Urgent management of symptomatic carotid artery stenosis: a critical review of the literature

Although there is a consensus on the role of carotid endarterectomy in symptomatic carotid stenosis, the optimal timing of surgery and its role in the context of acute stroke remain controversial. This study aims to review the key factors influencing treatment decisions, including patient characteristics, anatomical considerations, imaging findings and procedural risks associated with acute carotid endarterectomy (CEA) and carotid artery stenting (CAS). We performed a narrative review of the existing literature to summarize current evidence on the indications, timing, and outcomes of CEA and CAS in patients with recent ischemic stroke related to carotid stenosis. 86 articles were identified. After reviewing 10 studies were included in the review. The primary outcome evaluated in all studies was the perioperative day stroke/death rate. Although some discrepancies were found among the studies, CEA showed a stroke/death rate ranging from approximately 1.3% within the first 7 days to 3.6% after 7 days. In contrast, CAS had a higher rate in the early period (8.3%) compared to later (7.1%), highlighting an increased risk of CAS within the first 7 days. Managing symptomatic carotid stenosis requires a careful, individualized approach considering patient characteristics, comorbidities, and the timing of surgery. Early intervention is beneficial, but patient-specific risk factors must be weighed carefully.