1. Patients who present ≤ 6 hours of the onset of stroke should be considered for acute intervention to reduce the ultimate neurologic deficit. Interventions may include local or systemic thrombolysis (Grade 1, Level A). The role of endoluminal mechanical lysis or extraction remains to be defined.
2. Patients who present with fixed neurologic deficit of > 6 hours duration should be considered for CEA once their condition has been stabilized. CEA should be performed ≤ 2 weeks of the neurologic event (Grade 1, Level B).
3. Patients who present with repetitive (crescendo) episodes of transient cerebral ischemia unresponsive to antiplatelet therapy should be considered for urgent CEA. The risk of intervention is increased over elective surgery for neurologic symptoms, but not as much as for patients with stroke in evolution. CEA is preferred to CAS in these patients based on the presumptive increased embolic potential of bifurcation plaque in this clinical situation (Grade 1, Level C).
4. For acute stroke after CEA, emergent imaging (ultrasound or fast CTA) is indicated to evaluate the endarterectomy site. When imaging suggests thrombosis, is indeterminate or not available, immediate operative re-exploration is indicated (Grade 1, Level B).
5. When the endarterectomy site is patent, other modalities such as CT and angiography should be used to better identify the cause of the stroke. If CT excludes intracranial hemorrhage, anticoagulation is reasonable until a definitive decision regarding the appropriate diagnosis and therapy can be made (Grade 2, Level C). While the committee acknowledged the lack of robust data in this small group of patients, it was unanimous in its endorsement of this recommendation based on the data available and the low likelihood that new data would emerge in the near future.
6. No firm recommendations can be made on treatment of stent thrombosis associated with CAS. It is reasonable to attempt to restore patency by use of chemical lysis or clot extraction (Grade 2, Level C). While the committee acknowledged the lack of robust data in this small group of patients, it was unanimous in its endorsement of this recommendation based on the data available and the low likelihood that new data would emerge in the near future.