Stroke recurrence in patients with recently symptomatic carotid stenosis and scheduled for carotid revascularization

Introduction: Due to their exclusion from most clinical trials, outcomes of carotid revascularization via a carotid endarterectomy (CEA) or carotid artery stenting (CAS) among octogenarians are not well studied. Herein, we present analysis of thirty-day stroke and mortality of patients aged ≥ 80 using real-world data from a national surgical quality registry. Methods: The National Surgical Quality Improvement Program (NSQIP) targeted dataset for CEA and CAS was queried for patients aged ≥ 80 undergoing CEA and CAS between 2012-2018. Results: A total of 94 and 2,656 patients aged ≥ 80 with symptomatic carotid stenosis undergoing CAS and CEA (respectively) were identified. Patients in the CAS group were more likely to be over 90 (p=0.006). Patients in the CAS group were more likely to have high-risk anatomy (p<0.001) and more likely to be on aspirin preoperatively (p=0.02) but less likely to have higher ASA (p<0.001). Most patients in the group presented with an ipsilateral stroke (CAS: 43.6% and CEA: 41.7%). The rate of thirty-day composite outcome (stroke or death) was found to be 5.3% in the CAS group and 4.5% in the CEA group (p=0.714) (stroke: 2.1% for CAS and 3.2% for CEA; death: 4.3% for CAS and 1.7% for CEA). Upon multivariable analysis, procedure type (CAS vs CEA) was not found to be associated with the composite-outcome (OR 1.1, 95%CI 0.43-2.82,p=0.836). Symptom presentation other than ipsilateral stroke was found to be associated with significantly decreased odds of 30-day composite outcome (amaurosis-fugax/transient monocular blindness: OR 0.42,95%CI 0.21-0.86, p=0.02; TIA: OR 0.62, 95%CI 0.42-0.93,p=0.02), while higher age was found to be associated with significantly increased odds (OR 1.512, 95%CI 1.01-2.24, p=0.02). Conclusion: Real world analysis from a surgical quality registry show that both CAS and CEA are associated with optimal 30-day outcomes among octogenarians with symptomatic carotid stenosis.

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Hemodynamic Depression of Early Carotid Revascularization on Ischemic Stroke Patients with Symptomatic Carotid Stenosis

Journal of Neurocritical Care ◽

10.18700/jnc.170012 ◽

2017 ◽

Vol 10 (2) ◽

pp. 92-98

Author(s):

Jun Woo Kim ◽

Youngrok Do

Keyword(s):

Ischemic Stroke ◽

Carotid Stenosis ◽

Stroke Patients ◽

Carotid Revascularization ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis

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Abstract TMP119: Early Cerebral Ischemic Events in Symptomatic Carotid Stenosis are Related to Plaque Inflammation

Stroke ◽

10.1161/str.48.suppl_1.tmp119 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Prakash R Paliwal ◽

Arvind K Sinha ◽

Hock L Teoh ◽

James Hallinan ◽

Zhengdao Du ◽

...

Keyword(s):

Cerebral Ischemia ◽

Carotid Stenosis ◽

Fdg Pet ◽

Carotid Plaque ◽

Stroke Recurrence ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Plaque Inflammation ◽

Cerebral Ischemic ◽

Ischemic Events

Background and aims: Symptomatic carotid stenosis is associated with an increased risk of early stroke recurrence. Severity of the stenosis, current basis of revascularization, explains only the cerebral ischemic mechanism of regional hypoperfusion. Plaque inflammation, the initiating event for plaque rupture and thromboembolism (artery-to-artery embolism), is not evaluated routinely. Using 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/computed tomography (CT) and high resolution magnetic resonance imaging (HR-MRI), we investigated the role of plaque imaging and stroke recurrence in our cohort of stroke patients with recently symptomatic carotid stenosis. Methods: This ongoing prospective study included consecutive patients within 30-days of recent stroke and ipsilateral carotid stenosis (≥50%). FDG uptake was quantified as mean standardized uptake values (SUV, g/ml). The ratio of T1 hyperintensity of carotid plaque to the ipsilateral sternocleidomastoid muscle (SCM) was recorded on T1-weighted fat suppressed images. Patients were followed prospectively for stroke recurrence within 90-days. Embolic potential of carotid plaque is estimated by presence of spontaneous microembolic signals (MES) on extended transcranial Doppler monitoring of ipsilateral middle cerebral artery. Results: Of the 33 patients included in the study, 6 (18%) suffered from recurrent cerebral ischemic event in the same vascular territory within 90-days. Compared to patients without subsequent cerebral ischemic events, patients with recurrent cerebral ischemia showed higher mean T1 carotid-SCM ratio (2.49 versus 1.53; p<0.0001) and higher mean SUV value in the carotid plaque (3.52g/ml versus 1.51g/ml; p<0.0001). Higher T1 carotid-SCM ratio on HR-MRI (OR 4.249, 95%CI 1.818-5.18; p<0.0001), higher mean SUV on FDG-PET (OR 3.050, 95%CI 5.586-28.571; p=0.005) and MES on TCD (OR 2.186, 95%CI 1.652-47.619;p=0.037) were independent predictors of recurrent cerebral ischemia. Conclusions: FDG-PET/CT and HR-MRI imaging of carotid stenosis helps in identification of patients at higher risk of subsequent cerebral ischemic events and may aid in better therapeutic decision-making.

