Urgent carotid endarterectomy for crescendo transient ischemic attack

Background: Carotid endarterectomy (CEA) is a widely accepted treatment to mitigate stroke risk in patients with severe carotid stenosis. The timing of CEA, especially in cases of acute neurological symptoms like crescendo transient ischemic attack (TIA) and stroke-in-evolution, remains contentious. This study evaluates the effectiveness of urgent CEA (UCEA) within 6 hours of crescendo TIA onset compared to elective CEA (ECEA) performed within 2 weeks in preventing recurrent stroke. Patients and methods: This retrospective study analyzed 87 patients with crescendo TIA treated with UCEA and compared them with a matched control group of 174 patients who underwent ECEA for symptomatic carotid disease. All patients underwent preoperative multidetector computed tomography angiography. Primary outcomes included mortality, stroke, TIA, and major adverse cardiac events within 30 days and up to 6 months postoperatively. Results: The UCEA group demonstrated no postoperative strokes or TIAs, with a low complication rate. UCEA resulted in one stroke within 6 months, with complete recovery. The ECEA group experienced one stroke and one death. There were no significant differences in early postoperative complications between the groups. However, the UCEA group exhibited a higher overall mortality rate (4.6% vs. 0.6%; p = 0.044), predominantly due to myocardial infarction. Both groups demonstrated comparable outcomes regarding postoperative complications and carotid restenosis at follow-up. Conclusions: UCEA performed within six hours of crescendo TIA shows comparable perioperative outcomes to ECEA in preventing recurrent strokes. While these findings suggest early intervention with UCEA may be a viable approach for patients with crescendo TIA, significant methodological limitations preclude definitive conclusions about safety and efficacy.