Emergency carotid artery surgery in neurologically unstable patients.

Although angiography and carotid artery surgery are illadvised in patients with acute, profound stroke, there is no consensus on the management of patients with stroke in evolution, waxing and waning neurologic deficits, or crescendo transient ischemic attacks. This type of clinical picture was associated with a critical, unstable lesion of the internal carotid artery in each of 12 patients. Emergency angiography permitted identification of the lesions responsible for the varying neurologic manifestations, and emergency carotid thromboendarterectomy produced prompt, complete recovery in all but one patient, who had a total carotid occlusion, received no operation, and died of a cerebral infarction. Based on our experience with these 12 patients, an aggressive diagnostic and therapeutic approach is recommended for patients with acute unstable cerebrovascular disease.