Timing of Carotid Endarterectomy After Stroke

Ischemic Stroke?To the Editor:In the article by Wardlaw et al in the July issue of Stroke, 1 the outcome of stroke patients with an evident lesion on CT scan was compared with the outcome of stroke patients with no evident lesion.The result was that the prognosis for a patient with a "clinical stroke" evident on CT scan also was worse than the prognosis for a patient showing no evidence on CT scan of the lesion causing the clinical stroke.However, obvious, it may due to a bias.How severe were the patients without the CT lesion?How were the various times of their CT scans distributed.Was it in a manner similar to that shown in the article's Figure 2, for patients with CT lesions?In fact, patients with total anterior circulation infarcts (TACI) are more frequent (80%-95%) in the group with a positive CT, and vice-versa, lacunar infarcts (LACI) are more frequent in the group without positive CT scan (45%-60%): ie, the results may be due just to this unbalance.In fact, the sentence, "Patients who had a CT scan within a week of the stroke were more likely to be dead or dependent at 6 months than those scanned later . .." (p 1317), does not indicate a lethal effect of the CT scan but rather that in the Lothian Area physicians tend to ask for CT scan earlier in the more severe cases.Regarding the number of patients (nϭ124; 10% of the registry) who did not have a CT scan examination "for humane reasons" or for other reasons, I think that the AA made a little, but significant, error in calculating the percent of the patients who died within 14 days of stroke onset (p 1317): in fact, if the total number is 24 of 124, the result is 19%, instead of 15%.Finally, do the AA agree that an outcome as severe as 89% of death or dependence for TACI and 40% of death or dependence for partial anterior circulation infarcts (PACI) may well justify incisive therapeutical attempts?