Accepted Manuscript Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis E. Charmoille, V. Brizzi, S. Lepidi, G. Sassoust, S. Roulet, E. Ducasse, D. Midy, X. Berard PII: S0890-5096(15)00160-0 DOI: 10.1016/j.avsg.2015.01.013 Reference: AVSG 2313 To appear in: Annals of Vascular Surgery Received Date: 20 October 2014 Revised Date: 9 January 2015 Accepted Date: 10 January 2015 Please cite this article as: Charmoille E, Brizzi V, Lepidi S, Sassoust G, Roulet S, Ducasse E, Midy D, Berard X, Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.01.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis. E. Charmoille1,2, V. Brizzi1, S. Lepidi3, G. Sassoust1, S. Roulet1, E. Ducasse1,2, D. Midy1,2, X. Berard1,2. 1. Vascular Surgery Department, Bordeaux University Hospital, France RI PT 2. Bordeaux University, Bordeaux, France M AN U SC 3. Vascular Surgery Department, Padova University Hospital, Italy Corresponding Author : Vincenzo BRIZZI D Service de Chirurgie Vasculaire Hôpital Pellegrin Place Amelie Raba Leon 33000 Bordeaux, France AC C EP TE Phone : 00 33 5 56 79 61 77 Fax : 00 33 5 56 79 60 39 Email : vincenzo.brizzi@chu-bordeaux.fr ACCEPTED MANUSCRIPT Abstract Objective: Compare outcomes of early (<15 days) versus delayed carotid endarterectomy in symptomatic patients. RI PT Methods: All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and Myocardial Infarction (MI) rates were analysed in the Results: During the study period, 149 SC early and delayed CEA groups. patients were included. Carotid M AN U revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%). The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range, 115) in the early surgery group and 47.9 days (range, 16-157) in the delayed surgery D group. 30-day combined stroke & death rates were respectively 1.7% and 3.5% in TE the early and the delayed surgery groups. 30-day combined stroke, death, & MI rates were respectively 1.7% and 5.9% in the early and the delayed surgery groups. EP Conclusions: During the study period, the reduction of the symptom to knife time in application to the carotid revascularization guidelines did not impact our outcomes AC C suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA. ACCEPTED MANUSCRIPT Introduction Randomised controlled trials have clearly shown the benefit of carotid endarterectomy (CEA) in symptomatic patients1 with a perioperative complication rate less than 6%2. More recent reports present convincing evidence in favour of RI PT early revascularization after symptom onset3,4. An important finding in this regard is that cerebrovascular ischemic events exhibit an exponential recurrence rate reaching 8% and 11,5% at 7 days after a transient ischemic attack (TIA) or minor stroke SC respectively5-7. However, since the actual benefit of this prevention strategy in relation to perioperative complications has not been demonstrated8 and considering M AN U the lacks of early surgery protocols, some vascular surgery centres worldwide continue to perform delayed surgery. The adoption of the carotid guidelines2 in 2008 by reducing symptom to knife time required a new organization of our unit, therefore we decided to retrospectively review and compare outcomes of early (<15 days) D versus delayed carotid revascularization performed before and after this shift, on AC C EP TE symptomatic patients in order to discuss this attitude. Material and Methods Patient selection and preoperative management All CEA procedures performed for symptomatic carotid stenosis at our center between January 2006 and May 2010 were retrospectively reviewed in accordance ACCEPTED MANUSCRIPT with approved institutional review board protocols. Patients were classified as symptomatic if, within 3 months of their procedure, they presented hemispheric stroke or transient ischaemic attack (TIA) resulting in facial or upper/lower extremity weakness, aphasia, or amaurosis fugax documented by formal neurology evaluation. RI PT Crescendo transient ischemic attack (cTIA) was defined as repeated TIA over a relatively short time period. Stroke in evolution (SIE) was defined as worsening or fluctuating