1
|
Coelho A, Peixoto J, Mansilha A, Naylor AR, de Borst GJ. Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:3-23. [PMID: 34953681 DOI: 10.1016/j.ejvs.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/05/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). RESULTS Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50). CONCLUSION At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
Collapse
Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Portugal; Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | - João Peixoto
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.
| |
Collapse
|
2
|
SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
Collapse
|
3
|
Zakirzhanov NR, Komarov RN, Khalilov IG. [Carotid endarterectomy in acute period of ischemic stroke]. Khirurgiia (Mosk) 2020:74-78. [PMID: 32105259 DOI: 10.17116/hirurgia202002174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A review is devoted to carotid endarterectomy for symptomatic carotid stenosis in acute period of ischemic stroke. Patient selection criteria, dates of surgical intervention and perioperative risk were analyzed.
Collapse
Affiliation(s)
- N R Zakirzhanov
- Kazan Clinical Hospital No. 7 of the Ministry of Health of the Republic of Tatarstan, Kazan, Russia; Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - R N Komarov
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia; Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - I G Khalilov
- Kazan Clinical Hospital No. 7 of the Ministry of Health of the Republic of Tatarstan, Kazan, Russia
| |
Collapse
|
4
|
Khurana D, Padma MV, Bhatia R, Kaul S, Pandian J, Sylaja PN, Arjundas D, Uppal A, Pradeep VG, Suri V, Nagaraja D, Alurkar A, Narayan S. Recommendations for the Early Management of Acute Ischemic Stroke: A Consensus Statement for Healthcare Professionals from the Indian Stroke Association. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2516608518777935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dheeraj Khurana
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Rohit Bhatia
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Subhash Kaul
- Nizam’s Institute of Medical Sciences (NIMS), Hyderabad, India
| | | | - P. N. Sylaja
- Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India
| | | | | | | | - Vinit Suri
- Indraprastha Apollo Hospital, New Delhi, India
| | - D. Nagaraja
- National Institute of Mental Health & Neuro Sciences (NIMHANS), Hyderabad, India
| | | | - Sunil Narayan
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | | | | |
Collapse
|
5
|
de Donato G, Setacci F, Pasqui E, Benevento D, Palasciano G, Sterpetti A, di Marzo L, Setacci C. Early carotid artery stenting after onset neurologic symptoms. Semin Vasc Surg 2018; 31:15-20. [PMID: 29891028 DOI: 10.1053/j.semvascsurg.2018.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Multicenter clinical trials level 1 evidence favors the application of carotid endarterectomy in symptomatic patients, especially the in the elderly cohort. Carotid artery stenting has been proposed as a possible early alternative in selected patients after onset of ipsilateral neurologic symptoms. It is well known that treatment of acute stroke is time-dependent in patients with acute ischemic stroke caused by high-grade stenosis of the internal carotid artery, but intensive medical treatment in conjunction with intervention to improve stroke severity and clinical outcomes has not been established. Two major clinical concerns exist: (1) the risk of hemorrhagic infarction after cerebral revascularization in the acute stage and (2) application of carotid stenting in the acute embolic stage, which may be associated with continued embolic risk after carotid artery stenting compared to carotid endarterectomy, which removes the symptomatic plaque. This review summarizes the indications and results of early carotid artery stenting after onset of neurologic symptoms, considering the new carotid stents and cerebral protection systems available for clinical use and enhanced stenting techniques.
Collapse
Affiliation(s)
- Gianmarco de Donato
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University of Siena, Viale Bracci, 53100 Siena Siena, Italy.
