Urgent Carotid Revascularization for Symptomatic High-Grade Carotid Stenosis Associated with Ipsilateral Hemispheric Hypoperfusion: A Single-Centre Retrospective Observational Study

Symptomatic high-grade carotid stenosis may present with extensive ipsilateral hemispheric hypoperfusion without a large infarct core, a grey-zone phenotype between standard early and truly urgent carotid revascularization. This single-centre retrospective observational study described the procedural and clinical outcomes of urgent carotid revascularization in this imaging-defined subgroup. Consecutive patients treated between June 2015 and August 2025 were included when they had recent ipsilateral anterior-circulation symptoms, ipsilateral internal carotid stenosis > 70%, objective hemispheric hypoperfusion involving at least one third of the anterior circulation territory on CT or MR perfusion, and no intracranial haemorrhage or large established infarction. Twenty-seven patients met the criteria. Median NASCET-style stenosis was 92%, and 14 patients (51.9%) had at least one collateral-limiting feature. Revascularization was performed within 48 h in all cases, by carotid endarterectomy in 25 patients and carotid artery stenting in two. Technical success was 100%. No 30-day death, stroke, intracranial haemorrhage, major adverse event, or target-lesion reintervention occurred. Complete neurological recovery at discharge was observed in 25 patients (92.6%). During median follow-up of 48.6 months, no late ipsilateral stroke, carotid-related neurological event, neurological death, or target-lesion reintervention was recorded. In this small, selected, uncontrolled cohort, urgent carotid revascularization was technically achievable, and no prespecified 30-day safety events were observed. These descriptive findings do not establish comparative safety or clinical benefit and require prospective multicentre validation.