***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Rationale In patients with > 50 % carotid artery stenosis ( as measured by North American Symptomatic Carotid Endarterectomy Trial ( NASCET ) criteria ) suffering a transient ischemic attack or a minor ipsilateral stroke , carotid endarterectomy exerts maximum benefits , when performed within the first 15 days from the initial ischemic symptom . It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks . It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure . Aims Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions . Design Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with > 50 % carotid artery stenosis ( Nascet criteria ) , r and omized in two groups :  urgent carotid endarterectomy ( within 48 hours ) and delayed carotid endarterectomy ( operated between 48 hours and 15 days after onset of symptoms ) Risk factors will be evaluated at enrollment . TIA will be classified by ABCD2 scoring system , and minor stroke by National Institutes of Health Stroke Scale ( NIHSS ) scores . The study will last 90 days per patient , starting from their initial symptom , and the follow-up will be performed by an indipendent neurologist . A total of 456 patients ( 228 / group ) is needed to observe an absolute difference of 10 % between groups . Outcomes Primary end-point is reduction in all types of stroke , AMI or death in urgent endarterectomy groupo compared to delayed ones . Secondary end-points are : Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups Background : St and ard practice has been to delay carotid endarterectomy ( CEA ) for 2 months following acute stroke to avoid a perceived risk of cerebral haemorrhage . We investigated whether early CEA reduces early recurrent stroke and improves outcome in partial anterior circulation infa rct ion ( PACI ) . Methods : Patients with PACI and a Barthel score of > 18 before stroke underwent carotid duplex and CT imaging  within 7 days of stroke . Forty consenting patients fit for surgery with greater than 70 % ipsilateral carotid stenosis were r and omised , 19 to ‘ early ’ ( within 24 h ) and 21 to ‘ delayed ’ surgery ( at 8 weeks ) . Modified Rankin and Barthel scores were recorded at 1 week , 2 months , 6 and 12 months . Results : Rankin scores improved more rapidly following ‘ early ’ surgery to a score of 1 ( 0–4 ) at 2 and 6 months compared with 2.5 and 2 ( 1–4 ) , respectively , for delayed surgery ( p < 0.05 ) . Barthel scores were also significantly improved following ‘ early ’ CEA at 7 days but both groups reached a median score of 20 by 2 months . Four ‘ delayed ’ and 3 ‘ early ’ patients suffered extension or recurrence of neurological deficits with 1 death in each group . Conclusions : Early CEA within 7 days of ischaemic stroke improved functional outcome with earlier hospital discharge . A large multicentre study is needed to exclude the possibility that ‘ early ’ CEA increases the risk of cerebral haemorrhage or death Background and Purpose — This prospect i ve study was design ed to examine the course , associates , and predictors of depressive symptoms during the first 18 months after stroke . Methods — A total of 100 patients were followed up for 18 months after stroke .  Depressive symptoms were assessed at 2 weeks and 2 , 6 , 12 , and 18 months after stroke with the  Beck Depression Inventory  and the  Hamilton Rating Scale for Depression , and diagnoses were performed using criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders , Third Edition-Revised . Stroke severity was assessed with the Sc and inavian Stroke Scale and cognitive functions with a comprehensive neuropsychological battery . Patients participated in a r and omized clinical trial of antidepressive medication . Results — In all , 54 % of patients felt at least mildly depressive at some time during the follow-up ; 46 % of those who were depressive during the first 2 months were also depressive at 12 and /or 18 months . Only 12 % of patients were depressive for the first time at 12 or 18 months . The male sex was associated with a more negative change in depressive symptoms during the follow-up . Older age was associated with depressive symptoms during the first 2 months , stroke severity from 6 to 12 months , and the male sex at 18 months . Depressive symptoms were unrelated to the lesion location . Conclusions — Depressive symptoms are frequent and they often have a chronic course . Depression is associated with stroke severity and functional impairment , and with the male sex at 18 months . Attention should be focused on the long-term prognosis of mood disturbances and adaptation Background Carotid endarterectomy is usually delayed for 2 months following an acute stroke , but the stroke may progress or a further stroke may occur . A r and omized pilot study of  urgent carotid surgery for acute stroke was undertaken to assess the feasibility of a definitive multicentre trial Background and Purpose — Current Swedish guidelines recommend that carotid endarterectomy should be performed within 14 days of a qualifying neurological event , but it is not clear if very urgent surgery after an event is associated with increased perioperative risk . The aim of this study was to determine how the time between the event and carotid endarterectomy affects the procedural risk of mortality and stroke . Methods — We prospect ively analyzed data on all patients who underwent carotid endarterectomies for symptomatic carotid stenosis between May 12 , 2008 , and May 31 , 2011 , with records in the Swedish Vascular Registry ( Swedvasc ) . Patients were divided according to time between the qualifying event and surgery ( 0–2 days , 3–7 days , 8–14 days , 15–180 days ) . Stroke rate and mortality at 30 days postsurgery were determined . Results — We analyzed data for 2596 patients and found that the combined mortality and stroke rate for patients treated 0 to 2 days after qualifying event was 11.5 % ( 17 of 148 ) versus 3.6 % ( 29 of 804 ) , 4.0 % ( 27 of 677 ) , and 5.4 % ( 52 of 967 ) for the groups treated at 3 to 7 days , 8 to 14 days , and 15 to 180 days , respectively . In a multivariate