| | - Francesco Setacci
- Department of Vascular Surgery, Casa di Cura Giovanni XXIII, Monastier di Treviso, Italy
| | - Edoardo Pasqui
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University of Siena, Viale Bracci, 53100 Siena Siena, Italy
| | - Domenico Benevento
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University of Siena, Viale Bracci, 53100 Siena Siena, Italy
| | - Giancarlo Palasciano
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University of Siena, Viale Bracci, 53100 Siena Siena, Italy
| | - Antonio Sterpetti
- Department of Vascular Surgery, University Roma La Sapienza, Rome, Italy
| | - Luca di Marzo
- Department of Vascular Surgery, University Roma La Sapienza, Rome, Italy
| | - Carlo Setacci
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University of Siena, Viale Bracci, 53100 Siena Siena, Italy
| |
Collapse
|
6
|
Peri-procedural Risk with Urgent Carotid Artery Stenting: A Population based Swedvasc Study. Eur J Vasc Endovasc Surg 2015; 49:506-12. [DOI: 10.1016/j.ejvs.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/16/2015] [Indexed: 11/18/2022]
|
7
|
Charmoille E, Brizzi V, Lepidi S, Sassoust G, Roullet S, Ducasse E, Midy D, Bérard X. Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis. Ann Vasc Surg 2015; 29:977-84. [PMID: 25765637 DOI: 10.1016/j.avsg.2015.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients. METHODS All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups. RESULTS During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups. CONCLUSION During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.
Collapse
Affiliation(s)
- Emilie Charmoille
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Vincenzo Brizzi
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France.
| | - Sandro Lepidi
- Vascular Surgery Department, Padova University Hospital, Padova, Italy
| | - Gérard Sassoust
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Stéphanie Roullet
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Eric Ducasse
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Dominique Midy
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| | - Xavier Bérard
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France; Bordeaux University, Bordeaux, France
| |
Collapse
|
8
|
Merlini T, Péret M, Lhommet P, Debiais S, Marc G, Godard S, Martinez R, Enon B, Picquet J. Is Early Surgical Revascularization of Symptomatic Carotid Stenoses Safe? Ann Vasc Surg 2014; 28:1539-47. [DOI: 10.1016/j.avsg.2014.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/27/2014] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
|
9
|
Tsivgoulis G, Krogias C, Georgiadis GS, Mikulik R, Safouris A, Meves SH, Voumvourakis K, Haršány M, Staffa R, Papageorgiou SG, Katsanos AH, Lazaris A, Mumme A, Lazarides M, Vasdekis SN. Safety of early endarterectomy in patients with symptomatic carotid artery stenosis: an international multicenter study. Eur J Neurol 2014; 21:1251-7, e75-6. [DOI: 10.1111/ene.12461] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- G. Tsivgoulis
- Second Department of Neurology; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
- Department of Neurology; Democritus University of Thrace; School of Medicine; Alexandroupolis Greece
- International Clinical Research Center; St Anne's University Hospital in Brno; Brno Czech Republic
| | - C. Krogias
- Department of Neurology; St Josef Hospital; Ruhr University; Bochum Germany
| | - G. S. Georgiadis
- Department of Vascular Surgery; Democritus University of Thrace; School of Medicine; Alexandroupolis Greece
| | - R. Mikulik
- International Clinical Research Center; St Anne's University Hospital in Brno; Brno Czech Republic
- Department of Neurology; St Anne's University Hospital and Medical Faculty of Masaryk University; Brno Czech Republic
| | - A. Safouris
- Stroke Unit; Department of Neurology; Brugmann University Hospital; Brussels Belgium
| | - S. H. Meves
- Department of Neurology; St Josef Hospital; Ruhr University; Bochum Germany
| | - K. Voumvourakis
- Second Department of Neurology; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| | - M. Haršány
- International Clinical Research Center; St Anne's University Hospital in Brno; Brno Czech Republic
- Department of Neurology; St Anne's University Hospital and Medical Faculty of Masaryk University; Brno Czech Republic
