Association between index symptom and timing on perioperative stroke rate in patients undergoing carotid endarterectomy

Background and Purpose: Carotid endarterectomy (CEA) in symptomatic carotid stenosis (SCS) may have a higher risk of perioperative stroke due to disease severity or hemorrhagic conversion. This study aimed to evaluate CEA outcomes for SCS and examine causes of post-operative stroke based on intervention timing and preoperative symptoms. Methods: All CEAs performed for SCS from 2012 to 2023 across two metropolitan hospitals were analyzed. CEAs were performed with general anesthesia, patching, and shunting. Post-operative (30-day) strokes were classified as technical, hemorrhagic, or embolic and were evaluated by timing (<48 h, 48h–2 weeks, >2 weeks) and preoperative symptoms (TIA/amaurosis fugax, minor stroke, moderate-severe stroke, crescendo TIAs/stroke in evolution). Stroke severity was assessed using the modified Rankin Scale (mRS). Results: Among 664 CEAs, post-operative stroke occurred in 3.0 % of cases. Timing significantly influenced stroke rates: 5.7 % <48 h, 4.0 % between 48h–2 weeks, and 1.4 % >2 weeks (P = .04). Preoperative symptoms also affected stroke rates, with highest rates following crescendo TIAs/stroke in evolution (7.5 %, P = .02). Early CEA (<48 h) independently increased stroke risk (odds ratio 5.6, P = .04), and hemorrhagic strokes were associated with <48 h interventions (P = .005). Major strokes occurred in 1.1 % of cases, linked to preoperative symptoms (P = .05), but not intervention timing. Conclusions: CEA for SCS carries an acceptable stroke risk overall, though early intervention (<48 h) increases hemorrhagic stroke risk. Major strokes are more frequent following crescendo TIA/stroke in evolution, with no association to timing.