PC052. The Effects of Stroke Unit Centralization for Patients With a Symptomatic Carotid Stenosis in the Carotid Endarterectomy Pathway

Carotid endarterectomy (CEA) should be performed on symptomatic, surgically suitable patients who present a stenosis greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 14 days of their symptoms. Aim of this study was to evaluate the effects of Stroke Uni centralization for patients with symptomatic carotid stenosis undergoing CEA. We conducted a single-institution review of consecutive patients who underwent CEA for symptomatic carotid stenosis 50% in the period between January 2014 and November 2017. Patients recruited had acute neurologic impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale (NIHSS). They were divided in two groups if treated before (group A, 2014 to May 2016) or after (group B, June 2016 to November 2017) the establishment of a stroke unit. The 30-day neurologic status improvement was defined as a decrease (1) in the 30-day NIHSS score versus NIHSS score immediately before surgery. Other outcomes analyzed were 30-day major adverse event rate (composite of stroke, death, and myocardial infarct), death, stroke, disabling stroke, myocardial infarct, neck hematoma, cranial nerve palsy, reoperation, and readmissions in hospital at 30-days rate and timing to CEA. There were 81 CEAs included in the study, 32 in group A (40%) and in group B 49 (60%). Recruitment patient rate per month doubled (1.1 vs 2.8 patients per month) after stroke unit establishment. Comorbidities were similar between the two groups. Minor stroke and transient ischemic attack distribution was significantly different: 31% (n = 10) and 69% (n = 22), vs 59% (n = 29) and 41% (n = 20) in groups A and B, respectively (P = .014). Timing to CEA was similar and all CEAs of group B were performed within 7 days from symptoms onset. The Table sum ups the 30-day results. Any death or disabling stroke occurred in both groups. Thirty-day improvement in neurologic status was higher in group B (30.6% v s12.5%; P = .06) and predictors for improvement in neurologic status were centralization in a stroke unit (odds ratio [OR], 10.99; 95% confidence interval [CI], 5.3-22.9; P = .004), minor stroke as symptom onset (OR, 0.22; 95% CI, 0.15-0.34; P < .001), and timing to CEA between 2 and 7 days (OR, 1.89; 95% CI, 1.5-2.3; P < .001). Timing to CEA 2 increased the risk of impairment in neurologic status on univariate (P = .037), but not on multivariate analysis. According to this preliminary experience, the introduction of a stroke unit for selected (NIHSS < 5) symptomatic carotid stenosis increases significantly the rate of patients referred to CEA per month. Centralization in a stroke unit, and timing to CEA between 2 and 7 days are safe and associated with 30-day improved neurologic status.TableThirty-day results30-Day resultsGroup A, No. (%)Group B, No. (%)PMean duration of stay (min-max), days4.5 (2-23)4.98 (2-11).003Mean timing to CEA (min-max), days2.3 (1-11)2.5 (0-7).076Thrombolysis1 (3.1)3 (6.1).543Eversion CEA31 (97)44 (90).254Shunt1 (3.1)3 (6.1).543Dual antiplatelet therapy16 (50%)33 (67).076Death00-MAE2 (6.2)2 (4.1).981Overall stroke02 (4.1).247Hemorrhagic stroke00-Disabling stroke00-Minor stroke02.247Major stroke00-MI2 (6.2)0.076Re-intervention00Neck hematoma2 (6.2)0.076Cranial nerve palsy2 (6.2)3 (6.1).98130-Day hospital readmission1 (3.1)1 (2).94330-Day improvement in neurologic status4 (12.5)15 (30.6).0630-Day worsening in neurologic status02 (4.1).24730-Day unchanged neurologic status28 (87.5)32 (65.3).026CEA, Carotid endarterectomy; MAE, major adverse event (death + stroke + myocardial infarction [MI]).Group A, 2014 to May 2016; CEA was performed before Stroke Unit Establishment; group B, June 2016 to November 2017, CEA was performed after Stroke Unit Establishment. Open table in a new tab