| | - R. Staffa
- 2nd Department of Surgery; St Anne's University Hospital, and Faculty of Medicine; Masaryk University; Brno Czech Republic
| | - S. G. Papageorgiou
- Second Department of Neurology; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| | - A. H. Katsanos
- Department of Neurology; University of Ioannina; School of Medicine; Ioannina Greece
| | - A. Lazaris
- Vascular Unit; 3rd Surgical Department; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| | - A. Mumme
- Department of Vascular Surgery; St Josef Hospital; Ruhr University; Bochum Germany
| | - M. Lazarides
- Department of Vascular Surgery; Democritus University of Thrace; School of Medicine; Alexandroupolis Greece
| | - S. N. Vasdekis
- Vascular Unit; 3rd Surgical Department; ‘Attikon’ Hospital; University of Athens; School of Medicine; Athens Greece
| |
Collapse
|
10
|
Naylor AR. Interventions for carotid artery disease: time to confront some ‘inconvenient truths’. Expert Rev Cardiovasc Ther 2014; 5:1053-63. [DOI: 10.1586/14779072.5.6.1053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
11
|
Krylov VV, Luk'ianchikov VA. Cerebral revascularization for the treatment of patients with acute ischemic stroke. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:46-52. [DOI: 10.17116/jnevro201411412246-52] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
12
|
Mono ML, Steiger I, Findling O, Jung S, Reinert M, Galimanis A, Kuhlen D, Beck J, El-Koussy M, Brekenfeld C, Schroth G, Fischer U, Nedeltchev K, Mattle HP, Arnold M. Risk of very early recurrent cerebrovascular events in symptomatic carotid artery stenosis. J Neurosurg 2013; 119:1620-6. [DOI: 10.3171/2013.7.jns122128] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The risk of recurrence of cerebrovascular events within the first 72 hours of admission in patients hospitalized with symptomatic carotid artery (CA) stenoses and the risks and benefits of emergency CA intervention within the first hours after the onset of symptoms are not well known. Therefore, the authors aimed to assess 1) the ipsilateral recurrence rate within 72 hours of admission, in the period from 72 hours to 7 days, and after 7 days in patients presenting with nondisabling stroke, transient ischemic attack (TIA), or amaurosis fugax (AF), and with an ipsilateral symptomatic CA stenosis of 50% or more, and 2) the risk of stroke in CA interventions within 48 hours of admission versus the risk in interventions performed after 48 hours.
Methods
Ninety-four patients were included in this study. These patients were admitted to hospital within 48 hours of a nondisabling stroke, TIA, or AF resulting from a symptomatic CA stenosis of 50% or more. The patients underwent carotid endarterectomy (85 patients) or CA stenting (9 patients). At baseline, the cardiovascular risk factors of the patients, the degree of symptomatic CA stenosis, and the type of secondary preventive treatment were assessed. The in-hospital recurrence rate of stroke, TIA, or AF ipsilateral to the symptomatic CA stenosis was determined for the first 72 hours after admission, from 72 hours to 7 days, and after 7 days. Procedure-related cerebrovascular events were also recorded.
Results
The median time from symptom onset to CA intervention was 5 days (interquartile range 3.00–9.25 days). Twenty-one patients (22.3%) underwent CA intervention within 48 hours after being admitted. Overall, 15 recurrent cerebrovascular events were observed in 12 patients (12.8%) in the period between admission and CA intervention: 3 strokes (2 strokes in progress and 1 stroke) (3.2%), 5 TIAs (5.3%), and 1 AF (1.1%) occurred within the first 72 hours (total 9.6%) of admission; 1 TIA (1.1%) occurred between 72 hours and 7 days, and 5 TIAs (5.3%) occurred after more than 7 days. The corresponding actuarial cerebrovascular recurrence rates were 11.4% (within 72 hours of admission), 2.4% (between 72 hours and 7 days), and 7.9% (after 7 days). Among baseline characteristics, no predictive factors for cerebrovascular recurrence were identified.
Procedure-related cerebrovascular events occurred at a rate of 4.3% (3 strokes and 1 TIA), and procedures performed within the first 48 hours and procedures performed after 48 hours had a similar frequency of these events (4.5% vs 4.1%, respectively; p = 0.896).
