Why is the management of asymptomatic carotid disease so controversial?

[Stent angioplasty for internal carotid artery stenosis]

BACKGROUND

Stent angioplasty of carotid stenosis has become established as a safe and efficient treatment method alongside carotid endarterectomy due to developments in stent design and refinement of interventional techniques. Today, the protocol for stent angioplasty is largely standardized.

OBJECTIVE

The aim of this article is to provide sound insight into the development and current practice of stent angioplasty. Particular attention is paid to technical implementation and periprocedural management.

Risk factors of in-stent restenosis after carotid angioplasty and stenting: long-term follow-up study

Background

After carotid artery angioplasty with stenting (CAS), it is unclear which risk factors are related to long-term outcomes, including in-stent restenosis (ISR). This study aimed to assess the factors associated with restenosis after CAS with a median follow-up of 35.7 months.

Materials and methods

Patients who underwent CAS from January 2013 to December 2018 were included if they had symptomatic or asymptomatic carotid artery stenosis. The carotid Doppler ultrasonography (CDU) was followed up after the procedure. We defined at least 50% restenosis using the criteria that the internal carotid artery (ICA) peak systolic velocity (PSV) was greater than 224 cm/s or the ICA to common carotid artery PSV ratio was higher than 3.4. The risk factors for ISR were also assessed.

Results

Of the 189 patients, 122 had symptomatic carotid artery stenosis, and 67 had asymptomatic carotid artery stenosis. Patients were evaluated by CDU for a median of 35.7 months (interquartile range 19.5 to 70.0). Kaplan-Meier analysis showed that the longest time to ISR was 39 months, and ISR-free was better in the asymptomatic CAS group. In all groups, ISR was independently associated with current smoker [adjusted odds ratio (aOR), 3.425; 95% confidence interval (CI), 1.086 to 10.801] and elevated ICA PSV at baseline (aOR, 1.004; 95% CI, 1.001 to 1.007).

Conclusion

Independent risk factors for ISR in the CAS group included current smoking and elevated ICA PSV at baseline. In the symptomatic CAS group, alcohol was independently associated with the ISR. ISR did not occur after 39 months from the CAS procedure in our study patients. Future studies with extended follow-up are necessary to fully understand the long-term outcomes of CAS.

Treatment Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Bayesian Network Meta-Analysis

BACKGROUND AND OBJECTIVES

To compare the safety and efficacy of carotid endarterectomy (CEA), carotid stenting (CAS), and optimal medical therapy (OMT) in patients with asymptomatic carotid stenosis.

METHODS

Relevant randomized controlled trials were researched with PubMed, Web of Science, and the Cochrane Library databases. Fixed-effects model and random-effects model were used to estimate the relative risks and the hazard ratios (HRs). The results of the probabilistic analysis were reported as surfaces under the cumulative ranking curve.

RESULTS

Eight randomized controlled trials were included. Data from 10 348 patients (CEA: n = 4758; CAS: n = 3919; OMT: n = 1673) were evaluated. Compared with the previous OMT, CEA, CAS, and the current OMT (c-OMT) were all effective in reducing the risk of stroke (CEA: HR, 0.52; CI, 0.40-0.66; CAS: HR, 0.58; CI, 0.42-0.81; c-OMT: HR, 0.40; CI, 0.15-0.94); CEA and CAS reduced the risk of ipsilateral stroke (CEA: HR, 0.41; CI, 0.28-0.59; CAS: HR, 0.51; CI, 0.31-0.84), and the risk of fatal or disabling stroke (CEA: HR, 0.59; CI, 0.43-0.81; CAS: HR, 0.57; CI, 0.34-0.95). Regarding reducing the risk of stroke, only CEA was statistically significant in patients with any degree of stenosis compared with the previous medical treatment (<80%: HR, 0.48; CI, 0.33%-0.70%; 80%-99%: HR, 0.53; CI, 0.38-0.73).

CONCLUSION

In the treatment of asymptomatic carotid stenosis, the perioperative outcomes of CAS were similar to that of CEA; CEA, CAS, and c-OMT shared similar long-term outcomes; and CEA and CAS may be more effective in patients with high levels of asymptomatic stenosis.

Cost-Effectiveness of Screening Asymptomatic Carotid Stenosis by Atherosclerotic Cardiovascular Risk

Importance

Extracranial internal carotid artery stenosis (50-99% arterial narrowing) is an important risk factor for ischemic stroke. Yet, the benefits and harms of targeted screening for asymptomatic carotid artery stenosis (ACAS) have not been assessed in population-based studies.

Objective

To estimate the cost-effectiveness of one-time, targeted ACAS screening stratified by atherosclerotic cardiovascular disease (ASCVD) risk using the American Heart Association's Pooled Cohort Equations.

Design Setting and Participants

We developed a lifetime microsimulation model of ACAS and stroke for a hypothetical cohort representative of US adults aged 50-80 years without stroke history. We used the Cardiovascular Health Study to estimate the probability and severity of ACAS based on individual characteristics (e.g., age, sex, smoking status, blood pressure, and cholesterol). Stroke risks were functions of these characteristics and ACAS severity. In the model, individuals testing positive for >70% stenosis with Duplex ultrasound and a confirmatory diagnostic test undergo revascularization, which may reduce the risk of stroke but also introduces complication risks. Diagnostic performance parameters, revascularization benefits and risks, utility weights, and costs were estimated from published sources. Cost-effectiveness was assessed from the health care sector perspective using a $100,000/quality-adjusted life year (QALY) threshold.

Main Outcomes and Measures

Estimated stroke events prevented, lifetime costs, QALYs, and incremental cost-effectiveness ratios (ICERs) associated with ACAS screening. Costs (2023 USD) and QALYs were discounted at 3% annually.

