Occam's razor: Intervene early to prevent more strokes!

The early risk of stroke after a patient suffers a transient ischemic attack (TIA)/minor stroke is significantly higher than previously thought. In most health systems, this (unfortunately) means that many vulnerable patients will have suffered their stroke before having had any chance of being considered for carotid endarterectomy (CEA) or carotid angioplasty with stenting (CAS). The problem is then compounded by institutional delays in finally undertaking CEA/CAS, which leads to even greater diminishing benefit to the patient. Notwithstanding the fact that the international trials used a 6-month threshold for inclusion, it remains an unpalatable fact that if CEA/CAS is delayed beyond 12 weeks in symptomatic patients with North American Symptomatic Carotid Endarterectomy Trial (NASCET) 50% to 99% stenoses, the patient is exposed to all of the risks of intervening, but gains little in the way of long-term stroke prevention. The take-home message is, therefore, very simple; “intervene early to prevent more strokes”. Occam's razor has never been sharper!