Emergency carotid endarterectomy for fluctuating neurologic deficits

The merit of emergency carotid endarterectomy for patients with fluctuating neurologic deficits remains controversial. Twenty-four patients with fluctuating neurologic deficits underwent emergency carotid endarterectomy and were compared to 31 patients managed nonoperatively. Both groups were similar in age and sex distribution, indicence of hypertension (50%), myocardial infarction (16%), and diabetes mellitus (12%). The two groups were subdivided into patients with crescendo transient ischemic attack (CTIA) and patients with stroke in evolution (SIE). Within the operative CTIA group, all seven patients recovered completely. Among the five nonoperative CTIA patients, one recovered, three sustained moderate or severe neurologic deficits, and one died. Within the operative SIE group of 17 patients, none had a worsening of the deficit, four remained unchanged (24%), and 12 patients (70%) had complete recovery or only a mild deficit. One patient (6%) died postoperatively. Among 26 nonoperative SIE patients, five recovered or sustained mild deficits (19%), 17 had moderate or severe deficits (66%), and four died (15%). The 12 patients with complete or near recovery of neurologic function represented more than a threefold improvement (P less than 0.01) in the quality of life with endarterectomy. When compared with the natural history of fluctuating neurologic deficits, these data suggest that immediate operative intervention will result in better salvage.