Conclusions
The in-hospital recurrence of cerebrovascular events was quite low, but all recurrent strokes occurred within 72 hours. The risk of stroke associated with a CA intervention performed within the first 48 hours was not increased compared with that for later interventions. This raises the question of the optimal timing of CA intervention in symptomatic CA stenosis. To answer this question, more data are needed, preferably from large randomized trials.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dominique Kuhlen
- 5Department of Neurosurgery, Klinikum Rechts der Isar, Technical University Munich, Germany
| | | | - Marwan El-Koussy
- 3Neuroradiology, Inselspital, University Hospital Bern, Switzerland
| | - Caspar Brekenfeld
- 4Department of Neuroradiology, University Hospital Eppendorf, Hamburg; and
| | - Gerhard Schroth
- 3Neuroradiology, Inselspital, University Hospital Bern, Switzerland
| | | | | | | | | |
Collapse
|
13
|
Kaźmierski P, Stelągowski M, Kasielska-Trojan A, Bogusiak K, Glabinski A. Neurologic and functional long-term outcome after carotid endarterectomy. J Stroke Cerebrovasc Dis 2013; 23:686-93. [PMID: 23850085 DOI: 10.1016/j.jstrokecerebrovasdis.2013.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/30/2013] [Accepted: 06/08/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of this research was to assess the neurologic status of patients a year after endarterectomy with the use of National Institutes of Health Stroke Scale (NIHSS) and the degree of disability using the modified Rankin Scale (mRS) and to examine the patients' subjective evaluation of their health. METHODS One hundred two patients with symptomatic internal carotid artery stenosis who underwent endarterectomy and attended a 1-year follow-up examination were enrolled in the study. The material comprised 72 (70.6%) men and 30 (29.4%) women. Before the surgery, the patients' neurologic status was assessed according to the NIHSS, and their functional status was rated with the mRS. Additionally, the patients were asked to assess their life quality on a 10-point Likert scale. RESULTS The mean NIHSS score before the operation was 2.76 points (SD 2.47), whereas a year after it was 2.05 points (SD 1.84) (P < .0001). The NIHSS scores that improved significantly a year after endarterectomy were level of consciousness-questions and commands, motor leg, and sensory (P < .05). CONCLUSIONS The patients' neurologic status assessed with the NIHSS improved significantly 1 year after carotid endarterectomy mostly because of the improvement in their verbal and motor communication ability, physical condition and agility, and reduction in sensory disturbances. The observed changes in the neurologic status were reflected in the functional status and subjective life quality assessment, which appeared to be significantly better a year after the surgical treatment.
Collapse
Affiliation(s)
- Piotr Kaźmierski
- Department of Vascular, General, and Oncologic Surgery, Memorial Copernicus Hospital, Lodz, Poland.
| | - Mirosław Stelągowski
- Department of Vascular, General, and Oncologic Surgery, Memorial Copernicus Hospital, Lodz, Poland
| | - Anna Kasielska-Trojan
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Bogusiak
- Department of Cranio-Maxillofacial and Oncological Surgery, Medical University of Lodz, Lodz, Poland
| | - Andrzej Glabinski
- Department of Neurology, Epileptology, and Stroke, Medical University of Lodz, Lodz, Poland
| |
Collapse
|
14
|
Bruls S, Desfontaines P, Defraigne JO, Sakalihasan N. Urgent Carotid Endarterectomy in Patients with Acute Neurological Symptoms: The Results of a Single Center Prospective Nonrandomized Study. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2013; 1:110-6. [PMID: 26798682 DOI: 10.12945/j.aorta.2013.13-008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 05/10/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND To evaluate the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients with carotid stenosis presenting with repetitive transient ischemic attacks or progressing stroke. METHODS Thirty consecutive patients underwent urgent carotid endarterectomy for repetitive transient ischemic attacks (N = 12) or progressing stroke (N = 18) according to the following criteria: two or more transient ischemic attacks or a fluctuating neurological deficit over a period of less than 24 hours (progressing stroke), no impairment of consciousness, no cerebral infarct larger than 1.5 cm in diameter on computed tomography and a carotid artery stenosis of 70% or more on the appropriate side, diagnosed by echodoppler ultrasonography and/or arteriography. Patients with cerebral hemorrhage were excluded. All patients were examined pre- and postoperatively by the same neurologist and surgery was performed by the same vascular surgeon. All the patients underwent a cerebral CT scan within 5 days after surgery. RESULTS There were 19 men and 11 women. The mean age was 71 ± 7.6 years. The time delay of surgery after the onset of transient ischemic attacks or progressing stroke averaged 19.4 ± 11.5 hours. For patients suffering progressive stroke, one developed a fatal ischemic stroke 24 hours after surgery, five showed no improvement of their neurological status after surgery, but none worsened. Twelve patients experienced significant improvement of their neurological status with an European Stroke Scale of 77.9 ± 25.2 at admission and 95.8 ± 4.6 at discharge, and all but one of those patients had a Barthel's index value over 85/100 at discharge. The 12 patients with repetitive transient ischemic attacks had an uneventful postoperative outcome. The mean duration of follow-up was 3.4 ± 1.2 years. No patient developed another transient ischemic attack or ischemic stroke during the follow-up period. CONCLUSIONS The results of our series documented the feasibility and the safety of performing urgent (within 24 hours) carotid endarterectomy in patients presenting with repetitive transient ischemic attacks or progressing stroke. This procedure seems to us to be justified by the fact that waiting for surgery may lead to the development of a more profound deficit or another stroke in these neurologically unstable patients whose only chance for neurological recovery is in the early phase.
