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To the Editor: Carotid artery disease is a common and treatable cause of transient ischemic attacks and strokes. Carotid endarterectomy is a safe and effective means of reducing neurological complications, including the risk of stroke,¹ in the types of cases of severe internal carotid artery stenosis discussed in the Clinical Crossroads article by Dr Caplan.² The question of optimal timing of surgery following the incident event is critical to discuss in this patient population, especially since "early" intervention has had different meanings in various trials and timing may be associated with important effects on outcome.

A systematic review pooling data from randomized trials and surgical case series demonstrated a higher risk for carotid endarterectomy performed urgently for evolving symptoms when compared with carotid endarterectomy performed for stable symptoms in 13 studies (risk difference, 19.2; 95% confidence interval [CI], 10.7-27.8; P < .001). However, among 11 studies there was no difference between . . . [Full Text of this Article]

John R. Kapoor, MD, PhD
jkapoor@stanford.edu
Division of Cardiology
Stanford University
Stanford, California

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