Carotid endarterectomy stroke

The benefit of carotid endarterectomy for prevention of recurrent stroke has been studied previously in major trials.25,26 A recent meta-analysis has been completed that has combined these clinical trials to evaluate 6,092 patients.27 Carotid endarterectomy has been shown to be beneficial for preventing ipsilateral stroke in patients with symptomatic carotid artery stenosis of 70% or greater and is recommended in these patients. In patients with symptomatic stenosis of 50% to 69%, a moderate reduction in risk is seen in clinical trials. In all patients with stenosis of 50% to 69% and a recent stroke, carotid endarterectomy is appropriate. In other patients, surgical risk factors and surgeon skill should be considered prior to surgery. The patient should have, at a minimum, a life expectancy of 5 years, and the surgical risk of stroke and/or death should be less than 6%. Carotid endarterectomy is not beneficial for symptomatic carotid stenosis less than 50% and should not be considered in these patients. 

More recent reports conclude that early CEA after a nondisabling ischemic stroke can be performed with perioperative mortality and stroke rates comparable to those of delayed CEA. In a subgroup analysis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators, 42 patients who underwent early CEA (<30 days after stroke) were compared with 58 patients who underwent delayed CEA (>30 days), and no overall difference was demonstrated in the perioperative stroke rate (4.8% vs. 5.2%). Another recent prospective randomized study of 86 patients showed no difference in either perioperative stroke (2% in both groups) or survival rates (mean 23 months follow-up) between patients randomized to early or delayed CEA. ... 

Aleksic M, Rueger MA, Lehnhardt EG, Sobesky J, Matoussevitch V, Neveling M, Heiss WD, Bmnkwall J, Jacobs AH. Primary stroke unit treatment followed by very early carotid endarterectomy for carotid artery stenosis after acute stroke. Cerebrovasc Dis 2006 22 276-281. 

Ballotta E, Da Giau G, Baracchini C, Abbnizzese E, Saladini M, Meneghetti G. Early versus delayed carotid endarterectomy after a nondisabling ischemic stroke a prospective randomized study. Surgery 2002 131 287-293. 

McPherson CM, Woo D, Cohen PL, Panciob AM, Kissela BM, CarrozzeUa JA, Tomsick TA, ZuccareUo M. Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery. Stroke 2001 32 2075-2080. 

Krishnamurthy S, Tong D, McNamara KP, Steinberg GK, Cockroft KM. Early carotid endarterectomy after ischemic stroke improves diffusion/perfusion mismatch on magnetic resonance imaging report of two cases. Neurosurgery 2003 52 238-241 [discussion 242]. 

Caplan LR, Skilhnan J, Ojemann R, Eields WS. Intracerebral hemorrhage following carotid endarterectomy a h3fpertensive complication Stroke 1978 9 457-460. 

Gasecki AP, Eerguson GG, EUasziw M, Clagett GP, Pox AJ, Hachinski V, Barnett HJ. Early endarterectomy for severe carotid artery stenosis after a nondisabling stroke Results from the North American symptomatic carotid endarterectomy trial. J Vase Surg 1994 20 288-295. 

Heros RC. Carotid endarterectomy in patients with intraluminal thrombus. Stroke 1988 19 667-668. 

Clinical trials and meta-analyses have demonstrated that early carotid endarterectomy (CEA) is the preferred treatment for most patients with severe symptomatic internal carotid artery (ICA) stenosis and selected patients with moderate disease.However, CEA is often delayed in chnical practice, or may not be appropriate in some patients due to an unfavorable risk-benefit profile. In these settings, it is reasonable to consider acute antithrombotic treatment to prevent early recurrent stroke. 

Suwanwela N, Can U, Furie KL, Southern JF, Macdonald NR, Ogilvy CS, Hansen CJ, Buonanno FS, Abbott WM, Koroshetz WJ, Kistler JR Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Stroke 1996 27(11) 1965-1969. 

