Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis vs. Endarterectomy: SPACE2 – a Three-Arm Randomised-Controlled Clinical Trial

Moderate to severe (≥70%) asymptomatic stenosis of the extracranial carotid artery leads to an increased rate of stroke of approximately 11% in 5 years. Patients with asymptomatic carotid stenosis, however, are also at a higher risk of nonstroke vascular events. The estimated annual risks of such events in patients with asymptomatic stenosis are 7% for a coronary ischaemic event and 4–7% for overall mortality. The superiority of carotid endarterectomy compared with medical treatment in symptomatic carotid disease is established, provided that the surgical procedure can be performed with a perioperative morbidity and mortality of <6%. The advantage of carotid endarterectomy for asymptomatic patients is less established. An alternative treatment, carotid artery stenting, has been developed. This treatment is used frequently in both symptomatic and asymptomatic patients. In the last decade, major advantages in medical primary prevention of cerebrovascular and cardiovascular disease have been accomplished. The control groups in the large trials for asymptomatic carotid artery disease (ACAS and ACST) originate from more than a decade ago and, for the most part, have not received a medical primary prevention strategy that would now be considered the standard according to current national and international guidelines. For this reason, a three-arm trial (SPACE2; http://www.space-2.de ) with a hierarchical design and a recruitment target of 3640 patients is chosen. Firstly, a superior trial of intervention (carotid artery stenting or carotid endarterectomy) vs. state-of-the-art conservative treatment is designed. In case of superiority of the interventions, a noninferiority end-point will be tested between carotid artery stenting and carotid endarterectomy. This trial is registered at Current Controlled Trials ISRCTN 78592017.

[Ten years' experience at a major stroke center]

BACKGROUND

About 1,300 stroke patients from a primarily rural area are treated each year at the Department of Neurology of the University Hospital of Heidelberg, Germany. Demographic and treatment data of all stroke patients there were prospectively collected. In a retrospective study we report on the changes in this patient population from 1996 to 2006, with special consideration of those suitable for intravenous thrombolysis.

METHODS

For all stroke patients the basic data were collected--age, sex, type of stroke (transient ischemic attack, stroke, or intracerebral hemorrhage), NIH Stroke Scale, duration between symptom onset and hospital arrival, delay between arrival and first doctor's contact, patient's further whereabouts, and for patients treated by iv thrombolysis, start of treatment and dosage.

RESULTS

There were no changes in the total number of stroke patients and median stroke severity, according to the NIH Stroke Scale, from 1996 to 2006. The proportion of stroke patients admitted within the first 3 h after symptom onset increased from 12.1% (1996) to 21.9% (2006). Thus we managed to treat 10.1% of all our ischemic stroke patients with iv thrombolysis, which means 39% of those patients with cerebral infarction arriving within 3 h.

DISCUSSION

During the study period there were no significant changes in the patients' sociodemographic data. By consistent reduction of prehospital delay, the number of stroke patients that could be treated acutely by intravenous thrombolysis was increased.

Akuttherapie des Schlaganfalls

This article covers three major topics of acute stroke therapy: extension of the time window for thrombolysis with desmoteplase, decompressive surgery after malignant middle cerebral artery infarction, and the effect of hemostatic therapy with recombinant activated factor VII (rFVIIa) in patients with spontaneous primary intracerebral hemorrhage. Thrombolytic therapy with recombinant tissue or tissue-type plasminogen activator is still the only approved acute stroke therapy within a 3-h time window. Imaging-based patient selection seems to help extending this time window. After promising results of two phase II trials with the thrombolytic agent desmoteplase in an extended time window after acute ischemic stroke, the DIAS-II study was reconducted in Europe, North America, and Australia as a phase III trial. First results of the included 186 patients are shown. Surprisingly, patients treated with desmoteplase had no better outcome than placebo-treated patients, and there was increased mortality in the high-dose group. Among all stroke subtypes, space-occupying malignant middle cerebral artery is one with the poorest prognosis. Most patients die within a few days due to the development of massive brain edema, despite maximum intensive care. Decompressive hemicraniectomy represents a much more effective therapy for the treatment of local brain swelling. However, until recently this method was highly controversial. Here we present the results of the randomized trials published in 2007 and discuss their relevance for acute therapy. Hematoma growth occurs within 4 h in one third of patients who suffer from intracerebral hemorrhage. Prospective, placebo-controlled, multicenter trials have shown that intravenous application of rFVIIa reduces volume increase. We present preliminary results of the latest phase III trial (FAST: recombinant factor VIIa in acute hemorrhagic stroke), which tried to find whether the hemostatic effect will translate into clinical effect.

[Recommendations of the European Stroke Initiative for the diagnosis and treatment of spontaneous intracerebral haemorrhage]

This article summarises the recommendations for the management of managing patients with intracerebral haemorrhage published in 2006 by the European Stroke Initiative (EUSI) on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

[Secondary prevention of stroke]

Patients suffering a transient ischaemic attack (TIA) or ischaemic stroke (IS) have a high recurrence risk. Secondary prevention aims to prevent not only further strokes but also cardiac events. Important parts of secondary prevention regimens are the modification of vascular risk factors and the inhibition of platelet function or anticoagulation if indicated. The inhibition of platelet function is effective in the reduction of secondary vascular events in patients with TIA or stroke. This is true for acetylsalicylic acid (ASA), clopidogrel, and the combination of ASA plus slow-release dipyridamole. A prediction model which allows to identify patients in whom clopidogrel or dipyridamol plus ASA is superior to ASA for the secondary prevention of stroke is presented.

Sekundärprävention des Schlaganfalls

Patienten nach einer transitorisch-ischämischen Attacke oder einer zerebralen Ischämie sind von einem hohen Wiederholungsrisiko bedroht. Durch sekundärprophylaktische Maßnahmen sollen erneute zerebrale Ischämien, aber auch andere vaskuläre Erkrankungen (z. B. Myokardinfarkt) nach einem stattgehabten Schlaganfall verhindert werden. Wichtigste Bausteine in der Sekundärprävention der zerebralen Ischämie sind die Behandlung von Risikofaktoren, sowie die Einnahme von Thrombozytenfunktionshemmern bzw. Antikoagulation. An Thrombozytenfunktionshemmern stehen Azetylsalizylsäure (ASS), Clopidogrel und die Kombination aus retardiertem Dipyridamol und ASS zur Verfügung. Ein neues Risikomodell, das einen Anhaltspunkt für eine risikostratifizierte Differenzialtherapie liefern kann, wird vorgestellt.

Empfehlungen zur Statintherapie im Alter

Elderly patients are significantly less likely to receive statins than younger patients possibly because of doubts regarding compliance or concerns regarding the increased likelihood of adverse events and drug interactions. Poor compliance can be expected especially in patients suffering from dementia or depression as well as those whose stage of cardiovascular disease exhibits few symptoms. On the other hand, the clinical significance of CHD events is high in the elderly, and 80% of coronary deaths occur in patients aged over 65 years. The average statistical life expectancy of elderly and old patients is often underestimated. The HPS and PROSPER studies showed that statins reduce mortality and morbidity even in very elderly individuals with a high global cardiovascular risk and/or CAD. Patients up to the age of 79 years should be treated according to the same guidelines as younger patients. Statin therapy should only be considered for patients aged 80 years and older who are at a very high risk for cardiovascular events.