Results

We found that screening individuals with a 10-year ASCVD risk >30% was the most cost-effective strategy, with an ICER of $89,000/QALY. This strategy would make approximately 11.9% of the population eligible for screening, averting an estimated 24,084 strokes. Results were sensitive to variations in the efficacy and complication risk of revascularization. In probabilistic sensitivity analysis, screening those in lower ASCVD risk groups (0-20%) only had a 0.6% chance of being cost-effective.

Conclusion and Relevance

A one-time screening may only be cost-effective for adults at a relatively high ASCVD risk. Our findings provide a framework that can be adapted as future clinical trial data continue to improve our understanding of the role of revascularization and intensive medical therapy in contemporary stroke prevention secondary to carotid disease.

Evaluation of Turbulence Index and Flow Pattern for Atherosclerotic Carotid Stenosis: A High-Frame-Rate Vector Flow Imaging Study

OBJECTIVE

The emerging high-frame-rate vector flow imaging provides a new way of hemodynamic evaluation for complex blood flow. This study was aimed at exploring quantitatively the characteristics of complex flow with turbulence (Tur) index and analyzing flow patterns in atherosclerotic internal carotid artery stenosis (ICAS) using high-frame-rate vector flow imaging.

METHODS

This study prospectively included 60 patients with ICAS. Tur values in different segments of stenosis and cardiac phases were compared. Spearman correlation analysis was performed between clinical plaque characteristics with turbulence grading by ln(Tur). Three complex flow patterns were qualitatively drawn on vector flow mode, and the rates of detection of flow patterns in different stenosis groups and ulceration groups were compared.

RESULTS

Highly disordered blood flow was observed in the stenotic (Tur [M, QR] = 12.5%, 21.5%) and distal segment (15.4%, 27.2%), particularly during systole (21.0%, 30.7%, 33.3%, 38.7%, p < 0.05). Spearman correlation analysis revealed that stenosis rate was correlated with turbulence grading in the stenotic (ρ = 0.65, p < 0.05) and distal segment (ρ = 0.79, p < 0.05), and ulcer formation was correlated with turbulence grading in the stenotic segment (ρ = 0.58, p < 0.05). The overall rate of detection of three flow patterns was higher in the severe stenosis group (22/22) versus the mild to moderate stenosis group (21/38) (p < 0.001) and in the ulcer group (21/23) versus the non-ulcer group (23/37) (p < 0.001).

CONCLUSION

High-frame-rate vector flow imaging was helpful in assessing the severity and characteristics of flow turbulence. Lumen geometric factors could affect flow turbulence and blood flow patterns around the plaque. This would provide important hemodynamic information for the detection of high-risk plaque.

Similar long-term outcomes for venous, bovine pericardial, and polyester patches for primary carotid endarterectomy

BACKGROUND

Currently, the type of patch used for carotid endarterectomy closure depends on the preference of the operating surgeon. Various materials are available, including autologous venous patches, bovine pericardial patches (BPP), and synthetic patches. The purpose of this study was to compare the long-term outcomes.

METHODS

All patients who underwent primary carotid endarterectomy with patch angioplasty using a venous, bovine, or polyester patch between 2010 and 2020 at two high-volume medical centers were included in this retrospective analysis on largely prospectively collected data. Study endpoints included long-term ipsilateral transient ischemic attack or cerebrovascular accident, restenosis, reintervention, and all-cause mortality. Cox proportional hazard models were fitted to assess the effect of patch type to each outcome.

RESULTS

In total, 1481 CEAs were performed with a follow-up of 32 (13-65) months. Venous patch was used in 309 patients (20.9%), BPP in 1000 patients (67.5%), and polyester patch in 172 patients (11.6%). A preoperative symptomatic carotid artery stenosis of >50% was observed in 91.9% (n = 284) of the patients who received a venous patch, 92.1% (n = 921) of the patients who received BPP, and 90.7% (n = 156) of the patients who received a polyester patch (p = 0.799). Only in selected patients with an asymptomatic stenosis of >70% surgery was considered. Multivariable analyses showed no significant differences between the three patch types regarding long-term outcomes after adjusting for confounders.

CONCLUSIONS

In patients undergoing primary carotid endarterectomy, the use of venous, bovine pericardial, or polyester patches seems equally safe and durable in terms of comparability in long-term outcomes.

Short term outcomes of carotid surgery: the real-world experience of a single teaching center

Background

Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings.

Objectives

To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center.

Methods

Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded.

Results

A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes.

Conclusions

The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.

Serum from Stroke Patients with High-Grade Carotid Stenosis Promotes Cyclooxygenase-Dependent Endothelial Dysfunction in Non-ischemic Mice Carotid Arteries

Atherosclerosis is responsible for 20% of ischemic strokes, and severe carotid stenosis is associated with a higher incidence of first-ever and recurrent strokes. The release of pro-inflammatory mediators into the blood in severe atherosclerosis may aggravate endothelial dysfunction after stroke contributing to impair disease outcomes. We hypothesize that environments of severe carotid atherosclerotic disease worsen endothelial dysfunction in stroke linked to enhanced risk of further cerebrovascular events. We mounted nonischemic common carotid arteries from 2- to 4-month-old male Oncins France 1 mice in tissue baths for isometric contraction force measurements and exposed them to serum from men with a recent ischemic stroke and different degrees of carotid stenosis: low- or moderate-grade stenosis (LMGS; < 70%) and high-grade stenosis (HGS; ≥ 70%). The results show that serum from stroke patients induced an impairment of acetylcholine relaxations in mice carotid arteries indicative of endothelium dysfunction. This effect was more pronounced after incubation with serum from patients with a recurrent stroke or vascular death within 1 year of follow-up. When patients were stratified according to the degree of stenosis, serum from HGS patients induced more pronounced carotid artery endothelial dysfunction, an effect that was associated with enhanced circulating levels of IL-1β. Mechanistically, endothelial dysfunction was prevented by both nonselective and selective COX blockade. Altogether, the present findings add knowledge on the understanding of the mechanisms involved in the increased risk of stroke in atherosclerosis and suggest that targeting COX in the carotid artery wall may represent a potential novel therapeutic strategy for secondary stroke prevention.

Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting

BACKGROUND/AIMS

Data are limited on the frequency of 'consensus decisions' between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM 'adherence' to such advice.

METHODS

This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom 'consensus management decisions' were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), 'indeterminate symptomatic status stenosis' (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / - intervention.

RESULTS

One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50-99% SCS patients was 12.5 days (IQR: 9-18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1-7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up.

CONCLUSIONS

The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.

Heavy macrophage infiltration identified by optical coherence tomography relates to plaque rupture

OBJECTIVE

Risk stratification plays a critical role in patients with asymptomatic carotid atherosclerotic stenosis. Heavy macrophage infiltration (HMC) is an important factor of plaque destabilization. However, in vivo imaging technologies and screening criteria for HMC remain limited. We aimed to (i) introduce algorithms for in vivo detection of macrophage infiltrations using optical coherence tomography (OCT) and (ii) to investigate the threshold of HMC and its association with plaque vulnerability.

METHODS

Ex vivo OCT images were co-registered with histopathology in 282 cross-sectional pairs from 19 carotid endarterectomy specimens. Of these, 197 randomly selected pairs were employed to define the parameters, and the remaining 85 pairs were used to evaluate the accuracy of the OCT-based algorithm in detecting macrophage infiltrations. Clinical analysis included 93 patients receiving carotid OCT evaluation. The prevalence and burden of macrophage infiltration were analyzed. Multivariable and subgroup analysis were performed to investigate the association between HMC and plaque rupture.

RESULTS

The sensitivity and specificity of algorithm for detecting macrophage infiltration were 88.0% and 74.9%, respectively. Of 93 clinical patients, ruptured plaques exhibited higher prevalence of macrophage infiltration than nonruptured plaques (83.7% [36/43] vs 32.0% [16/50], p < 0.001). HMC was identified when the macrophage index was greater than 60.2 (sensitivity = 74.4%, specificity = 84.0%). Multivariable analysis showed that HMC and multiple calcification were independent risk factors for non-lipid-rich plaque rupture.

INTERPRETATION

This study provides a novel approach and screening criteria for HMC, which might be valuable for atherosclerotic risk stratification.

12-Month Outcomes of Carotid Artery Stenting With CGuard MicroNET-Covered Stent: A Single-Center Study in 113 Patients

Dual layer mesh stents constitute a novel treatment option for patients who undergo carotid artery stenting (CAS). The aim of this prospective study is to report 12 month outcomes of patients who underwent CAS with CGuard (Inspire MD, Tel Aviv, Israel) microNET self-expanding stent with embolic protection system in a tertiary center from October 2018 to March 2022. Primary endpoints included in-stent restenosis >70% verified by ultrasound (DUS), ipsilateral transient ischemic attack (TIA), and stroke at 12 months. Secondary endpoints included cardiovascular-related mortality (stroke, myocardial infarction, heart failure) and all-cause mortality during follow-up. One hundred thirteen patients were included in the study (male 72.5%), symptomatic 47.8%. Median follow-up was 25 months (2-48). By 12 months, there was one in-stent occlusion that manifested as stroke (1/113, 0.8%) but no other forms of in-stent restenosis. Two patients experienced contralateral TIA (1.7%). CVRM was 3.5% (4 MI) and all-cause mortality was 6% at follow-up. This prospective study shows that CAS with CGuard MicroNET-covered stent is safe with minimal neurological adverse events at 12 months follow-up. Larger, and longer-term studies are necessary to define CGuard long-term safety and protection against carotid-related stroke.

Best Medical Treatment in Patients with Asymptomatic Carotid Stenosis: Myth or Reality?

BACKGROUND

Approximately 1.4 million strokes/year causing about 1.1 million deaths annually occur in Europe and 10%-15% of those strokes are result of thromboembolism from a previously significant asymptomatic carotid stenosis (ACS). Medical treatment has improved considerably in the last 15 years; however, its success depends on patient compliance. The aim of our study was to evaluate, in patients with ACS, the implementation and patient adherence to best medical treatment (BMT). Additionally, we sought to determine the "real-world" incidence of cerebrovascular/coronary events in a cohort of nonoperated ACS patients and weighing this risk against surgical complications in patients with ACS undergoing surgical treatment at our Department.

METHODS

Patients with ACS ≥ 60% identified by a carotid ultrasound performed at our Department were retrospectively evaluated. Patients selected to BMT were excluded if the follow-up period was inferior to 2 years, as well as patients lost in follow-up, with missing clinical information and submitted to carotid stenting. Patients' data collection was supported by hospital reporting system and data were introduced into a database created for the purpose. Statistical analysis was performed using SPSS-25 software.

RESULTS

After exclusion criteria were applied, the last 120 consecutive patients (60 with ACS submitted do carotid endarterectomy and 60 with ACS under BMT) were retrospectively evaluated. Twenty one patients had ipsilateral events for more than 6 months. Most patients had hypertension (n = 107; 89%), dyslipidemia (n = 101; 84%), 40% had diabetes, 33% diagnosed coronary disease, 32% were overweight or obese, and 17% were current smokers. Blood pressure control, normal weight, statin with/without ezetimibe association, and antiaggregant therapy were only achieved in 33 patients and only 5 had additionally low-density lipoprotein levels < 70 mg/dL, hemoglobin A1c < 7%, and were nonsmokers. Of the 60 patients assigned to medical treatment, 3 (5%) had a stroke at 2 years of follow-up, which was fatal in 1 patient. Among patients submitted to carotid endarterectomy, perioperative stroke was documented in 3% of the patients, none of them disabling or fatal.