Norris JW, Halliday A. Is ultrasound sufficient for vascular imaging prior to carotid endarterectomy Stroke 2004 35(2) 370-371. 

It is unknown whether carotid endarterectomy is of value when performed emergently after stroke, meaning within the first 24 hours after symptoms begin.9 It appears that patients with mild to moderate neurologic deficits, crescendo TIAs or stroke-in-evolution can be operated on safely within the first few hours after the onset of symptoms. Patients with more severe neurologic deficits should only be considered for carotid endarterectomy when the procedure can be performed within the first few hours after the onset of symptoms. It is not indicated for patients with permanent deficits from a moderate to severe completed stroke. 

CHD = myocardial infarction (Ml), significant myocardial ischemia (angina), history of coronary artery bypass graft (CABG), history of coronary angioplasty, angiographic evidence of lesions, carotid endarterectomy, abdominal aortic aneurysm, peripharal vascular disease (claudication), thrombotic/embolic stroke, transient ischemic attack (TIA)... 

Halliday A, Mansfield A, MarroJ, et al, Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms randomised controlled trial. Lancet 2004 363 1491-1502. 

I I Paciaroni M, Eliasziw M, Kappelle LJ, Finan JW, Ferguson GG, Barnett HJ. Medical complications associated with carotid endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET). Stroke 1999 30 1759-1763. 

Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial surgical results in 1415 patients. Stroke 1999 30 1751 -1758. 

Biller J, FeinbergWM, CastaldoJE, etal, Guidelines for carotid endarterectomy a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1998 29 554-562. 

Eliasziw M, Smith RE Singh N, Holdsworth DW, Fox AJ, Barnett HJ. Further comments on the measurement of carotid stenosis from angiograms. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Stroke 1994 25 2445-2449. 

Soinne L, Helenius J, Tatlisumak T, Saimanen E, Salonen O, Lindsberg PJ, Kaste M (2003b) Cerebral hemodynamics in asymptomatic and symptomatic patients with high-grade carotid stenosis undergoing carotid endarterectomy. Stroke 34 1655-1661... 

Fig. 15.13. A 76-year-old woman with a subtotal stenosis of the left internal carotid artery shows no sufficient collateral flow and only faint flow signal in the left middle cerebral artery (upper row), severe hypoperfusion (time-to-peak maps) of the left middle cerebral artery territory (middle row) and small acute hemodynamic stroke lesions on DWI (bottom row). The patient was later successfully treated with carotid endarterectomy...

Eliasziw M, Streifler JY, Fox AJC for the North American Symptomatic Carotid Endarterectomy Trial (1994). Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. Stroke 25 304-308... 

Is impaired cerebral vasomotor reactivity a predictive factor of stroke in asymptomatic patients Stroke 27 2188-2190 HaUiday A, Mansfield A, Marro JC for the MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms randomised controlled trial Lancet 363 1491-1502 Hand PJ, Wardlaw JM, Rivers CS et al. (2006). MR diffusion-weighted imaging and outcome prediction after ischemic stroke. Neurology 66 1159-1163... 

Norris JW, Morriello F, Rowed DW et al. (2003). Vascular imaging before carotid endarterectomy. Stroke 34 el6... 

However, without formal risk models, clinicians are often inaccurate in assessment of risk in their patients (Grover et al. 1995). Moreover, the absolute risk of a poor outcome for patients with multiple specific characteristics cannot simply be derived arithmetically from data on the effect of each individual characteristic such as age or severity of illness that is, one cannot simply multiply risk ratios for these characteristics together as if they were independent. Even if one could, it would still be rather complicated. In a patient with symptomatic carotid stenosis, for example, what would the risk of stroke without endarterectomy be in a 78-year-old (high risk) female (lower risk) with 80% stenosis who presented within two days (high risk) of an ocular ischemic event (low risk) and was found to have an ulcerated carotid plaque (high risk) ... 

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