analysis , time was an independent risk factor for perioperative complications : patients treated at 0 to 2 days had a relative OR of 4.24 ( CI , 2.07–8.70 ; P<0.001 ) compared with the reference 3- to 7-day group . Conclusions — In this study of patients treated for symptomatic carotid disease , it was safe to perform surgery as early as Day 3 after a qualifying neurological event in contrast to patients treated within 0 to 2 days , which has a significantly increased perioperative risk Background Carotid endarterectomy yields greater risk reduction for ipsilateral ischemic stroke when performed within two-weeks of the last cerebrovascular symptom than when performed two-weeks or more after the last symptom . However , additional benefit might be gained if carotid endarterectomy is performed earlier than within two-weeks . Aims To investigate the 90-day risk of ipsilateral ischemic stroke recurrence after amaurosis fugax , retinal artery occlusion , transient ischemic attack , or minor ischemic stroke in patients with 50–99 % carotid stenosis before carotid endarterectomy , with emphasis on the first 14 days . Methods Prospect i ve cohort study . 230 consecutive patients with symptomatic 50–99 % carotid stenosis ( North American Symptomatic Carotid Endarterectomy Trial grading method ) who underwent evaluation before carotid endarterectomy .  Of these , 183 underwent carotid endarterectomy ; the median delay to carotid endarterectomy was 29 days . Blood pressure lowering medication was used by 93 % and lipid-lowering medication by 90 % . Results The risk of ipsilateral ischemic stroke recurrence before carotid endarterectomy was 5·2 % ( n = 12 ) within two-days , 7·9 % ( n = 18 ) within seven-days , 11·2 % ( n = 25 ) within 14 days , and 18·6 % ( n = 33 ) within 90 days of the presenting event . The risk of ipsilateral ischemic stroke recurrence was higher if the presenting event was a stroke ( adjusted hazard ratio 12·4 , P = 0·015 ) or transient ischemic attack ( adjusted hazard ratio 10·2 , P = 0·026 ) compared with an amaurosis fugax . Discussion The risk of recurrent ipsilateral ischemic stroke was high within the first days of the presenting event . Many recurrences would likely have been avoided if carotid endarterectomy had been performed within the first days of the presenting event Although the latest recommendations suggest that carotid endarterectomy ( CEA ) should be performed in symptomatic carotid artery stenosis ( sCAS ) patients within 2 weeks of the index event , only a minority of patients undergo surgery within the recommended time‐frame . The aim of this international multicenter study was to prospect ively evaluate the safety of early CEA  in patients with sCAS in everyday clinical practice setting Objective : In the North Dublin Population Stroke Study , we investigated the risk of recurrent stroke within the 14-day time window recommended for endarterectomy . Methods : In a population -based prospect i ve cohort study , all ischemic stroke patients were identified over 1 year and categorized into those with ( CS-positive ) and without  ( CS-negative ) ipsilateral carotid stenosis ( CS ) ( ≥50 % lumen narrowing ) . Nonprocedural stroke recurrence was determined at 72 hours and 7 and 14 days . Results : Of 365 ischemic stroke patients with carotid imaging , 51 were excluded due to posterior circulation or nonlateralizing stroke , ipsilateral carotid occlusion , or intracranial stenosis , leaving 314 included for analysis ( 36 CS-positive and 278 CS-negative ) . Recurrent stroke occurred in 5.6 % ( 2/36 ) CS-positive and 0.4 % ( 1/278 ) CS-negative patients by 72 hours of symptom onset ( p = 0.003 ) , 5.6 % ( 2/36 ) CS-positive and 0.7 % ( 2/278 ) CS-negative patients ( p = 0.01 ) by 7 days , and in 8.3 % ( 3/36 ) CS-positive and 1.8 % ( 5/278 ) CS-negative patients by 14 days ( p = 0.02 ) . On multivariable Cox regression analysis , CS was the only independent predictor of recurrence at 72 hours ( adjusted hazard ratio [ HR ] 36.1 , 95 % confidence interval [ CI ] 1.6–837.5 , p = 0.03 ) , and 7 days ( HR 9.1 , 1.1–79.2 , p = 0.05 ) , with a trend at 14 days ( HR 4.6 , 0.9–22.8 , p = 0.06 ) . Conclusions : Although only a minority of patients with symptomatic CS had a recurrent stroke within 14 days , early recurrent stroke risk was high , particularly within the first 72 hours . Earlier carotid revascularization or improved acute medical treatment may reduce recurrence in this high-risk group . Neurology ® Background : Each of the embolic protection devices used in carotid artery stenting ( CAS ) has advantages and disadvantages . The prospect i ve , multicenter , single‐arm EMPiRE Clinical Study investigated a proximally placed device ( GORE Flow Reversal System ) that provides distal neuroprotection during CAS by reversing blood flow in the internal carotid artery , thereby directing emboli away from the brain . Methods : The study evaluated 30‐day outcomes in 245 pivotal high‐surgical‐risk patients ( mean age , 70 years ; 32 % symptomatic ; 16 % ≥80‐years old ) with carotid stenosis who underwent CAS using the flow reversal system .  The primary endpoint was a major adverse event ( MAE ; stroke , death , myocardial infa rct ion , or transient ischemic attack ) within 30 days of CAS . The MAE rate was compared with an objective performance criterion ( OPC ) derived from CAS studies that included embolic protection . Results : The MAE rate was 4.5 % ( 11 patients ; P = 0.002 compared with the OPC ) . The stroke and death rate was 2.9 % . No patient had a major ischemic stroke . Six patients ( 2.4 % ) had intolerance to flow reversal . The death and stroke rates in the symptomatic , asymptomatic , and octogenarian subgroups were 2.6 , 3 , and 2.6 % , respectively , meeting American Heart Association gu 
    Output:
    
To date , no results are available to confirm the optimal timing for surgery .
There is currently no high- quality evidence available to support either very early or delayed cerebral revascularization  after a recent ischemic stroke .
Currently , there is one ongoing RCT that is examining the timing of cerebral revascularization