The role of cranial computed tomography in carotid surgery

In patients who present with TIA, RIND, or CVA, the cranial CT scan can rule out other etiologies for neurologic symptoms. In addition to the clinical presentation, the CT scan allows further stratification of patients being considered for carotid endarterectomy. We propose that patients be classified as TIA (+), TIA (-), RIND (+), or CVA (-). The CT scan has defined a new subgroup of patients, TIA (+) and RIND (+)--the Silent Cerebral Infarction. Patients who are categorized as TIA (+), RIND (+), and CVA (+) (cerebral infarction on CT or by history) are at increased risk for intraoperative ischemia and postoperative neurologic deficit. As such, they should be selectively shunted based on intraoperative EEG monitoring or routinely shunted. There is a strong association between ulcerative plaque at the carotid bifurcation and cerebral infarction on CT. The CT scan is a critical diagnostic procedure in evaluating the patient with an acute neurologic event. Patients with negative CT scans are candidates for early operation. Carotid endarterectomy should generally be delayed for 4 to 6 weeks in patients with positive CT scans.