Get thee to the OR

Carotid endarterectomy can prevent a future stroke in TIA patients � but make that sooner rather than later

By Brian Hoyle

Donald Peruse is 68 years old. One evening, while watching TV with his wife, his left arm started to feel weak and then went completely numb. He went to the ER where, that same evening, he was diagnosed as having suffered a transient ischemic attack (TIA). This 'warning-stroke' shook him up; he and his wife were afraid he'd have another, more serious, cerebral vascular accident. After reviewing the options, Mr Peruse and his doctor decided to book him in for carotid endarterectomy surgery to unplug the carotid artery, four months after the initial TIA.

It turns out that was the right decision, but it could have turned out to be the wrong time. Mr Peruse had a successful operation and is doing fine, but the four month wait might well have proved fatal. According to new findings published in the March 20 issue of The Lancet, carotid endarterectomy is best done within the first few weeks after a TIA if a more serious and potentially lethal stroke is to be prevented.

"Unfortunately, in the UK and elsewhere the operation is often not done until several months after the [TIA] � even if the patient seeks medical attention immediately after their warning stroke," said Dr Peter Rothwell, lead author of the study, in a news release. "Benefit from surgery is reduced at this time and many patients who would have benefited have their major stroke while waiting for surgery."

Dr Rothwell and his colleagues from the Stroke Prevention and Research Unit at the Radcliffe Infirmary in Oxford, UK, sifted through data from 5,893 patients who took part in the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET), adding up to a post-endarterectomy followup time of 33,000 patient years. Both trials produced similar results. The researchers found that the stroke-lessening benefit of endarterectomy was significantly greater in men (especially those over 75), and when done quickly after a TIA. The benefits fell rapidly the longer the procedure was delayed.

Analysis focused on the outcomes and risks of the carotid surgery, and to what degree stenosis affected the procedure, among patients randomized into several subgroups. They found that for patients with 50% or higher stenosis, nine men and 36 women needed to be operated on to prevent one ipsilateral stroke in five years; for those over the age of 75, the number was five, and 18 for those younger than 65 years. Of patients randomized within two weeks of their ischemic event, five needed the operation as opposed to 125 for patients randomized after more than 12 weeks.