Feasibility and Clinical Impact of Point-of-Care Carotid Artery Examinations by Experts using Hand-Held Ultrasound Devices in Patients with Ischemic Stroke or Transitory Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis. This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

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P119: B-mode point-of-care ultrasound without doppler may help include or exclude significant carotid stenosis in stroke and transient ischemic attack patients - a prospective pilot study

CJEM ◽

10.1017/cem.2016.294 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S118-S118

Author(s):

R. Simard ◽

S. Socransky

Keyword(s):

Emergency Department ◽

Carotid Artery ◽

Carotid Stenosis ◽

Transient Ischemic Attack ◽

Emergency Physician ◽

Point Of Care ◽

External Carotid ◽

Point Of Care Ultrasound ◽

Flow Measurements ◽

Ischemic Attack

Introduction: Emergency physicians can use B-mode Point-of-Care Ultrasound (POCUS) to identify a patient’s carotid vasculature including the common carotid artery (CCA), and carotid bulb (CB) as well as carotid bifurcation into the internal carotid artery (ICA) and external carotid artery (ECA). Radiology performed carotid ultrasound (RPCU) is performed using both B-mode and spectral Doppler ultrasound, a combination termed “duplex” ultrasound where first arteries are evaluated for stenosis using B-mode ultrasound, which is followed by flow measurements using Doppler. Performing flow measurements using Doppler may add a significant amount of time to the ultrasound, which makes it impractical for an emergency physician in a busy emergency department. Some institutional practices include arranging for outpatient RPCU to assess patients with Transient Ischemic Attack (TIA) and have them follow up in an outpatient TIA clinic. This study explored whether B-mode POCUS without Doppler may help identify Stroke or TIA patients in the emergency department with significant carotid stenosis (CS) by measuring the CCA, CB, and ICA lumen. Methods: Adult patients with an emergency physician diagnosis of stroke or TIA who were sent for RPCU were included in this study. An emergency medicine resident in their POCUS fellowship training performed a B-mode POCUS of the patient’s right and left CCA, CB and ICA with the patient sitting 90 degrees. Three measurements of each of the 3 sections were obtained and the mean calculated. This was then compared to the results from the RPCU as CS >50% or CS <50%. Results: 38 patients were included in the study between February and June 2013. We observed a correlation between absolute differences in comparing the right side of the carotid vasculature to the left side of the carotid vasculature with CS >50%. Also, in one case, the absolute lumen diameter with B-mode POCUS without Doppler predicted near complete CS which was confirmed on the RPCU. Conclusion: B-mode POCUS without Doppler may be useful in identifying patients with CS above and below 50% and may help identify patients who need expedited referrals for CS. However, further research is required before this method can be recommended.

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Clinical Guideline for the Diagnostics and Treatment of Patients with Ischemic Stroke and Transitory Ischemic Attack – Version 2016

Česká a slovenská neurologie a neurochirurgie ◽

10.14735/amcsnn2016351 ◽

2016 ◽

Vol 79/112 (3) ◽

pp. 351-363 ◽

Cited By ~ 3

Author(s):

Ondřej Škoda ◽

Roman Herzig ◽

Robert Mikulík ◽

Jiří Neumann ◽

Daniel Václavík ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Guideline ◽

Transitory Ischemic Attack ◽

Ischemic Attack

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Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

10.2310/vasc.2096 ◽

2020 ◽

Author(s):

Kenneth R. Ziegler ◽

Thomas C. Naslund

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Ct Scan ◽

Hemorrhagic Stroke ◽

Fibromuscular Dysplasia ◽

The United States ◽

Carotid Artery Dissection ◽

Artery Dissection ◽

Ct Angiogram ◽

Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis. This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

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Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

10.2310/neuro.2096 ◽

2020 ◽

Author(s):

Kenneth R. Ziegler ◽

Thomas C. Naslund

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Ct Scan ◽

Hemorrhagic Stroke ◽

Fibromuscular Dysplasia ◽

The United States ◽

Carotid Artery Dissection ◽

Artery Dissection ◽

Ct Angiogram ◽

Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis. This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

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Clinical, Laboratory, and Imaging Characteristics of Transient Ischemic Attack Caused by Large Artery Lesions: A Comparison between Carotid and Intracranial Arteries