neurological deficit with no improvement between episodes. Referral to SC our stroke care unit was by primary care practitioners and neurologists. None of the patients of this study underwent preoperative thrombolytic therapy. M AN U In all patients, preoperative bilateral carotid artery duplex ultrasonography demonstrated ≥ 50% stenosis on the symptomatic side according to the NASCET measurement9. According to French recommendations, all patients underwent CT angiography and/or MR angiography of the neck and brain to assess carotid and D cerebral circulation and identify the location and size of any infarct. . If not already TE on-going, antiplatelet therapy (aspirin 75 or 160 mg/day) was implemented EP preoperatively. In some cases, Clopidogrel therapy (75 mg) prescribed by the referring physician was continued. AC C Before 2008, only patients presenting unstable symptomatic carotid stenosis associated or not with cerebral infarct less than 3 cm in diameter underwent early revascularization (<15 days) at our institution. Since January 2008, this policy has changed with revascularization being performed within 15 days of symptom onset in all patients, whenever possible10. Patients with extensive ischemic lesions were always re-evaluated 6 weeks later and proposed delayed surgery. In the present study, patients who underwent CEA within 15 days of symptom onset were included in the early CEA group while patients treated later were included in the delayed CEA ACCEPTED MANUSCRIPT group. Symptomatic patients treated by carotid angioplasty due to hostile neck, surgically inaccessible lesions, or fibrotic restenosis were excluded from study. Surgical treatment was not proposed to patients with acute carotid occlusion, RI PT haemorrhagic stroke, or extensive permanent neurologic deficits. Operative technique Standard endarterectomy with patch closure or eversion endarterectomy was SC performed under general anaesthesia by experienced board-certified vascular surgeons. Common-to-internal-carotid-artery bypass was used in cases involving M AN U long-segment stenosis or associated pathologies such as post-stenotic dilatation. All patients received an intravenous bolus of heparin (50 UI/kg). The common carotid artery was clamped if mean arterial pressure (MAP) exceeded 100 mmHg. Carotid stump pressure was the only method used to assess cerebral haemodynamic status. D Selective shunting was utilized at the discretion of the operating surgeon in patients TE with MAP <100mmHg or stump pressure <40mmHg. Postoperatively, patients were kept in the anaesthesia recovery area to allow close monitoring of arterial pressure EP for 24 hours and then transferred to the standard surgical ward. Following the procedure, all patients continued single-antiplatelet therapy and, if not already AC C prescribed, began single-statin therapy. Definitions Postoperative stroke was defined as occurrence of any new central neurologic deficit persisting more than 24 hours with or without CT or MRI evidence of cerebral infarct. Postoperative TIA was defined as any new central neurologic deficit resolving within 24 hours. Unstable patients were defined as patients presenting crescendo TIA ACCEPTED MANUSCRIPT (CTIA) or stroke in evolution (SIE). Myocardial infarction (MI) was defined as any combination of two or more of the following criteria: typical chest pain lasting 20 minutes or longer; serum levels of creatine kinase (CK), CK-MB, or troponin two or more times higher than the upper normal limit; and presence of new Q waves on at RI PT least two adjacent derivations or predominant R waves in V1 (R wave ≥1 mm > S wave in V1). SC Follow-up All patients underwent neurological examination by the operating surgeon using the M AN U standard scoring form at discharge and 30 days after surgery. In case of doubt or sign of deterioration, advice from the neurologist was sought. Doppler ultrasound surveillance was performed at 1, 6 and 12 month and yearly thereafter. D Outcomes TE Postoperative mortality (within 30 days), stroke, and MI rates were analysed in the EP early and delayed CEA groups. AC C Statistical