CONCLUSIONS

Although some recent studies report a risk of ipsilateral stroke of only 0.34% per year in patients with ACS ≥ 50% under BMT therapy in our everyday practice strict compliance to medical treatment fails in most patients. In consequence, we think that a "one-size-fits-all" guideline policy may not be appropriate for all patients and the management of specific ACS patients may need to be individualized.

Transcranial Doppler detects micro emboli in patients with asymptomatic carotid stenoses undergoing endarterectomy

OBJECTIVE

The objective of this study was to assess the primary endpoint defined as the detection of micro-embolic signals (MES) by the use of transcranial Doppler (TCD) in patients with asymptomatic carotid stenosis (≥70%) scheduled for carotid endarterectomy. The secondary endpoint consisted of testing the association of MES with stenosis severity, histopathological, and ultrasound characteristics.

METHODS

This was a single-center, single-arm, prospective, observational trial. Computed tomography angiography and ultrasound assessment (Geroulakos classification) were mandatory as well as being under best medical therapy. MES number and characteristics were investigated in Holter mode TCD-X device with a standard 1.5 MHz probe. The time points of evaluation were: 24 hours preoperative, 24 hours postoperative, and 30 days postoperative. The histopathological analysis was performed according to the modified American Heart Association classification. One-way analysis of variance tested MES differences over time. Univariable and multivariable logistic regression tested variables potentially associated with MES.

RESULTS

A total of 120 patients demonstrated a significant reduction of the mean number of MES (3.35 ± 10.04 and 0.82 ± 2.39; pre- and post-carotid endarterectomy, respectively), becoming undetectable at 30 days (P = .001). Hypoechogenic plaques assessed by ultrasound were a significant risk factor for MES (P = .001). The features of plaque vulnerability, such as hemorrhagic component (P = .011), neovascularization (P = .025), signs of inflammation (P = .027), and rupture of the fibrous cap (P = .002) were predictors of MES. Cap rupture was the only predictor in the multivariate analysis (odds ratio, 5.98; P = .030). The stenosis severity was not associated with MES (P = .95) CONCLUSIONS: Patients under best medical therapy had a preoperative embolic activity becoming no more detectable after surgery. Both ultrasound and histologic markers of vulnerability were predictors of MES, and stenosis severity was not associated. TCD gives better insight into the real embolic risk, and future studies should evaluate clinical results coming from its implementation with standard imaging techniques.

CLINICALTRIAL

gov registration number NCT05134493.

The Unstable Carotid Plaque

Carotid revascularization is performed to prevent cerebrovascular events in patients with symptomatic (>50%) and asymptomatic high degree (>70%) carotid stenosis. As this operation carries significant risks for perioperative stroke, careful selection of patients who will benefit from the procedure is essential. Certain plaque characteristics, including texture, are associated with increased tendency for rupture and can be used to identify high-risk patients. Medical therapy, carotid endarterectomy, and carotid stenting are the mainstays for patient management. With careful selection of patients, all anesthesia techniques (general anesthesia, monitored anesthesia care, and regional anesthesia) can be used safely for these revascularization procedures.

Ischemic and haemorrhagic stroke risk estimation using a machine-learning-based retinal image analysis

Background

Stroke is the second leading cause of death worldwide, causing a considerable disease burden. Ischemic stroke is more frequent, but haemorrhagic stroke is responsible for more deaths. The clinical management and treatment are different, and it is advantageous to classify their risk as early as possible for disease prevention. Furthermore, retinal characteristics have been associated with stroke and can be used for stroke risk estimation. This study investigated machine learning approaches to retinal images for risk estimation and classification of ischemic and haemorrhagic stroke.

Study design

A case-control study was conducted in the Shenzhen Traditional Chinese Medicine Hospital. According to the computerized tomography scan (CT) or magnetic resonance imaging (MRI) results, stroke patients were classified as either ischemic or hemorrhage stroke. In addition, a control group was formed using non-stroke patients from the hospital and healthy individuals from the community. Baseline demographic and medical information was collected from participants' hospital medical records. Retinal images of both eyes of each participant were taken within 2 weeks of admission. Classification models using a machine-learning approach were developed. A 10-fold cross-validation method was used to validate the results.

Results

711 patients were included, with 145 ischemic stroke patients, 86 haemorrhagic stroke patients, and 480 controls. Based on 10-fold cross-validation, the ischemic stroke risk estimation has a sensitivity and a specificity of 91.0% and 94.8%, respectively. The area under the ROC curve for ischemic stroke is 0.929 (95% CI 0.900 to 0.958). The haemorrhagic stroke risk estimation has a sensitivity and a specificity of 93.0% and 97.1%, respectively. The area under the ROC curve is 0.951 (95% CI 0.918 to 0.983).

Conclusion

A fast and fully automatic method can be used for stroke subtype risk assessment and classification based on fundus photographs alone.