Collapse
Affiliation(s)
- Samuel Bruls
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liege, Liege, Belgium
| | | | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liege, Liege, Belgium
| | | |
Collapse
|
15
|
Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3203] [Impact Index Per Article: 291.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
Collapse
|
16
|
Di Legge S, Koch G, Diomedi M, Stanzione P, Sallustio F. Stroke prevention: managing modifiable risk factors. Stroke Res Treat 2012; 2012:391538. [PMID: 23213626 PMCID: PMC3504482 DOI: 10.1155/2012/391538] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/08/2012] [Indexed: 12/12/2022] Open
Abstract
Prevention plays a crucial role in counteracting morbidity and mortality related to ischemic stroke. It has been estimated that 50% of stroke are preventable through control of modifiable risk factors and lifestyle changes. Antihypertensive treatment is recommended for both prevention of recurrent stroke and other vascular events. The use of antiplatelets and statins has been shown to reduce the risk of recurrent stroke and other vascular events. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are indicated in stroke prevention because they also promote vascular health. Effective secondary-prevention strategies for selected patients include carotid revascularization for high-grade carotid stenosis and vitamin K antagonist treatment for atrial fibrillation. The results of recent clinical trials investigating new anticoagulants (factor Xa inhibitors and direct thrombin inhibitors) clearly indicate alternative strategies in stroke prevention for patients with atrial fibrillation. This paper describes the current landscape and developments in stroke prevention with special reference to medical treatment in secondary prevention of ischemic stroke.
Collapse
Affiliation(s)
- Silvia Di Legge
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Giacomo Koch
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Paolo Stanzione
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| | - Fabrizio Sallustio
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| |
Collapse
|
17
|
Setacci C, Sirignano P, Galzerano G, Setacci F. Urgent CAS: a revolution in the treatment of symptomatic patients in the hyperacute phase. J Endovasc Ther 2012; 19:636-7. [PMID: 23046329 DOI: 10.1583/jevt-12-3852c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Surgery, University of Siena, Italy.
| | | | | | | |
Collapse
|
18
|
Battocchio C, Fantozzi C, Rizzo L, Persiani F, Raffa S, Taurino M. Urgent Carotid Surgery: Is It Still out of Debate? Int J Vasc Med 2012; 2012:536392. [PMID: 22506117 PMCID: PMC3317123 DOI: 10.1155/2012/536392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/08/2012] [Accepted: 01/09/2012] [Indexed: 11/17/2022] Open
Abstract
Patients with symptomatic tight carotid stenosis have an increased short-time risk of stroke and an increased long-term risk of ischaemic vascular events compared with the general population. The aim of this study is to assess the safety, efficacy, and limitations of urgent CEA or CAS, in patients with carotid stenosis greater than 70% and clinically characterized by recurrent TIA or brain damage following a stroke (<2.5 cm). This study involved 28 patients divided into two groups. Group A consisted of sixteen patients who had undergone CEA, and group B consisted of twelve patients who had undergone CAS. Primary endpoints were mortality, neurological morbidity (by NIHSS) and postoperative hemorrhagic cerebral conversion, at 30 days. Ten patients (62.5%) of group A experienced an improvement in their initial neurological deficit while in 4 cases (26%) the deficit remained stable. Two cases of neurologic mortality are presented. At 1 month, 9 patients (75%) of group B experienced an improvement in their initial neurological deficit while 3 patients (25%) had a neurological impairment. Urgent or deferred surgical or endovascular treatment have a satisfactory outcome considering the profile in very high-risk patient population. Otherwise in selected patients CEA seems to be preferred to CAS.
