Seizures Following Carotid Endarterectomy: A Comprehensive Meta-Analysis of 69,479 Patients and Evidence-Based Recommendations for Perioperative Care

<b>Background:</b> Seizures are a rare but potentially serious complication following carotid endarterectomy (CEA). Understanding their prevalence and associated factors is crucial for optimizing perioperative care and improving patient outcomes. This meta-analysis aimed to estimate the pooled prevalence of seizures following CEA and explore clinical and procedural factors contributing to their occurrence. <b>Methods</b>: We conducted a systematic review and meta-analysis of studies reporting on seizures following CEA. A systematic search of PubMed, Embase, and Cochrane CENTRAL databases was performed, following PRISMA and MOOSE guidelines. Random-effects meta-analysis was used to calculate the pooled prevalence of postoperative seizures. Heterogeneity was assessed using the I² statistic. A total of 20 studies, encompassing 69,479 patients, were included. <b>Results</b>: The overall pooled prevalence of seizures following CEA was 1% (95% CI: 0-2%; <i>p</i> < 0.001), with significant heterogeneity (I² = 93.52%). Prospective studies reported a higher pooled prevalence (2%, 95% CI 0-4%; I² = 76.34%) compared to retrospective studies (0%, 95% CI 0-1%; I² = 91.51%). Male predominance was noted among patients who experienced seizures, and hypertension was the most common comorbidity. Cerebral hyperperfusion syndrome was identified as a key contributing factor to postoperative seizures. Data on long-term outcomes, including the development of epilepsy, were insufficient for further analysis. The methodological quality of the included studies varied, with most studies demonstrating a moderate risk of bias. <b>Conclusions</b>: Seizures occur in approximately 1% of patients following CEA, with higher rates observed in prospective studies. Cerebral hyperperfusion syndrome is an important contributor to this rare complication. We provide evidence-based specific recommendations for seizure management and introduce the SMART-CEA Checklist, a practical framework to guide perioperative care and reduce complications. Future research should focus on long-term outcomes, including epilepsy, and incorporate standardized methodologies to improve data reliability and guide clinical practice.