Development of Molecular Magnetic Resonance Imaging Tools for Longitudinal Tracking of Carotid Atherosclerotic Disease Using Fast Imaging with Steady-State Precession

Identification of patients with high-risk asymptomatic carotid plaques remains a challenging but essential step in stroke prevention. Current selection criteria for intervention in carotid disease are still determined by symptomatology and degree of luminal stenosis. This strategy has been less effective in identifying the high-risk asymptomatic individual patients. Inflammation is the key factor that drives plaque instability causing clinical sequelae. Currently, there is no imaging tool in routine clinical practice to assess the inflammatory status within atherosclerotic plaques. Herein we describe the development of a novel molecular magnetic resonance imaging (MRI) strategy to interrogate plaque inflammation, and hence its vulnerability in vivo, using dual-targeted iron particle-based probes and fast imaging with steady-state precession (FISP) sequence, adding further prognostic information to luminal stenosis alone. A periarterial cuff was used to generate high-risk plaques at specific timepoints and location of the carotid artery in an apolipoprotein-E-deficient mouse model. Using this platform, we demonstrated that in vivo dual-targeted iron particles with enhanced FISP can (i) target and characterise high-risk vulnerable plaques and (ii) quantitatively report and track the inflammatory activity within carotid plaques longitudinally. This molecular imaging tool may permit (i) accurate monitoring of the risk of carotid plaques and (ii) timely identification of high-risk asymptomatic patients for prophylactic carotid intervention, achieving early stroke prevention.

Does Current Evidence Support Carotid Artery Stenting for Asymptomatic Patients?

Carotid interventions, carotid endarterectomy and carotid artery stenting (CAS) have proven to be effective treatments for the prevention of ischaemic stroke in recently symptomatic patients. Most studies were conducted before the development of strict statin guidance and the systematic use of antiplatelet drugs. The advances in medical treatments have raised questions regarding the benefit of carotid endarterectomy or CAS, especially for high-grade asymptomatic internal carotid artery stenosis. Reviewing the literature indicates that carotid artery stenosis of any degree is a relatively weak predictor of ipsilateral stroke, in the absence of recent symptoms referable to the carotid disease. This risk does not appear reduced by revascularisation by CAS if added to modern day best medical therapy. On-going trials are key to understanding if current techniques can provide an additional benefit.

Clinical risk scores for stroke correlate with molecular signatures of vulnerability in symptomatic carotid patients

Unstable carotid stenosis is an important cause of ischemic stroke, yet the basis of disease pathophysiology remains largely unknown. We hypothesized that integrated analyses of symptomatic carotid stenosis patients at increased stroke risk stratified by clinical scores, CAR and ABCD2, with transcriptomic and clinical data could improve identification of molecular pathways and targets for instability. We show that high CAR score reflects plaque instability processes related to intra-plaque hemorrhage, angiogenesis, inflammation, and foam cell differentiation, whereas ABCD2 associates with neutrophil-mediated immunity, foam cell differentiation, cholesterol transport, and coagulation. Repressed processes in plaques from high-risk patients were ossification, chondrocyte differentiation, SMC migration, and ECM organization. ABCB5 gene was found as the top upregulated in high-risk patient’s plaques, localized to macrophages in areas with neovascularization and intra-plaque hemorrhage. The link between ABCB5 and intra-plaque hemorrhage suggests its key role for plaque instability that warrants further exploration.

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We integrated stroke risk in carotid stenosis patients with plaque transcriptomics

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High CAR and ABCD2 scores reflect plaque instability processes and hemorrhage

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ABCB5 is upregulated in high-risk plaques, macrophages, and around neovessels

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CAR and ABCD2 capture vulnerable plaque features and improve risk stratification

Revised cardiac score index is a predictor of long-term outcomes after carotid endarterectomy

Summary: Background: Cardiac complications represent the main cause of mortality after non-cardiac surgery and the Revised Cardiac Risk Index (RCRI) was created to estimate the perioperative risk of these events. It considers history of ischaemic heart disease, congestive heart failure, diabetes requiring preoperative insulin, stroke or transient ischaemic attack and renal impairment. We aim to describe the accuracy of the RCRI for predicting perioperative major adverse cardiovascular events (MACE) - a composite of heart failure, ischemic events and all-cause death. Also, the authors aimed to review the score for better prediction of cardiovascular outcomes. Patients and methods: From January 2012 to January 2020, patients who underwent Carotid endarterectomy (CEA) with regional anaesthesia (RA) were selected. RCRI was calculated for each case. Estimated and reported cardiovascular complications were compared using multivariate logistic regression and cox proportional hazards. An alternative and optimized carotid-RCRI (CtRCRI) was obtained. Overall predictive accuracy was assessed and compared by measuring model discrimination. Adjustments for overfitting and evaluation of the new model were performed by bootstrap. Results: 186 patients were selected, of which 80% were male with a mean age of 70.0±9.05 years old. The median follow-up was 50 months, interquartile range 21–69 months. None of the scores were able to predict MACE in the perioperative period. Both were associated with 30-day Clavien-Dindo ≥2 (p=0.022 and p=0.041, respectively). Regarding long-term prognosis, both were able to predict MACE (RCRI: hazard ratio (HR) 3.54 (95% confidence interval [CI] 1.04–11.48) vs. CtRCRI: HR 2.08 (95%CI 1.08–3.98) and all-cause mortality (RCRI: HR 3.33, 95%CI 0.99–11.11 vs. CtRCRI: HR 1.57, 95%CI 1.14–7.04). Conclusions: RCRI and CtRCRI did not predict MACE in the perioperative period but are good predictors of 30-day complications (Clavien-Dindo ≥2). Both RCRI and CtRCRI have good prognostic value as predictors of long-term cardiovascular events.

A narrative review of plaque and brain imaging biomarkers for stroke risk stratification in patients with atherosclerotic carotid artery disease

Objective

In this narrative review, we aim to review imaging biomarkers that carry the potential to non-invasively guide stroke risk stratification for treatment optimization.

