Vasileios-Arsenios Lioutas, MD
Witt AH, Johnsen SP, Jensen LP, Hansen AK, Hundborg HH, Andersen G. Reducing Delay of Carotid Endarterectomy in Acute Ischemic Stroke Patients: A Nationwide Initiative. Stroke. 2013; 44: 686-690.
Carotid artery disease is a frequent cause of ischemic infarction and carotid endarterectomy (CEA) is a well established method in preventing recurrent stroke. In the past, unjustified fear of complications delayed operation for several weeks post-stroke, in effect negating its beneficial effect. Analysis of pooled data from large CEA trials clearly showed that the benefit from surgery is time-dependent and maximal if performed within the first two weeks after stroke, leading to a revision of guidelines and clinical practice.
In this study, Witt et al. describe the effect of a multidisciplinary nationwide initiative aiming to reduce the time to CEA after acute ischemic stroke, using data from the Danish Stroke and Vascular Registries. Percentage of patients receiving CEA within 2 weeks and carotid ultrasound within 4 days from stroke is used as metrics.
The results undeniably show an improvement in both outcomes following the implementation of new, stricter national guidelines. Many questions are raised, however: Was there a similar trend toward reduction in stroke recurrence? Was there in increase in CEA-related complications? Additionally, patients with TIAs were not included in this analysis and it would be interesting to know how this would affect the results.
It is striking that a majority of patients (exceeding 50%) are still operated more than 2 weeks after the stroke and despite the nationwide initiative, the median time to surgery is 16 days. Notably, this occurs in the context of a well organized, essentially universal healthcare system, not lacking access to technological advances. First and foremost, the study shows very clearly that there is still significant potential for improvement.