analysis Baseline patient characteristics and postoperative outcomes in the early and delayed CEA groups were compared using the Fischer and Student t tests. Data were summarized using descriptive statistics, i.e., count and frequency for categorical variables and mean and range for continuous variables. Statistical significance was determined at a two-sided P value of < 0,05. All statistical analyses were conducted using SAS v. 9.2 (SAS Inc, Cary, NC). ACCEPTED MANUSCRIPT RI PT RESULTS Patient characteristics During the study period, a total of 621 CEA were performed in our unit including 149 SC symptomatic carotid stenosis. Procedures for symptomatic carotid stenosis were performed within 15 days after symptoms onset (early surgery) in 62 (41.6%) patients M AN U and later (delayed surgery) in 87 (58.4%). Mean age was 71,5 years (range, 47-93), 79,9% of patients were males and 73,8% presented hypertension. History of ischemic cardiac disease was more frequent in the delayed surgery group (p=0.03). TE D Patient characteristics are summerized in Table I. Neurological events and carotid lesions EP Neurologic event was stroke in 75% of cases, TIA in 60% and amaurosis fugax in AC C 9,4%. There were no statistical differences between the two groups. The carotid lesion was considered as neurologically “unstable” in 25 patients including 13 in the early surgery group and 12 in the delayed surgery group. Among the 62 patients in the early surgery group, 11 (17,7%) presented cTIA and 2 (3,2%) SIE. In the delayed surgery group, 21,8% presented cTIA and 4,6% presented SIE. These preoperative neurologic status and carotid lesions are described in Table II. All 149 patients underwent preoperative duplex ultrasonography followed by CT angiography in 103 patients and/or MR-angiography in 61. ACCEPTED MANUSCRIPT Intervention The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range, 1-15) in the early surgery group and 47.9 days (range, 16-157) in the RI PT delayed surgery group. The procedure consisted in CEA in 147 patients and common-to-internal-carotid-artery bypass in 2. Patch-closure was performed in 34,2% of procedures, and a shunt was used in 19,5% of the procedures. There was M AN U revascularization are reported in Table III. SC no statistical difference between the two groups. Technical details of carotid Outcomes Both clinical examination and duplex ultrasonography at one-month were available in 144 patients. The remaining 5 patients were lost to follow-up after discharge. D Complications occurring during hospitalization and the 30-day postoperative period TE are summarised in Table IV. No significant difference in postoperative complications was noted between the two groups. Injury of the facial or hypoglossal nerves EP occurred in 3 patients in each group. In the recovery room, TIA characterized by worsening of preoperative symptoms that resolved within 6 hours with a normal AC C cerebral MR scan was observed in 5 cases. Postoperative stroke occurred in 4 patients. In the first case, duplex ultrasonography revealed ICA occlusion that was successfully treated by surgical revision with restoration of blood flow allowing reversal of postoperative aphasia but not of hemiplegia. In the second, the ICA was patent but MR-angiography showed minor ischemic lesions in the territory of the middle cerebral artery (MCA) probably due to micro-embolism. In the remaining 2 patients including one with crescendo TIA, the ACCEPTED MANUSCRIPT ICA was patent but MR angiography showed massive ischaemic lesions in territories supplied by the MCA and anterior cerebral artery (ACA). Both of these patients died, one on postoperative day 3 and the other of postoperative day 6. Mean duration of hospitalisation was 6,1 days in the early CEA group versus 6,7 days in the delayed RI PT one (p NS). In the subgroup of 25 patients whose preoperative neurologic status was considered as unstable, 6 presented SIE and 19 presented cTIA. The percentage of these SC patients undergoing early revascularization rose from 33% (5/15) before 2008 to 80% (8/10) thereafter. Thirty-day postoperative complications in