Early (<6 Days) Extracranial Carotid Revascularization After Intravenous Thrombolysis for Stroke: A Scoping Review

Background: Current guidelines recommend delaying extracranial carotid revascularization for at least 6-7 days after intravenous thrombolysis (IVT). However, evidence remains inconclusive, and patients with minimal or no brain lesions may benefit from earlier intervention. Objective: This scoping review evaluates outcomes of carotid revascularization performed within six days of IVT in patients with small strokes or no imaging-detected lesions. Design: We searched Medline, EMBASE, and Cochrane CENTRAL for studies published between 2005 and 2025 reporting carotid revascularization after IVT. Primary outcomes included perioperative ischemic stroke, symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial bleeding (aICB), and wound complications. Data on timing, imaging findings (CT/MRI), and stroke severity (NIHSS or modified Rankin scale) were extracted. The review followed PRISMA-ScR guidelines. Results: Seventeen studies (1459 patients) were included; 97.6% underwent carotid endarterectomy (CEA) and 2.4% carotid artery stenting (CAS). Data for procedures within six days post-IVT were available for 402 patients, with some treated within 24-72 h. Mean NIHSS at admission was 10.2 ± 2.8. Brain lesion characterization was poor and only used as an exclusion criterion. Thirty-day ischemic stroke incidence was 2.5%, while combined sICH/aICB was 4.0%, with symptomatic cases at 2.5%. Most hemorrhages occurred in patients operated within 48-72 h from IVT and in patients with higher NIHSS. CAS carried higher sICH risk than CEA (8.6% vs. 1.9%). Overall mortality was 1.1%; wound complications occurred in 3.7%. Conclusions: The available literature provides limited characterization of brain lesion extent. Neurological complications after CEA are rare, mainly limited to patients operated within 48-72 h from IVT. Further research is needed to optimize treatment in this patient group, although delaying CEA only to 48-72 h seems reasonable in case of low NIHSS.