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Abstract P566: Identifying Sex-Specific Differences in the Carotid Revascularization Literature: Findings From a Scoping Review

Stroke ◽

10.1161/str.52.suppl_1.p566 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Vignan Yogendrakumar ◽

Michel C Shamy ◽

Brian Dewar ◽

Dean Fergusson ◽

Dar Dowlatshahi ◽

...

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Scoping Review ◽

Sufficient Information ◽

Significant Heterogeneity ◽

Long Term Outcomes ◽

Carotid Revascularization ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis

Background and Purpose: No systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in women. In this scoping review, we aimed to identify all randomized controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularization, and determine whether sufficient information is reported within these studies to assess women’s short and long-term outcomes. Methods: We systematically searched Medline, Embase, Pubmed, and Cochrane libraries for RCTs published between 1991 and 2020 that included women and compared either endarterectomy with stenting, or any revascularization (endarterectomy or stenting) with medical therapy in patients with symptomatic high grade (greater than 50%) carotid stenosis. Results: From 1,537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled women were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment were limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex. Conclusions: Half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analysis on the benefits of carotid artery intervention for women with symptomatic stenosis is limited . Further analysis with individual patient data and a network meta-analysis is the necessary next step to better assess the treatment effects of carotid management in women.

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Stroke recurrence risk modelling in symptomatic carotid stenosis patients: Preliminary study

Journal of the Neurological Sciences ◽

10.1016/j.jns.2017.08.2465 ◽

2017 ◽

Vol 381 ◽

pp. 874-875

Author(s):

M. Kumar ◽

D. Khurana ◽

C.K. Ahuja ◽

N. Khandelwal ◽

B. Singh ◽

...

Keyword(s):

Carotid Stenosis ◽

Recurrence Risk ◽

Stroke Recurrence ◽

Risk Modelling ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Preliminary Study

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Carotid artery stenosis, an underestimated cause of stroke recurrence in patients with ischaemic monocular visual loss

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0071 ◽

2019 ◽

Vol 101 (8) ◽

pp. 579-583

Author(s):

SF Cheng ◽

A Zarkali ◽

T Richards ◽

R Simister ◽

A Chandratheva

Keyword(s):

Carotid Stenosis ◽

Transient Ischaemic Attack ◽

Visual Loss ◽

Surgical Intervention ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Ischaemic Attack ◽

Transient Visual Loss

Introduction Isolated monocular ischaemic events are thought to be low risk for stroke recurrence. In the presence of carotid stenosis however, the risks should not be treated similarly and surgical intervention should be considered at an early stage. The aim of this study was to determine the vascular risk profile and stroke recurrence in patients with ischaemic monocular visual loss. Methods and methods Consecutive records for all patients with monocular ischaemia were reviewed from January 2014 to October 2016. Stroke, transient ischaemic attack or monocular ischaemia recurrence within 90 days were recorded. Carotid stenosis was assessed with duplex ultrasound, computed tomography or magnetic resonance angiography. Results In total, 400 patients presented with monocular ischaemia; 391 had carotid imaging (97.8%). Causality was symptomatic carotid stenosis ≥ 50% in 53 (13.6%), including carotid stenosis ≥ 70% in 31 (7.9%). Patients with permanent visual loss (n = 131) were more likely to have significant stenosis compared with patients with transient visual loss (n = 260), 19.8% compared with 10.4% (P = 0.012). Recurrent stroke, transient ischaemic attack or monocular ischaemia within 90 days after presentation occurred in three patients (5.7%) in the carotid stenosis group, compared to three (0.9%) who did not have stenosis (P = 0.035). Age, male sex and hypertension were associated with carotid stenosis but hypercholesterolaemia, diabetes and smoking were not. Conclusions Carotid stenosis ≥ 50% is present in patients with ocular ischaemia in approximately 20% of those with persistent visual loss and in 10% with transient visual loss. Those with carotid stenosis have a higher risk of stroke recurrence and should be considered urgent surgical intervention as other forms of stroke.

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Plaque Inflammation and Unstable Morphology Are Associated With Early Stroke Recurrence in Symptomatic Carotid Stenosis

Stroke ◽

10.1161/strokeaha.113.003657 ◽

2014 ◽

Vol 45 (3) ◽

pp. 801-806 ◽

Cited By ~ 71

Author(s):

Michael Marnane ◽

Susan Prendeville ◽

Ciaran McDonnell ◽

Imelda Noone ◽

Mary Barry ◽

...

Keyword(s):

Carotid Stenosis ◽

Stroke Recurrence ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Plaque Inflammation ◽

Early Stroke

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Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery

Neurosurgery ◽

10.1093/neuros/nyy557 ◽

2019 ◽

Vol 85 (2) ◽

pp. E214-E225 ◽

Cited By ~ 4

Author(s):

Amey R Savardekar ◽

Vinayak Narayan ◽

Devi P Patra ◽

Robert F Spetzler ◽

Hai Sun

Keyword(s):

Systematic Review ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Current Literature ◽

Meta Analysis ◽

Review Of Literature ◽

Carotid Revascularization ◽

Symptomatic Carotid ◽

Index Event ◽

Symptomatic Carotid Stenosis

Abstract Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.

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