this subgroup are AC C EP TE D M AN U summarised in Table V. ACCEPTED MANUSCRIPT Discussion Perusal of the literature clearly demonstrates that early revascularization of RI PT symptomatic carotid stenosis is associated with a reduction in symptoms recurrence rate3,10. However, despite Naylor’s suggestion that “a 30-day death/stroke risk of 8% is acceptable if CEA is performed within 2 weeks of the index event”8, the exact risk- SC to-benefit ratio of early revascularization remains unclear11. Our centre has adopted a M AN U policy of revascularizing every symptomatic carotid lesion ≥50% within 15 days after onset of neurological symptoms. As described herein, our outcomes suggest that early CEA achieves 30-day stroke and death rate at least equivalent to those of delayed CEA. Few authors describing early CEA12-42 have provided information allowing comparative analysis with their own previous delayed CEA experience D (table VI). However, some authors35-37,40,42 have recently reported that early CEA TE within 2 weeks in comparison with a delayed surgery was not associated with higher perioperative stroke and death risk, thus supporting our findings. In her study EP describing very early CEA, i.e., within 2 days, Stromberg et al34 showed an AC C impressive 30-day stroke and death rate of 11.5% but this observation was not confirmed by the most recent publications35-38 in which 30-day stroke and death rate range from 2.4% to 4.5%. In 2008, our vascular surgery team began introducing measures designed to give scheduling priority to revascularization of newly symptomatic carotid artery stenosis. The goal was to shorten our “symptom-to-knife time” as much as possible, in accordance with recently published experiences43,44. Despite implementation of this policy, mean waiting time for surgery stayed at 9.3 days and treatment was delayed ACCEPTED MANUSCRIPT beyond the set 2-week limit in some cases. As previously reported, the main sources of delay were: failure to recognize symptoms immediately and/or late referrals by general practitioners. Another obstacle for early revascularization involved obtaining test results on short notice, underlining the need for re-organization at the institutional RI PT level5. The need for more extensive assessment in high-risk patients is also a major issue in scheduling early revascularization. The number of patients with a history of cardiac SC ischemic disease was significantly higher in the delayed surgery group (25%) than in the early surgery group (11%). In our experience, the percentage of patients with M AN U unstable neurologic status operated within 15 days after symptom onset rose from 33% at the beginning of our study to 80% after 2008. At the end of the study, the main reason for delayed surgery was the need for additional cardiac testing and interventions. Cardiac-related factors also explain higher morbidity rates as pointed D out by Karkos et al45 in a review of 28 series describing emergency carotid surgery in TE patients with SIE and cTIA. The combined stroke/death/major cardiac event rate was 10.9% for cTIA and 20.8% for SIE. In our experience, the overall combined EP stroke/death rate was higher in this subgroup of patients (12%) than in stable patients but the rate in the early CEA subgroup was lower than in delayed CEA group AC C (7.7% vs. 16.7%, p=0.49). At the beginning of the present study, patients presenting cerebral lesions greater than 3 cm were systematically considered ineligible for early revascularization as suggested by Sbarigia et al24. This policy was changed since, as subsequently reported by the same author46, we now know that the real limit is infarction > 2/3 of the middle cerebral artery territory. Following this principle, haemorrhagic conversion of cerebral ischaemic lesions was never required. ACCEPTED MANUSCRIPT An interesting observation in this study involves symptoms during the postoperative wake-up period. Five patients in this series displayed initial worsening of neurological clinical status at wake-up that regressed spontaneously in the recovery room. A possible explanation is injury to