Background

Carotid atherosclerosis plays a fundamental part in the occurrence of ischemic stroke. International guidelines select the optimal treatment strategy still mainly based on the presence of clinical symptoms and the degree of stenosis for stroke prevention in patients with atherosclerotic carotid plaques. These guidelines, based on randomized controlled trials that were conducted three decades ago, recommend carotid revascularization in symptomatic patients with high degree of stenosis versus a conservative approach for most asymptomatic patients. Due to optimization of best medical therapy and risk factor control, it is suggested that a subgroup of symptomatic patients is at lower risk of stroke and may not benefit from revascularization, whereas a selective subgroup of high-risk asymptomatic patients would benefit from this procedure.

Methods

A literature search was performed for articles published up to December 2020 using PubMed, EMBASE and Scopus. Based on the literature found, change in stenosis degree and volume, plaque echolucency, plaque surface, intraplaque haemorrhage, lipid-rich necrotic core, thin fibrous cap, inflammation, neovascularization, microembolic signals, cerebrovascular reserve, intracranial collaterals, silent brain infarcts, diffusion weighted imaging lesions and white matters lesions have the potential to predict stroke risk.

Conclusions

The applicability of imaging biomarkers needs to be further improved before the potential synergistic prognostic ability of imaging biomarkers can be verified on top of the clinical biomarkers. In the future, the routine and combined assessment of both plaque and brain imaging biomarkers might help to improve optimization of treatment strategies in individual patients with atherosclerotic carotid artery disease.

Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis

Rupture of a vulnerable carotid plaque is an important cause of ischemic stroke. Prediction models can support medical decision-making by estimating individual probabilities of future events, while magnetic resonance imaging (MRI) can provide detailed information on plaque vulnerability. In this review, prediction models for medium to long-term (>90 days) prediction of recurrent ischemic stroke among patients on best medical treatment for carotid stenosis are evaluated, and the emerging role of MRI of the carotid plaque for personalized ischemic stroke prediction is discussed. A systematic search identified two models; the European Carotid Surgery Trial (ECST) medical model, and the Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score. We critically appraised these models by means of criteria derived from the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) and PROBAST (Prediction model Risk Of Bias ASsessment Tool). We found both models to be at high risk of bias. The ECST model, the most widely used model, was derived from data of large but relatively old trials (1980s and 1990s), not reflecting lower risks of ischemic stroke resulting from improvements in drug treatment (e.g., statins and anti-platelet therapy). The SCAIL model, based on the degree of stenosis and positron emission tomography/computed tomography (PET/CT)-based plaque inflammation, was derived and externally validated in limited samples. Clinical implementation of the SCAIL model can be challenging due to high costs and low accessibility of PET/CT. MRI is a more readily available, lower-cost modality that has been extensively validated to visualize all the hallmarks of plaque vulnerability. The MRI methods to identify the different plaque features are described. Intraplaque hemorrhage (IPH), a lipid-rich necrotic core (LRNC), and a thin or ruptured fibrous cap (TRFC) on MRI have shown to strongly predict stroke in meta-analyses. To improve personalized risk prediction, carotid plaque features should be included in prediction models. Prediction of stroke in patients with carotid stenosis needs modernization, and carotid MRI has potential in providing strong predictors for that goal.

Development of Molecular Magnetic Resonance Imaging Tools for Risk Stratification of Carotid Atherosclerotic Disease Using Dual-Targeted Microparticles of Iron Oxide

Identification of patients with high-risk asymptomatic carotid plaques remains a challenging but crucial step in stroke prevention. Inflammation is the key factor that drives plaque instability. Currently, there is no imaging tool in routine clinical practice to assess the inflammatory status within atherosclerotic plaques. We have developed a molecular magnetic resonance imaging (MRI) tool to quantitatively report the inflammatory activity in atherosclerosis using dual-targeted microparticles of iron oxide (DT-MPIO) against P-selectin and VCAM-1 as a smart MRI probe. A periarterial cuff was used to generate plaques with varying degree of phenotypes, inflammation and risk levels at specific locations along the same single carotid artery in an Apolipoprotein-E-deficient mouse model. Using this platform, we demonstrated that in vivo DT-MPIO-enhanced MRI can (i) target high-risk vulnerable plaques, (ii) differentiate the heterogeneity (i.e. high vs intermediate vs low-risk plaques) within the asymptomatic plaque population and (iii) quantitatively report the inflammatory activity of local plaques in carotid artery. This novel molecular MRI tool may allow characterisation of plaque vulnerability and quantitative reporting of inflammatory status in atherosclerosis. This would permit accurate risk stratification by identifying high-risk asymptomatic individual patients for prophylactic carotid intervention, expediting early stroke prevention and paving the way for personalised management of carotid atherosclerotic disease.

[Variant of endarterectomy from common carotid artery in its total occlusion]

Currently, there are relatively few publications in the literature on reconstruction of the common carotid artery (CCA). CCA occlusion occurs in 2-4% of patients examined for cerebrovascular disease. Most described surgical techniques of blood flow restoration for CCA occlusions are: coronary artery bypass grafting, retrograde loop endarterectomy, endovascular and hybrid interventions. These techniques yield good remote results, however they are not devoid of disadvantages. This article describes a clinical case report concerning successful autotransplantation of the CCA in a female patient presenting with a tandem lesion: total occlusion of the right CCA and haemodynamically significant stenosis of the ostium of the right internal carotid artery (ICA). This technique is considered to be an effective method of surgical treatment of lesions of the right CCA.

Prevalence of High-risk Plaques and Risk of Stroke in Patients With Asymptomatic Carotid Stenosis: A Meta-analysis

Importance

There is an ongoing debate regarding the management of asymptomatic carotid stenosis. Previous studies have reported imaging features of high-risk plaques that could help to optimize the risk-benefit ratio of revascularization. However, such studies have not provided an accurate estimate of the prevalence of high-risk plaques and the associated annual incidence of ipsilateral ischemic cerebrovascular events to inform the design of clinical trials using a risk-oriented selection of patients before randomization.