Collapse
Affiliation(s)
| | | | | | - F. Persiani
- Azienda Ospedaliera Sant'Andrea, Facoltà di Medicina e Psicologia, Sapienza-Università di Roma, 00189 Roma, Italy
| | | | | |
Collapse
|
19
|
Strömberg S, Gelin J, Osterberg T, Bergström GML, Karlström L, Osterberg K. Very urgent carotid endarterectomy confers increased procedural risk. Stroke 2012; 43:1331-5. [PMID: 22426315 DOI: 10.1161/strokeaha.111.639344] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Current Swedish guidelines recommend that carotid endarterectomy should be performed within 14 days of a qualifying neurological event, but it is not clear if very urgent surgery after an event is associated with increased perioperative risk. The aim of this study was to determine how the time between the event and carotid endarterectomy affects the procedural risk of mortality and stroke. METHODS We prospectively analyzed data on all patients who underwent carotid endarterectomies for symptomatic carotid stenosis between May 12, 2008, and May 31, 2011, with records in the Swedish Vascular Registry (Swedvasc). Patients were divided according to time between the qualifying event and surgery (0-2 days, 3-7 days, 8-14 days, 15-180 days). Stroke rate and mortality at 30 days postsurgery were determined. RESULTS We analyzed data for 2596 patients and found that the combined mortality and stroke rate for patients treated 0 to 2 days after qualifying event was 11.5% (17 of 148) versus 3.6% (29 of 804), 4.0% (27 of 677), and 5.4% (52 of 967) for the groups treated at 3 to 7 days, 8 to 14 days, and 15 to 180 days, respectively. In a multivariate analysis, time was an independent risk factor for perioperative complications: patients treated at 0 to 2 days had a relative OR of 4.24 (CI, 2.07-8.70; P<0.001) compared with the reference 3- to 7-day group. CONCLUSIONS In this study of patients treated for symptomatic carotid disease, it was safe to perform surgery as early as Day 3 after a qualifying neurological event in contrast to patients treated within 0 to 2 days, which has a significantly increased perioperative risk.
Collapse
Affiliation(s)
- Sofia Strömberg
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | | | | | | | | | | | | |
Collapse
|
20
|
Lanza G, Ricci S, Speziale F, Toni D, Sbarigia E, Setacci C, Pratesi C, Somalvico F, Zaninelli A, Gensini GF. SPREAD-STACI Study: A Protocol for a Randomized Multicenter Clinical Trial Comparing Urgent with Delayed Endarterectomy in Symptomatic Carotid Artery Stenosis. Int J Stroke 2011; 7:81-5. [DOI: 10.1111/j.1747-4949.2011.00699.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Rationale In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure. Aims Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions. Design Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups: urgent carotid endarterectomy (within 48 hours) and delayed carotid endarterectomy (operated between 48 hours and 15 days after onset of symptoms) Risk factors will be evaluated at enrollment. TIA will be classified by ABCD2 scoring system, and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores. The study will last 90 days per patient, starting from their initial symptom, and the follow-up will be performed by an indipendent neurologist. A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups. Outcomes Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones. Secondary end-points are: Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups.