the penumbra zone due to carotid clamping shortly RI PT after stroke. To our knowledge, this observation frequently debated during carotid meetings has never been specifically studied in relation to the timing of CEA. The main limitations of present study are retrospective design with data collection SC from medical charts and lack of independent neurologic assessment and M AN U neuroimaging details. Conclusions D During the study period, the reduction of the symptom to knife time obtained by TE applying the carotid revascularization guidelines had no effect on outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least AC C EP equivalent to those of delayed CEA. ACCEPTED MANUSCRIPT References AC C EP TE D M AN U SC RI PT [1] Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003;361(9352):107‑116. [2] Liapis CD, Bell PRF, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, et al. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009;37(4 Suppl):1‑19. [3] Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJM. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. 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[44] Vikatmaa P, Sairanen T, Lindholm J-M, Capraro L, Lepäntalo M, Venermo M. Structure of delay in carotid surgery--an observational study. Eur J Vasc Endovasc Surg 2011;42(3):273‑279. [45] Karkos CD, Hernandez-Lahoz I, Naylor AR. Urgent carotid surgery in patients with crescendo transient ischaemic attacks and stroke-in-evolution: a systematic review. Eur J Vasc Endovasc Surg 2009;37(3):279‑288. [46] Sbarigia E, Toni D, Speziale F, Acconcia MC, Fiorani P. Early carotid endarterectomy after ischemic stroke: the results of a prospective multicenter Italian study. Eur J Vasc Endovasc Surg 2006;32(3):229‑235. SC RI PT ACCEPTED MANUSCRIPT Titles of tables M AN U Table I. Characteristics of patients in early and delayed surgery groups. Table II. Neurological symptoms and preoperative carotid artery status in early and delayed surgery groups. Table III. Technical aspects of revascularization in early and delayed surgery groups. D Table IV. Perioperative and thirty-day complications in early and delayed surgery TE groups. Table V. Thirty-day postoperative complications in unstable carotid artery stenosis EP group. cTIA : crescendo transient ischemic attack. SIE : stroke in evolution. MI : myocardial infarction. AC C Table VI. Studies reporting early carotid revascularization following neurological events. SIE: stroke in evolution. cTIA: crescendo transient ischemic attack. ACCEPTED MANUSCRIPT Early Surgery 62 (41 .6) 70.3 (50-88) 11 (17.7) 51 (82.3) Delayed Surgery 87 (58.4) 72.3(47–93) 19(21.8) 68 (78.2) Overall 149 71.5 30 (20.1) 119 (79.9) p 45 (72.6) 16 (25.8) 31 (50) 29 (46.8) 3 (4.8) 7 (11.3) 5 (7.9) 14 (22.6) 65 (74.7) 31(35.6) 43 (49.4) 40 (46) 4 (4.6) 22 (25.3) 5 (5.7) 20 (23) 110 (73.8) 47 (31.5) 74 (49.7) 69 (46.3) 7 (4.7) 29 (19.5) 10 (6.7) 34 (22.8) NS NS NS NS NS 0.0326 NS NS RI PT Patient characteristics Patients. n (%) Age. Mean (range) Female. n (%) Male. n (%) Risk Factors. n (%) Hypertension Diabetes Dyslipidemia Tabacco use Obesity (Body Mass Index>30) Ischemic Cardiac Diseases. n (%) Cardiac Arythmia. n (%) Peripheral Vascular Disease. n.(%) AC C EP TE D M AN U SC Table I. Characteristics of patients in early and delayed surgery groups. NS NS NS ACCEPTED MANUSCRIPT Neurological Event Patients. n (%) Stroke Early Surgery 62 (41.6) 27 (43.5) Delayed Surgery 87 (58.4) 48 (55.2) Total 149 75 (50.3) 2 ( 3.2) 4 (4.6) 6 (4) p 31 (35.6) 60 (40.3) 11 (17.7) 8 (21.8) 19 (12.7) Amaurosis Fugax 6 (9.7) 8 (9.2) 14 (9.4) Ipsilateral Carotid stenosis. n (%) 50-69% 70-79% 80-89% 90-99% 7 (11.3) 17 (27.4) 13 (21) 25 (40.3) 19 (21.8) 18 (20.7) 19 (21.8) 31 (35.6) 26 (17.4) 35 (23.5) 32 (21.5) 56 (37.6) NS NS NS NS Contralateral Carotid status. n (%) No stenosis 50-69% 70-99% Occlusion 48 (77.4) 7 (11.3) 6 (9.7) 1 (1.6) 55(63.2) 14 (16.1) 16 (18.4) 2 (2.3) 103 (69.1) 21 (14.1) 22 (14.8) 3 (2) NS NS NS NS SC TIA RI PT 29 (46.8) Crescendo TIA NS NS NS NS NS Stroke in Evolution AC C EP TE D M AN U Table II. Neurological symptoms and preoperative carotid