Is size of infarct or clinical picture that should delay urgent carotid endarterectomy? A meta-analysis.

INTRODUCTION: The best timing for carotid endarterectomy in patients with stroke is still matter of debate, particularly in case of significant cerebral ischemic lesion or neurological deterioration. The present review and meta-analysis aimed to report the best evidence in the outcome of patients submitted to urgent (<48h) or standard elapsing time (<2-week) CEA for stroke and to evaluate the impact of cerebral ischemic lesion size and clinical manifestation in the postoperative outcome. EVIDENCE ACQUISITION: A systematic review and meta-analysis was performed by searching through Scopus and PubMed all papers reporting carotid endarterectomy (CEA) outcome (stroke and stroke/death) in patients who suffered a stable stroke, treated within 48h and 2 weeks from symptoms. A subgroup analysis of studies reporting the presence and size of cerebral lesion and clinical manifestation was planned. The pooled 30-day stroke and stroke/death risk (effect size) was expressed by crude percentage and 95% confidence interval (CI), by random effect model. EVIDENCE SYNTHESIS: Sixteen studies were included in the meta-analysis, 7 reporting the CEA outcome performed <48h from stroke and 13 reporting the outcome of CEA performed <2-week. The effect size of stroke and stroke/death of CEA performed <48h from symptoms was 7.4% (95% CI: 3.7-11.2) and 7.9% (95% CI: 4.0-11.8) respectively, and for CEA <2-week was 4.5% (95% CI: 2.8-6.3) and 5.4% (95% CI: 3.4-7.4) respectively. The authors agreed in considering the severity of stroke and the volume of the cerebral ischemic lesion a risk factor for postoperative complication however, due to the extremely high heterogeneity of the studies data, the effect size was not calculated. Two studies evaluated the effect of the cerebral ischemic lesion distribution; the presence of a border-zone infarct was associated with a significant increase in the risk of postoperative stroke/death rate compared with territorial cerebral ischemic lesion (OR: 6.0; 95%CI 1.1-32.0). CONCLUSIONS: CEA for patients with a recent stroke is associated with 5.4% and 7.9% of stroke/death. A large volume of the cerebral ischemic lesion and a deteriorated neurological status are associated with a higher perioperative risk; urgent carotid revascularization seems to further increase this risk.