Collapse
Affiliation(s)
- Gaetano Lanza
- Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy
| | - Stefano Ricci
- Department of Neurology, ASL 1 Citta’ di Castello and Branca, Italy
| | - Francesco Speziale
- Vascular Surgery Department, Policlinico Umberto I, ‘La Sapienza’ University, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, La Sapienza University, Rome, Italy
| | - Enrico Sbarigia
- Vascular Surgery Department, Policlinico Umberto I, ‘La Sapienza’ University, Rome, Italy
| | - Carlo Setacci
- Vascular Endovascular Surgery Unit, Department of Surgery, University of Siena, Italy
| | - Carlo Pratesi
- Vascular Surgery Unit, University of Florence, Italy
| | - Francesco Somalvico
- Biostatistics Service, IRCCS Multimedica Hospital, Sesto San Giovanni, Italy
| | | | | |
Collapse
|
21
|
Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011; 54:e1-31. [PMID: 21889701 DOI: 10.1016/j.jvs.2011.07.031] [Citation(s) in RCA: 439] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 06/21/2011] [Accepted: 07/12/2011] [Indexed: 11/30/2022]
Affiliation(s)
- John J Ricotta
- Washington Hospital Center, Georgetown University School of Medicine, Washington, DC 20010, USA.
| | | | | | | | | | | |
Collapse
|
22
|
Salem M, Sayers R, Bown M, Eveson D, Robinson T, Naylor A. Rapid Access Carotid Endarterectomy can be Performed in the Hyperacute Period without a Significant Increase in Procedural Risks. Eur J Vasc Endovasc Surg 2011; 41:222-8. [DOI: 10.1016/j.ejvs.2010.10.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 10/27/2010] [Indexed: 11/30/2022]
|
23
|
Capoccia L, Sbarigia E, Speziale F, Toni D, Fiorani P. Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events. J Vasc Surg 2010; 53:622-7; discussion 627-8. [PMID: 21129904 DOI: 10.1016/j.jvs.2010.09.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 08/27/2010] [Accepted: 09/02/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event. METHODS The study involved patients with acute neurologic impairment, defined as ≥ 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis ≥ 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation ≥ 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or ≥ 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging. RESULTS Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 ± 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 ± 3.41 on admission and 3.11 ± 3.62 at discharge in the entire group (P < .01). Patients with an NIHSS score of ≥ 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 ± 1.03 preoperatively vs 1.31 ± 1.7 postoperatively, NIHSS ≥ 8 10.32 ± 1.94 vs 4.03 ± 3.67; P < .001). CONCLUSIONS In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis ≤ 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome.
Collapse
MESH Headings
- Aged
- Aged, 80 and over
- Carotid Stenosis/complications
- Carotid Stenosis/diagnosis
- Carotid Stenosis/mortality
- Carotid Stenosis/surgery
- Cerebral Angiography/methods
- Chi-Square Distribution
- Disability Evaluation
- Endarterectomy, Carotid/adverse effects
- Endarterectomy, Carotid/mortality
- Female
- Humans
- Ischemic Attack, Transient/diagnosis
- Ischemic Attack, Transient/etiology
- Ischemic Attack, Transient/mortality
- Ischemic Attack, Transient/prevention & control
- Italy
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Neurologic Examination
- Patient Selection
- Practice Guidelines as Topic
- Prospective Studies
- Risk Assessment
- Risk Factors
- Secondary Prevention
- Severity of Illness Index
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Ultrasonography, Doppler, Duplex
- Ultrasonography, Doppler, Transcranial
Collapse
Affiliation(s)
- Laura Capoccia
- Vascular Surgery Division, Department of Surgery Paride Stefanini, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
| | | | | | | | | |
Collapse
|
24
|
Setacci C, de Donato G, Chisci E, Setacci F. Carotid artery stenting in recently symptomatic patients: a single center experience. Ann Vasc Surg 2009; 24:474-9. [PMID: 19892518 DOI: 10.1016/j.avsg.2009.07.