated by timing (<48 h, 48h–2 weeks, >2 weeks) and preoperative symptoms (TIA/amaurosis fugax, minor stroke, moderate-severe stroke, crescendo TIAs/stroke in evolution). Stroke severity was assessed using the modified Rankin Scale (mRS).

Results

Among 664 CEAs, post-operative stroke occurred in 3.0 % of cases. Timing significantly influenced stroke rates: 5.7 % <48 h, 4.0 % between 48h–2 weeks, and 1.4 % >2 weeks (P = .04). Preoperative symptoms also affected stroke rates, with highest rates following crescendo TIAs/stroke in evolution (7.5 %, P = .02). Early CEA (<48 h) independently increased stroke risk (odds ratio 5.6, P = .04), and hemorrhagic strokes were associated with <48 h interventions (P = .005). Major strokes occurred in 1.1 % of cases, linked to preoperative symptoms (P = .05), but not intervention timing.

Conclusions

CEA for SCS carries an acceptable stroke risk overall, though early intervention (<48 h) increases hemorrhagic stroke risk. Major strokes are more frequent following crescendo TIA/stroke in evolution, with no association to timing.