To the Editor: Carotid artery disease is a common and treatable cause of transient ischemic attacks and strokes. Carotid endarterectomy is a safe and effective means of reducing neurological complications, including the risk of stroke,1 in the types of cases of severe internal carotid artery stenosis discussed in the Clinical Crossroads article by Dr Caplan.2 The question of optimal timing of surgery following the incident event is critical to discuss in this patient population, especially since “early” intervention has had different meanings in various trials and timing may be associated with important effects on outcome.
A systematic review pooling data from randomized trials and surgical case series demonstrated a higher risk for carotid endarterectomy performed urgently for evolving symptoms when compared with carotid endarterectomy performed for stable symptoms in 13 studies (risk difference, 19.2; 95% confidence interval [CI], 10.7-27.8; P < .001). However, among 11 studies there was no difference between early (less than 3-6 weeks) vs late (greater than 3-6 weeks) carotid endarterectomy for stroke in stable patients (odds ratio, 1.13; 95% CI, 0.79-1.62; P = .62).3 Another systematic review from the American Academy of Neurology noted that although among 3 small case series there was neurological improvement in 81% to 93% of patients undergoing emergent carotid endarterectomy, at 1 institution there was a reported postoperative stroke and death rate of 20%.4 This analysis also found that of 6 retrospective cohort studies that divided patients after stroke into an “early group” receiving carotid endarterectomy (either less than 4 weeks or less than 6 weeks) vs a “late group,” no outcome differences (operative morbidity or longer-term follow-up) were found.4
However, in another study the greatest benefit from carotid endarterectomy was seen in patients randomized within 2 weeks of the neurological event, and the benefit rapidly decreased with time (P = .009).5 This was true for the severe (70% to 99%) stenosis group and the 50% to 69% stenosis group. For patients with 50% or greater stenosis, the number of patients needed to treat to prevent 1 stroke in 5 years was 5 for those randomized within 2 weeks of the neurological event compared with 125 for patients randomized after 12 weeks.5
These data suggest a lack of benefit from carotid endarterectomy in patients with progressing stroke (<24 hours) and the greatest benefit in those patients undergoing carotid endarterectomy within 2 weeks of the incident neurological event.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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