Cerebrovascular Diseases Extra ◽

10.1159/000440731 ◽

2015 ◽

Vol 5 (3) ◽

pp. 115-123 ◽

Cited By ~ 3

Author(s):

Toshiyuki Uehara ◽

Tomoyuki Ohara ◽

Kazunori Toyoda ◽

Kazuyuki Nagatsuka ◽

Kazuo Minematsu

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Transient Ischemic Attack ◽

Clinical Laboratory ◽

Stroke Care ◽

Large Artery ◽

Intracranial Artery ◽

Imaging Characteristics ◽

Artery Disease ◽

Ischemic Attack

Background/Aims: The aims of this study were to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 h of TIA onset between April 2008 and December 2013, 85 patients (63 men, mean age 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared with those in the extracranial group. Eleven patients in the extracranial group and none in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2 vs. 0%, p = 0.044) and the 90-day risk (17.1 vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Among our patients with TIA caused by large artery disease, patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

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Relationship between microemboli in the internal carotid artery and the occurrence of ischemic stroke after transient ischemic attack

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2012.11.008 ◽

2013 ◽

Vol 20 (10) ◽

pp. 1366-1370 ◽

Cited By ~ 5

Author(s):

Wei-song Liu ◽

Shao-fen Zhu ◽

Wei-Feng Liu ◽

Guo-lin Li ◽

Hong-quan Jiang

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Transient Ischemic Attack ◽

Internal Carotid ◽

Ischemic Attack

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Nonfocal transient neurological attacks in patients with carotid artery occlusion

European Stroke Journal ◽

10.1177/2396987318818779 ◽

2018 ◽

Vol 4 (1) ◽

pp. 50-54

Author(s):

Eline A Oudeman ◽

Eline J Volkers ◽

Jacoba P Greving ◽

Catharina JM Klijn ◽

Ale Algra ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Vertebral Artery ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Time Interval ◽

Anterior Circulation ◽

History Of ◽

Calculated Risk ◽

Ischemic Attack

Introduction Nonfocal transient neurological attacks (TNAs) are episodes with atypical, nonlocalizing cerebral symptoms. We examined the prevalence of nonfocal TNAs, in patients with and without carotid artery occlusion (CAO). Methods We included 67 patients with CAO and 62 patients without CAO. In both groups, patients had a history of transient ischemic attack (TIA) or nondisabling ischemic stroke in the anterior circulation that had occurred >6 months before inclusion. Patients without CAO did not have ipsilateral or contralateral carotid artery stenosis of ≥50%. All patients were interviewed with a standardized questionnaire on the occurrence of nonfocal TNA symptoms during the preceding six months. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for the occurrence of ≥1 and ≥2 different nonfocal TNAs after adjustments for age, sex, systolic blood pressure and time interval between most recent TIA or ischemic stroke and administration of the questionnaire. Results Forty-three of all patients (33%) had had one or more nonfocal TNAs in the preceding six months. Nonrotatory dizziness (24%) was reported most often. The prevalence of ≥1 nonfocal TNAs was not significantly different between patients with and without CAO (39% vs. 27%; adjusted RR 1.47, 95% CI 0.83–2.61), but the prevalence of ≥2 or more different nonfocal TNAs was higher in patients with CAO (16% vs. 3%; adjusted RR 4.77, 95% CI 1.20–18.98). In patients with CAO who also had a contralateral carotid or vertebral artery steno-occlusion, nonfocal TNAs occurred more often than in patients without any carotid or vertebral artery steno-occlusion (46% vs. 27%; adjusted RR 2.22, 95% CI 1.08–4.60 for ≥1 and 21% vs. 3%; adjusted RR 8.27, 95% CI 1.83–37.32 for ≥2 nonfocal TNAs). Conclusions Patients with CAO more often experienced multiple nonfocal TNAs than patients without CAO.

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Effectiveness of staged angioplasty for avoidance of cerebral hyperperfusion syndrome after carotid revascularization

Journal of Neurosurgery ◽

10.3171/2018.8.jns18887 ◽

2020 ◽

Vol 132 (1) ◽

pp. 51-61 ◽

Cited By ~ 1

Author(s):

Mikito Hayakawa ◽

Kenji Sugiu ◽

Shinichi Yoshimura ◽

Tomohito Hishikawa ◽

Hiroshi Yamagami ◽

...

