Early Carotid Endarterectomy after Cerebral Infarction

The objective of the study was to review our recent experience with carotid endarterectomy performed within 30 days of completed cerebral infarction and to evaluate the role of computed tomographic (CT) scanning in the decisionmaking process. Twenty-seven of 302 operations (9%) were carried out during the 30-day time period. The mean interval between cerebral infarction and surgery was 14 days. Angiography revealed severe stenosis (>75%) of the internal carotid artery in 19 patients. Severe stenosis with deep ulceration found in 6 patients and moderate stenosis (i.e., 50-75%) with deep ulceration was found in 2 patients. CT scans showed recent infarction in 4 patients and an old subcortical lacune in 2 patients. Twenty-two patients were neurologically stable with mild deficits and showed normal results on a CT scan performed 24 hours or more after the ischemic event. These patients underwent early cerebral angiography and carotid endarterectomy without permanent morbidity or mortality. Two patients with moderate stable neurological deficits and findings of recent infarction on CT scans had uneventful postoperative courses. Five patients who were neurologically unstable underwent surgery. The 2 patients with repeated transient ischemic attacks and normal findings on CT scans had uneventful postoperative courses. Two of the three patients with progressive neurological deficits and CT findings of recent cerebral infarction experienced extension of their infarcts after surgery. One of these patients died. Our personal experience, together with a review of previous reports, indicated that patients who have minimal residual neurological deficits and whose CT scans show normal findings are at low surgical risk, perhaps approaching that of patients with transient ischemic attacks. The surgical risk is high in patients with progressive neurological deficits and CT scan findings of recent cerebral infarction. Patients with moderate, stable neurological deficits and CT scan findings of recent cerebral infarction appear to carry an intermediate surgical risk.