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Revised: 05/03/2009] [Accepted: 07/27/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND The effective and early management of patients with acute symptoms due to carotid stenosis remains the subject of debate. The inability to predict who is at higher early risk of a recurrent stroke after a cerebrovascular event (transient ischemic attack [TIA] or stroke) may explain the variation in management of acute strokes from physician to physician and institution to institution. The aim of this study is to evaluate the clinical outcome of recently symptomatic patients with carotid stenosis treated with urgent or deferred carotid artery stenting (CAS) on the basis of a preidentified protocol in a single center. METHODS From January 2006 to October 2008, 43 patients with symptomatic carotid stenosis greater than 70% underwent urgent or deferred CAS (26 TIA, 17 minor stroke). The exclusion criteria were major stroke, cerebral ischemic lesion greater than 2.5 cm as documented by a computed tomography scan, loss of consciousness, and signs of intracranial hemorrhage. Patients who had a TIA underwent urgent CAS within 24 hours of the cerebral event, while patients who had had a minor stroke underwent deferred CAS, performed within a short space of time from the event (treatment within 1 to 30 days from the onset of symptoms, according to the stabilization of cerebral symptoms: mean time, 6.5 days; range, 2 to 28 days). RESULTS Successful stent implantation was achieved in all cases (100%), respecting the use of a cerebral protection device (filter device: 76%, proximal occlusion device: 24%). The new adverse events in the TIA patients at 1 month were 1 non-neurological death (3.8%) and 1 TIA (3.8%). In the minor stroke group, at 1 month, 10 of 17 patients (58.8%) experienced an improvement in their initial neurological deficit (decrease in National Institutes of Health Stroke Scale less than 2), while in 35.3% of patients (6 of 17), the deficit remained stable, and only one patient had a neurological impairment. CONCLUSION Our study demonstrated that early treatment with protected carotid stenting is both feasible and safe in selected patients with first episode or recurrent TIA or minor stroke. This preliminary study in a limited series of patients revealed that an urgent endovascular approach is associated with a satisfactory outcome considering the very high-risk profile of the patient population.
Collapse
Affiliation(s)
- Carlo Setacci
- Department of Surgery, Vascular and Endovascular Surgery Unit, University of Siena, 53100 Siena, Italy.
| | | | | | | |
Collapse
|
25
|
Rerkasem K, Rothwell PM. Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery. Stroke 2009; 40:e564-72. [PMID: 19661467 DOI: 10.1161/strokeaha.109.558528] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke.
Methods—
We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel–Haenszel meta-analysis.
Results—
Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus ≥1 week, OR=1.2, 0.9 to 1.7,
P
=0.17; <2 weeks versus ≥2 weeks, OR=1.2, 0.9 to 1.6,
P
=0.13).
Conclusions—
Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.
Collapse
Affiliation(s)
- Kittipan Rerkasem
- From the Vascular Surgery Division, Department of Surgery, Faculty of Medicine (K.R.), Chiang Mai University, Chiang Mai, Thailand; and the Stroke Prevention Research Unit, University Department of Clinical Neurology (P.M.R.), John Radcliffe Hospital, Oxford, UK
| | - Peter M. Rothwell
- From the Vascular Surgery Division, Department of Surgery, Faculty of Medicine (K.R.), Chiang Mai University, Chiang Mai, Thailand; and the Stroke Prevention Research Unit, University Department of Clinical Neurology (P.M.R.), John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
26
|
Naylor AR. Occam's razor: Intervene early to prevent more strokes! J Vasc Surg 2008; 48:1053-9. [DOI: 10.1016/j.jvs.2008.06.044] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 06/16/2008] [Accepted: 06/17/2008] [Indexed: 11/16/2022]
|
27
|
Setacci C, de Donato G. Is early carotid stenting indicated in patients with recent neurological events? Eur J Vasc Endovasc Surg 2008; 36:251-2. [PMID: 18617427 DOI: 10.1016/j.ejvs.2008.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 06/09/2008] [Indexed: 11/29/2022]
|
28
|
Setacci C, de Donato G, Chisci E, Setacci F, Stella A, Faggioli G, Reimers B, Cernetti C, Lopera Quijada M, Cappi B, Sangiorgi G. Deferred Urgency Carotid Artery Stenting in Symptomatic Patients: Clinical Lessons and Biomarker Patterns from a Prospective Registry. Eur J Vasc Endovasc Surg 2008; 35:644-51. [DOI: 10.1016/j.ejvs.2008.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 02/17/2008] [Indexed: 11/28/2022]
|
29
|
Naylor A. Delay May Reduce Procedural Risk, But at What Price to the Patient? Eur J Vasc Endovasc Surg 2008; 35:383-91. [DOI: 10.1016/j.ejvs.2008.01.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 01/09/2008] [Indexed: 11/24/2022]
|