artery status in early and delayed surgery groups. ACCEPTED MANUSCRIPT Early Surgery Delayed Surgery Total p CEA. n (%) 61 (98) 86 (99) 147 (99) NS Patch Closure. n (%) 18 (29) 33 (38) 51 (34) NS Direct Suture. n (%) 15 (24) 13 (15) 28 (19) NS Eversion. N (%) 28 (45) 40 (46) 68 (46) NS Bypass. n (%) 1 (2) 1 (1) 2 (1) NS Shunt Use. n (%) 11 (17.7) 18 (20.7) 29 (19.5) NS RI PT Procedure AC C EP TE D M AN U SC Table III. Technical aspects of revascularization in early and delayed surgery groups. ACCEPTED MANUSCRIPT Early Surgery Delayed Surgery Total P 3 (4.8) 1 2 (3.2) 9 (10.3) 5 4 (4.6) 12/149 (8) 0.36 6/149 (4) 0.99 3 (4.8) 0 3 (5.1) 1 (1.7) 0 1 (1.7) 1 (1.7) 1 (1.7) 1 (1.7) 2 (2.3) 3 (3.5) 2 (2.3) 3 (3.5) 2 (2.3) 1 (1.2) 1 (1.2) 3 (3.5) 5 (5.9) 5/149 (3.4) 3/144 (2.1) 5/144 (3.5) 4/144 (2.8) 2/144 (1.4) 2/144 (1.4) 2/144 (1.4) 4/144(2.8) 6/144 (4.2) 0.26 0.65 0.64 0.51 0.99 0.99 0.64 0.40 RI PT Complication. Perioperative period Cervical hematoma. n (%) Requiring surgical revision Cranial nerve injury. n (%) Thirty-day period Lost to follow-up Myocardial infarction. n (%) TIA. n (%) Stroke. n (%) Non-fatal stroke Fatal stroke Death. n (%) Combined stroke & death. n (%) Combined stroke, death, & MI. n (%) AC C EP TE D M AN U SC Table IV. Perioperative and thirty-day complications in early and delayed surgery groups. ACCEPTED MANUSCRIPT Early Surgery (%) 13 (52) 11 (85) 2 (15) 1 (7.7) 1 (7.7) 1 (7.7) 1 (7.7) 0 1 (7.7) 1 (7.7) Patients. n Preoperative cTIA Preoperative SIE TIA. n (%) Stroke. n (%) Fatal Stroke Death. n (%) MI. n (%) Combined Stroke&Death. n (%) Combined Stroke&Death&MI. n (%) Delayed Surgery (%) 12 (48) 8 (67) 4 (33) 0 2 (16.7) 0 0 1 (8.3) 2 (16.7) 3 (25) Total (%) P 25 (100) 19 (76) 6 (24) 1 (4) 3 (12) 1 (4) 1 (4) 1 (4) 3 (12) 4 (16) 0.38 0.38 0.99 0.60 0.99 0.99 0.48 0.60 0.32 RI PT Variable AC C EP TE D M AN U SC Table V. Thirty-day postoperative complications in unstable carotid artery stenosis group. cTIA : crescendo transient ischemic attack. SIE : stroke in evolution. MI : myocardial infarction. ACCEPTED MANUSCRIPT Symptoms 13 1981 1984 1985 1994 2000 2002 2002 2003 2004 2004 2005 2006 2006 2006 2007 2008 2009 2010 2011 2011 2011 2012 2012 24 28 110 42 72 45 164 67 126 66 36 43 33 226 70 102 28 131 241 62 64 44 148 SIE/cTIA Stroke TIA Stroke Stroke Stroke Stroke Stroke/TIA Stroke Stroke Stroke Stroke/TIA Stroke Stroke TIA/cTIA Stroke Stroke/cTIA Stroke/TIA Stroke/TIA Stroke cTIA Stroke/TIA Stroke/TIA 2013 21 Stroke/TIA Mentzer 14 Whittemore 15 Dosick 16 Gasecki 17 Ricco 18 Ballotta 19 Eckstein 20 Huber 21 Paty 22 Wolfle 23 Rantner 24 Aleksic 25 Sbarigia 26 Rantner 27 Dorigo 28 Ballotta 29 Gorlitzer 30 Ferrero 31 Rantner 32 Capoccia 33 Leseche 34 Annambothla 35 Stromberg Mono 36 37 Neurological Assessment 30-day stroke and death rate / / / / / / Rankin Rankin NIHSS Rankin / Rankin / Rankin / Rankin Rankin Rankin Rankin NIHSS / / Rankin 4.1% 3.5% 0.9% 4.8% 2.8% 2% 6.7% 16% 3.1% 10% 3.4% 6.9% 3% 8.4% 1.4% 0% 0% 3.8% 2.1% 1.6% 0% 2.2% 11.5% Comparison with delayed surgery (n) / / / 5.2% (58) / 2% (41) / / 2.9% (102) / 4.8% (62) / / / 0.3% (352) / 1% (302) 3.2% (154) 4.7% (215) / / 2.9% (267) 4.4% (2448) <2 days NIHSS 4,5% 4,1% (73) 41 Stroke/TIA <2 days Rankin 2.4% 1.2% (434) 219 Stroke/TIA <2 days / 4,4% 2,7%(542) 2014 176 SIE/cTIA/TIA <2 days NIHSS 3,9% / 2014 165 Stroke/TIA <14 days Rankin 5,5% / 2014 100 Stroke/TIA <14 days NIHSS 3% 0,4% (222) 2014 91 Stroke/TIA <14 days Rankin 3,3% / Kretz 2104 158 Stroke/TIA <14 days Rankin 3.2% 3,1% (259) Present study 2014 62 Stroke/TIA <15 days / 1.7% 3.5% (87) 4 Ferrero 40 Chisci Merlini 41 42 Table VI. Studies reporting early carotid revascularization following neurological events. SIE: stroke in evolution. cTIA: crescendo transient ischemic attack. AC C Tsivgoulis 39 TE 38 D 2013 2014 Rantner EP Sharpe Delay m (mean) M (Median) emergent 11 days (m) 10 days (m) <30 days <15 days <18 days (M) <17 days(M) 2 days (M) < 15 days 10 days (M) <28 days 4 days (M) <7 days 12 days (M) <1 day 8 days (M) 4 days (m) <14 days <7 days 34 hours (m) 5 days (M) <14 days <2 days RI PT N° of Patients SC Year M AN U Reference