Carotid artery stenosis, an underestimated cause of stroke recurrence in patients with ischaemic monocular 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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Abstract TP135: Urgent Treatment for Symptomatic Carotid Stenosis: The Pittsburgh Revascularization and Treatment Emergently After Stroke Protocol

Stroke ◽

10.1161/str.51.suppl_1.tp135 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Daniel Tonetti ◽

Brian Jankowitz ◽

Kenmuir Cynthia ◽

Benjamin Zussman ◽

Rahul Rao ◽

...

Keyword(s):

Carotid Stenosis ◽

Primary Outcome ◽

Recurrent Stroke ◽

Carotid Stenting ◽

Clinical Equipoise ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Recorded Data ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Patients with symptomatic carotid stenosis remain at high risk of early recurrent stroke without revascularization. The aim of this report is to analyze prospectively-recorded data from an institutional protocol that standardized the urgent (<48 hours) treatment of patients presenting with symptomatic carotid stenosis and underwent either carotid stenting (CAS) or carotid endarterectomy (CEA). Methods: All patients presenting over 28 months to a comprehensive stroke center with symptomatic carotid stenosis within 48 hours of index event were screened for inclusion. All patients were given dual antiplatelet therapy. If there was clinical equipoise between CEA and CAS, patients underwent angiography and subsequently revascularization if DSA demonstrated ≥50% stenosis. The primary outcome was a composite of stroke or death within 30 days. Results: 178 patients with a diagnosis of recently symptomatic carotid stenosis were included; 120 patients (67%) met criteria. 59 patients underwent CEA and 61 patients underwent CAS. There were not significant differences in the primary outcome; 3 patients (5.1%) in the CEA arm and 3 patients (4.9%) in the CAS arm met the primary outcome. Conclusion: In this prospective analysis, urgent revascularization for symptomatic carotid stenosis can be done with equivalently low rates of stroke or death, regardless of revascularization strategy.

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Obstructed Flow

10.1093/med/9780190495541.003.0011 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Early Period ◽

Carotid Stenting ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Ischemic Attack

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

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Carotid intervention following transient ischaemic attack: What are we waiting for?

Vascular ◽

10.1177/1708538116648063 ◽

2016 ◽

Vol 24 (5) ◽

pp. 556-558 ◽

Cited By ~ 1

Author(s):

Mahim I Qureshi ◽

Alun H Davies

Keyword(s):

Transient Ischaemic Attack ◽

Recurrent Stroke ◽

Meta Analysis ◽

Stroke Recurrence ◽

International Studies ◽

Ocular Symptoms ◽

Policy Adjustment ◽

Neurological Event ◽

Ischaemic Attack ◽

Delayed Intervention

Transient ischaemic attack secondary to carotid stenosis has the highest risk of stroke recurrence compared with other aetiological subtypes. International guidelines advocate carotid intervention within one to two weeks of the index neurological event. Traditionally, delayed carotid intervention was perceived to be a safer management strategy, yet classic trials of endarterectomy and recent meta-analysis of carotid intervention demonstrate the safety of hyperacute carotid intervention. Data from international studies suggest that targets are not being met, the reasons for which are multifactorial, but patients suffering transient or ocular symptoms are particularly delayed. Efforts should be made to conduct regional studies investigating the root causes of delayed intervention, with subsequent policy adjustment to expedite intervention, and interim optimisation of medical management to reduce the incidence of recurrent stroke.

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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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Risk of Early Recurrent Stroke in Symptomatic Carotid Stenosis

Journal of Vascular Surgery ◽

10.1016/j.jvs.2014.12.017 ◽

2015 ◽

Vol 61 (2) ◽

pp. 570

Author(s):

S. Strömberg ◽

A. Nordanstig ◽

T. Bentzel ◽

K. Österberg ◽

G.M.L. Bergström

Keyword(s):

Carotid Stenosis ◽

Recurrent Stroke ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis

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Risk of early recurrent stroke in symptomatic carotid stenosis after best medical therapy and before endarterectomy

International Journal of Stroke ◽

10.1177/1747493015609777 ◽

2015 ◽

Vol 11 (1) ◽

pp. 41-51 ◽

Cited By ~ 21

Author(s):

S Shahidi ◽

A Owen-Falkenberg ◽

B Gottschalksen ◽

K Ellemann

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Recurrent Stroke ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Best Medical Therapy

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Risk of Early Recurrent Stroke in Symptomatic Carotid Stenosis

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2014.11.004 ◽

2015 ◽

Vol 49 (2) ◽

pp. 137-144 ◽

Cited By ~ 27

Author(s):

S. Strömberg ◽

A. Nordanstig ◽

T. Bentzel ◽

K. Österberg ◽

G.M.L. Bergström

Keyword(s):

Carotid Stenosis ◽

Recurrent Stroke ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis

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Abstract 84: Low Risk of Stroke or Death Among Patients With Recently Symptomatic Carotid Stenosis Awaiting Revascularisation - A Pooled Analysis of Randomised Trials

Stroke ◽

10.1161/str.45.suppl_1.84 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Leo H Bonati ◽

Stefanie von Felten ◽

Gary S Roubin ◽

Willem P Mali ◽

Olav Jansen ◽

...

Keyword(s):

Carotid Stenosis ◽

Median Time ◽

Historical Data ◽

Recurrent Stroke ◽

Pooled Analysis ◽

Symptomatic Carotid ◽

Kaplan Meier ◽

Symptomatic Carotid Stenosis ◽

Patients At Risk ◽

Severe Degree

Background: Historical data suggest that patients with recently symptomatic carotid stenosis are at high risk of early recurrent stroke. Guidelines therefore recommend revascularization within 2 weeks of symptoms. We assessed the risk of stroke or death occurring before revascularization in modern trials of symptomatic carotid stenosis. Methods: We pooled data of all individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in the EVA-3S, SPACE, ICSS and CREST trials. The outcome event (OE) was death or any stroke occurring between randomization and treatment by CAS or CEA, or up to 120 days after randomization among patients not undergoing treatment in this period. Results: 4707 patients were included in the analysis. Median time from qualifying event until randomization was 18 (interquartile range 7-50) days. Median time from randomization until treatment was 6 (2-11) days in the CAS group, and 7 (3-12) days in the CEA group (p<0.001). 31% of patients in the CAS group and 27% in the CEA group underwent revascularization within 14 days of the qualifying event. The OE occurred in 21 patients (CAS: 8, CEA: 13), all within 31 days of randomization (Kaplan Meier estimate: 2.4%, standard error 0.7%; fig.), including 18 non-fatal strokes, 1 fatal stroke, and 2 non-stroke related deaths. In 2 of the patients, the date of the qualifying event was unknown, in 8 patients the OE occurred within 14 days of the qualifying event and in 11 patients >14 days after the qualifying event. All patients with the OE had severe (70-99% degree) stenosis. No other baseline variables predicted the OE. Discussion: Despite the fact that less than a third of patients underwent revascularization within 14 days of the qualifying event, only 2.4% of patients had a recurrent stroke or died before treatment. The risk is lower than expected from historical data, which may reflect advances in medical therapy. Patients at risk are those with severe degree of stenosis.

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