Objective

To assess the relevance and feasibility of risk-oriented selection of patients for revascularization.

Data Sources

A systematic search of PubMed and Ovid Embase from database inception to July 31, 2019, was performed.

Study Selection

Prospective observational studies that reported prevalence of high-risk plaques and incidence of ipsilateral ischemic cerebrovascular events were included.

Data Extraction and Synthesis

Aggregated data were pooled using random-effects meta-analysis. Data were analyzed from December 16, 2019, to January 15, 2020.

Main Outcomes and Measures

Prevalence of high-risk plaques and annual incidence of ipsilateral ischemic events.

Results

Overall, 64 studies enrolling 20 751 participants aged 29 to 95 years (mean age range, 55.0-76.5 years; proportion of men, 45%-87%) were included in the meta-analysis. Among all participants, the pooled prevalence of high-risk plaques was 26.5% (95% CI, 22.9%-30.3%). The most prevalent high-risk plaque features were neovascularization (43.4%; 95% CI, 31.4%-55.8%) in 785 participants, echolucency (42.3%; 95% CI, 32.2%-52.8%) in 12 364 participants, and lipid-rich necrotic core (36.3%; 95% CI, 27.7%-45.2%) in 3728 participants. The overall incidence of ipsilateral ischemic cerebrovascular events was 3.2 events per 100 person-years (22 cohorts with 10 381 participants; mean follow-up period, 2.8 years; range, 0.7-6.5 years). The incidence of ipsilateral ischemic cerebrovascular events was higher in patients with high-risk plaques (4.3 events per 100 person-years; 95% CI, 2.5-6.5 events per 100 person-years) than in those without high-risk plaques (1.2 events per 100 person-years; 95% CI, 0.6-1.8 events per 100 person-years), with an odds ratio of 3.0 (95% CI, 2.1-4.3; I2 = 48.8%). In studies focusing on severe stenosis (9 cohorts with 2128 participants; mean follow-up period, 2.8 years; range, 1.4-6.5 years), the incidence of ipsilateral ischemic cerebrovascular events was 3.7 events per 100 person-years (95% CI, 1.9-6.0 events per 100 person-years). The incidence of ipsilateral ischemic cerebrovascular events was also higher in patients with high-risk plaques (7.3 events per 100 person-years; 95% CI, 2.0-15.0 events per 100 person-years) than in those without high-risk plaques (1.7 events per 100 person-years; 95% CI, 0.6-3.3 events per 100 person-years), with an odds ratio of 3.2 (95% CI, 1.7-5.9; I2 = 39.6%).

Conclusions and Relevance

High-risk plaques are common in patients with asymptomatic carotid stenosis, and the associated risk of an ipsilateral ischemic cerebrovascular event is higher than the currently accepted estimates. Extension of routine assessment of asymptomatic carotid stenosis beyond the grade of stenosis may help improve risk stratification and optimize therapy.

Prevalence of asymptomatic carotid artery stenosis in Chinese patients with lower extremity peripheral arterial disease: a cross-sectional study on 653 patients

OBJECTIVE

This study aimed to investigate the prevalence and identify predictive factors of asymptomatic carotid artery stenosis (ACAS) in Southern Chinese patients with peripheral arterial disease (PAD).

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

A total of 653 patients with PAD admitted to the First Affiliated Hospital of Chongqing Medical University from July 2014 to July 2019.

MAIN OUTCOME MEASURES

The degree of carotid stenosis was assessed by Duplex ultrasound and classified as normal (no stenosis), mild (<50% stenosis), moderate (50%-69% stenosis), severe (≥70% stenosis or near occlusion) and total occlusion. Patients with stenosis ≥50% were classified as having significant ACAS. Multivariable logistic regression analysis was used to calculate the risk associated with concomitant factors of ACAS.

RESULTS

The mean age was 71.5±5.5 years, and 55.9% of the patients were men. Significant ACAS stenosis accounted for 128 (19.6%) cases, including 68 (10.4%) cases of moderate stenosis (50%-69%), 46 (7.0%) cases of severe stenosis (70%-99%) and 14 (2.1%) cases of total occlusion. Multivariable analysis revealed that age ≥70 years (OR 2.0, 95% CI 1.25 to 3.18), an ankle brachial index (ABI) ≤0.5 (OR 3.39, 95% CI 1.34 to 8.55), an ABI ≤0.4 (OR 3.86, 95% CI 1.47 to 10.06) and Fontaine stage IV (OR 4.53, 95% CI 1.47 to 13.88) are predictive factors of significant ACAS.

CONCLUSION

The prevalence of significant ACAS (stenosis ≥50%) in patients with PAD was approximately 19.6%. Significant ACAS was more common in patients with PAD older than 70 years, particularly in patients with an ABI <0.5 and those classified as Fontaine stage IV. Selective carotid screening may be more worthwhile in these high-risk patients with PAD.

Thirty-Day Results of the Novel CGuard-Covered Stent in Patients Undergoing Carotid Artery Stenting

OBJECTIVE

The aim of this study was to provide early-term evaluation, safety, and efficacy of the novel CGuard (Inspire MD, Tel Aviv, Israel) micromesh self-expanding stent with embolic protection system (EPS) during carotid artery stenting (CAS) procedure.

MATERIALS AND METHODS

All patients who underwent CAS with CGuard carotid stent system from January 2018 to September 2020 in a tertiary center were prospectively evaluated. Primary endpoints included technical success and perioperative neurological events (0-48 hours). Secondary endpoint was the rate of neurologic, cardiac events, and death (major adverse event or MAE) at 30 days. Patency of CGuard, peak systolic velocity (PSV), and end diastolic velocity (EDV) were evaluated at 30 days with duplex ultrasound.