Keyword(s):

Multivariate Analysis ◽

Ischemic Stroke ◽

High Risk ◽

Carotid Artery ◽

Revascularization Procedure ◽

Cerebral Hyperperfusion Syndrome ◽

Carotid Revascularization ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion ◽

Ischemic Attack

OBJECTIVECerebral hyperperfusion syndrome (CHS) is a serious complication after carotid artery stenting (CAS). Staged angioplasty (SAP)—i.e., angioplasty followed by delayed CAS—has been reported as a potential CHS-avoiding procedure. The purpose of this study was to clarify the effectiveness of SAP in avoiding CHS after carotid revascularization for patients at high risk for this complication.METHODSThe authors retrospectively studied cases involving patients at high risk for CHS from 44 Japanese centers who were scheduled for SAP, regular CAS, angioplasty, or staged procedures other than SAP between October 2007 and March 2014. They investigated the rate of CHS in the population scheduled for SAP or regular CAS, and for safety analysis, the composite rate of transient ischemic attack (TIA) and ischemic stroke in the population eventually receiving SAP or regular CAS.RESULTSData from a total of 525 patients (532 lesions, mean age 72.5 ± 7.5 years, 74 women ) were analyzed. Scheduled procedures included SAP for 113 lesions and regular CAS for 419 lesions. The rate of CHS was lower in the SAP group than in the regular CAS group (4.4% vs 10.5%, p = 0.047). Multivariate analysis showed that SAP was negatively related to CHS (OR 0.315; 95% CI 0.120–0.828). In the population eventually receiving SAP (102 lesions) or regular CAS (428 lesions), the composite rate of TIA and ischemic stroke was comparable between the SAP group and the regular CAS group (9.8% vs 9.3%).CONCLUSIONSSAP may be an effective and safe carotid revascularization procedure to avoid CHS.

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Coronary artery calcium and carotid artery intima-media thickness for the prediction of stroke and benefit from statins

European Journal of Preventive Cardiology ◽

10.1177/2047487318798058 ◽

2018 ◽

Vol 25 (18) ◽

pp. 1980-1987 ◽

Cited By ~ 13

Author(s):

Kazuhiro Osawa ◽

Maria Esther Perez Trejo ◽

Rine Nakanishi ◽

Robyn L McClelland ◽

Michael J Blaha ◽

...

Keyword(s):

Ischemic Stroke ◽

Coronary Artery ◽

Carotid Artery ◽

Statin Therapy ◽

Transient Ischemic Attack ◽

Intima Media Thickness ◽

Number Needed To Treat ◽

Atherosclerotic Cardiovascular Disease ◽

Media Thickness ◽

Ischemic Attack

Background Current guidelines suggest treatment for many individuals who may never develop a stroke. We hypothesized that a combination of coronary artery calcification (CAC) and carotid artery intima-media thickness (C IMT) data could better individualize risk assessment for ischemic stroke and transient ischemic attack events. Methods A total of 4720 individuals from the Multi-Ethnic Study of Atherosclerosis were evaluated for ischemic stroke and transient ischemic attack. Cox proportional hazards models for time to incident ischemic stroke/transient ischemic attack were used to examine CAC and CIMT as ischemic stroke/transient ischemic attack predictors in addition to traditional risk factors. We calculated the 10-year number needed to treat by applying the benefit observed in ASCOT-LLA to the observed event rates within CAC and CIMT strata. Results Median follow-up was 13.1 years. Compared with individuals with no CAC and with CIMT ≤ 75th percentile, stroke/transient ischemic attack risk increased progressively with each CAC category (0, 1–100, >100) among individuals with CIMT > 75th percentile. Among participants eligible for statin therapy based on the 2013 atherosclerotic cardiovascular disease (ASCVD) guidelines (ASCVD risk of >5%), 739/2906 (25%) had no CAC and CIMT ≤ 75th percentile and an observed ischemic stroke/transient ischemic attack rate of 2.49 per 1000 person-years. The predicted 10-year number needed to treat was 292 for no CAC and CIMT ≤ 75th percentile and 57 for CAC > 100 and CIMT > 75th percentile. Conclusion The combination of CIMT and CAC could serve to further refine risk calculation for ischemic stroke/transient ischemic attack prevention and may prioritize those in most need of statin therapy to reduce ischemic stroke/transient ischemic attack risk.

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