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Q1: Treatment thresholds (2 min)
"At what stenosis level do you offer CEA?"
- Symptomatic over 70%: CEA within 2 weeks (NASCET, ARR 17%, NNT 6)
- Symptomatic 50-69%: CEA for selected patients
- Asymptomatic over 60%: CEA if perioperative risk under 3% (ACAS, NNT 17)
- Under 50% symptomatic or asymptomatic moderate: medical therapy only
Q2: Timing (2 min)
"When should CEA be performed after symptoms?"
- Within 2 WEEKS for maximum benefit
- NNT is 5 if within 2 weeks, 125 if delayed beyond 12 weeks
- Highest stroke risk is in first few days after TIA
- "Time is brain"
Q3: CEA complications (3 min)
"Describe complications of carotid endarterectomy."
- Perioperative stroke or death (under 6% symptomatic, under 3% asymptomatic)
- Cranial nerve injury: XII (hypoglossal) commonest - tongue deviation
- Wound haematoma - airway compromise, surgical emergency
- Cerebral hyperperfusion syndrome - headache, seizures, BP control
- MI - commonest cause of perioperative death
- Restenosis - patch angioplasty reduces risk
Q4: CEA vs CAS (2 min)
"Compare CEA and carotid stenting."
- CEA: open surgery, lower perioperative stroke, higher cranial nerve injury and MI
- CAS: endovascular, higher perioperative stroke, lower MI and nerve injury
- CREST trial: similar composite endpoint
- CAS for: high-risk surgery patients (previous neck surgery/radiotherapy, recurrent stenosis, contralateral nerve palsy)
- CEA for: over 70s (better outcomes)