Timing and Risk of Stroke After Carotid Endarterectomy

Temporal Distribution of Post‑Operative Stroke Risk

The highest risk for stroke after carotid endarterectomy occurs within the first 24–48 hours post‑operatively; about 60 % of strokes present after an initially uneventful recovery from anesthesia, whereas only 40 % are identified within the first 24 hours. 1
The peri‑operative period (within 30 days) carries the highest overall risk, with the peak incidence concentrated in the first 48 hours. 1
The 30‑day stroke‑or‑death risk ranges from 1.5 % to 3.1 %, varying with patient selection and symptom status. 2, 3

Cerebral hyperperfusion syndrome typically presents 2–7 days after the procedure and may manifest as ipsilateral headache, hypertension, seizures, or focal neurological deficits. 4
Management requires strict blood‑pressure control with a systolic target of 120–130 mm Hg to mitigate the syndrome. 4

Continuous blood‑pressure and electrocardiogram monitoring should be instituted immediately after surgery, keeping systolic blood pressure < 180 mm Hg to reduce the risk of intracranial hemorrhage and hyperperfusion syndrome. 4
A formal neurological examination should be performed within 24 hours after surgery to document any new deficits. 4

Step	Recommended Action	Rationale
1	Obtain an urgent non‑contrast head CT	Excludes intracranial hemorrhage.
2	If ischemic stroke is suspected, follow with CT angiography or MRI with diffusion‑weighted imaging	Identifies arterial occlusion or infarction.
3	Assess for carotid thrombosis using urgent duplex ultrasound or CT angiography	Detects acute carotid occlusion that may be amenable to thrombectomy.

*All three steps are endorsed by current guideline recommendations. 4 (steps 1‑2) and 1 (step 3)

Clinicians should not assume that all post‑operative strokes occur immediately; vigilance must be maintained for delayed presentations up to 7 days after the procedure. 1