Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Authors analyzed blood flow in ICA after CEA by transit time flowmetry. This is an interesting paper, however, there a few points to be modified.

1. The most dangerous complication after carotid revascularization is hyperperfusion. To predict hyperperfusion, preoperative blood flow and increase of flow are important. In this study authors did not measure pre-CEA blood flow to avoid embolization. Please discuss hyperperfusion phenomenon and usefulness of this method in prediction of hyperperfusion. 
2. Please indicate the actual data of flow in each case of severe or non-severe contralateral stenoocclusive disease, as cases with shunt placement.

Author Response

We have added the point-to-point replies to the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This single-centre study presents one of the largest systematically recorded cohorts of intraoperative post-CEA ICA flow measurements using transit-time flowmetry, with 196 consecutive procedures performed at a high-volume neurosurgical centre. The study addresses a clinically relevant and underexplored question, and the findings are physiologically coherent and add meaningful data to a sparse literature. The manuscript is well-structured, the registry-based design is a strength, and the institutional protocol is clearly described. With targeted revisions addressing the points below, this manuscript has good potential for acceptance.

1. Please resolve the inconsistency regarding the IQR (The Abstract and Highlights report a median post-CEA ICA flow of 170 mL/min with IQR 140–245, while the Results section (line 44) reports IQR 140–214)
2. The manuscript argues that TTF enables early detection of inadequate flow restoration and improves intraoperative quality control, but no perioperative clinical outcomes (stroke, TIA, death, re-exploration rate) are reported or linked to the flow measurements. Without this, the clinical utility argument remains inferential. Even a descriptive summary of perioperative events and whether any were preceded by abnormal TTF values would meaningfully strengthen the paper's conclusions and its translational relevance.
3. Line 150: "A 6mm flow probe is routinary used". This should be changed into "routinely used." A careful English language review of the full manuscript is recommended, as there are occasional similar minor phrasing issues throughout.
4. The subanalysis of patients requiring shunt placement is based on only 9 patients, which limits statistical power and the strength of conclusions that can be drawn about collateral patterns and compensatory flow. The authors should explicitly acknowledge this limitation within the subanalysis section itself, not only in the limitations paragraph, and ensure that the language used does not overstate the findings.

Comments on the Quality of English Language

English revision is needed as there are multiple minor phrasing issues throughout the entire manuscript

Author Response

We have added the point-to-point replies to the attachment.

Author Response File: Author Response.pdf