RESULTS

A total of 103 patients underwent CAS procedure. Forty patients were symptomatic, and 63 patients were asymptomatic with stenosis greater than 70%. Technical success was 100%. Local anesthesia was applied in 94 patients (93%). Embolic protection devices were used in 6 patients (5.8%). Access site complications were 1.9%. Mean internal carotid artery stenosis diameter reduced from 79.47% to 14.68%. Two patients had transient ischemic attack (1.9%) and 1 patient experienced a cerebral hyperperfusion syndrome (CHS) perioperatively. External carotid artery (ECA) occlusion occurred in 1.9%. Four patients experienced jaw claudication (3.8%) postoperatively. Mean time of operation was 41 minutes. Mean duration of hospitalization was 3.1 days. The 30-day rate of MAE was 0%. CGuard patency was 100%, mean internal carotid PSV was reduced from 251.57 to 77.29 cm/s, and mean internal carotid EDV was reduced from 154.62 to 24.63 cm/s at 30 days.

CONCLUSION

Our study shows that CGuard stent with EPS is an effective and safe device for treatment of carotid artery stenosis with acceptable low perioperative neurologic events, even with low embolic protection device usage. Larger multicenter and randomized studies are necessary to confirm its long-term efficacy.

Neurovascular disease, diagnosis, and therapy: Cervical and intracranial atherosclerosis, vasculitis, and vasculopathy

Stroke is a leading cause of death, disability, and financial burden in the United States. Perhaps more than any other disease process, the rapidity with which the diagnosis and treatment of stroke are successfully achieved is paramount to the reduction of its associated morbidity and mortality. Steno-occlusive intracranial vascular disease, the most notorious culprit of cerebral ischemia and/or hemorrhage, traces its etiology to native and embolic atherosclerosis as well as various forms of vascular inflammation, insult, and dysfunction. Distinguishing between these causes is a critical first step in the diagnosis and treatment of a patient presenting with cerebrovascular compromise. In this chapter, we delineate the clinical and imaging features of cervical and intracranial atherosclerosis, vasculitis, and vasculopathy, along with the evidence behind the treatments which comprise their current-day standard of care. The modern imaging armamentarium is diverse and complex, with contrast-enhanced and non-contrast MR angiography, CT angiography, digital subtraction angiography, and ultrasound; each playing an important role in providing rapid insight into the patient's disease process. Understanding these imaging techniques and their application in the acute setting is critical for the provider caring for stroke patients.

Solitaire stents deployment may reduce ischemic events in staged angioplasty for severe carotid stenosis

OBJECTIVES

Cerebral hyperperfusion syndrome is a fatal complication that can occur after stent angioplasty in patients with severe carotid artery stenosis. Staged angioplasty can prevent cerebral hyperperfusion syndrome. Conventional staged angioplasty consists of small balloon angioplasty in the first stage and carotid artery stenting in the second stage two to four weeks later. Sometimes, antegrade flow during stage 1 could hardly be maintained and stent will be needed. Solitaire stents were used in some patients in our center. This study aimed to examine the safety and effectiveness of Solitaire stents in staged angioplasty.

METHODS

A retrospective analysis was performed on patients with severe carotid artery stenosis and preoperative computed tomography perfusion indicating risk of cerebral hyperperfusion syndrome from 2011 to 2018. Small balloon angioplasty (<3 mm in diameter) only was performed in stage 1 (group 1). If antegrade flow during stage 1 is compromised, then a solitaire stent is deployed (group 2). After two to four weeks, cerebral angiography was undertaken in both groups to determine whether to perform stage 2. If the residual stenosis was more than 50%, carotid artery stenting was deployed. Angiographic results, clinical results, and follow-up results were collected and analyzed.

RESULTS

Twenty-five patients were included in the study (group 1, n = 19; group 2, n = 6). After stage 1, no patient in group 2 and two patients in group 1 developed new symptomatic cerebral infarction (0.0% vs. 10.5%, p = 1.000). One patient in group 2 and three patients in group 1 (16.7% vs. 15.8%, p = 1.000) developed symptomatic cerebral hyperperfusion syndrome. One patient in group 2 (n = 4) and three patients in group 1 (n = 12) (25% vs. 25%, p = 1.000) developed hyperperfusion phenomenon. Two patients in group 2 and five patients in group 1 (33.3% vs. 26.3%, p = 1.000) developed symptomatic cerebral hyperperfusion syndrome or hyperperfusion phenomenon. One patient in group 1 developed symptomatic cerebral hyperperfusion syndrome and hyperperfusion phenomenon. After stage 2, no new cerebral infarction occurred in both groups. No patient in group 2 (n = 3) and one patient in group 1 (n = 17) developed symptomatic cerebral hyperperfusion syndrome (0.0% vs. 5.9%, p = 1.000). In the combined analysis of both stages, two patients (10.5%) developed new symptomatic cerebral infarction and four patients (21.1%) developed symptomatic cerebral hyperperfusion syndrome in group 1, no patient (0.0%) developed symptomatic cerebral infarction and one patient (16.7%) developed symptomatic cerebral hyperperfusion syndrome in group 2. There was no significant difference in symptomatic cerebral infarction and symptomatic cerebral hyperperfusion syndrome between the two groups (p = 1.000; p = 1.000). Three patients in group 2 and 17 patients in group 1 (50% vs. 89.5%, p = 0.070) underwent stage 2 angioplasty. No cerebral hemorrhage or cerebral infarction occurred in the Solitaire group during the one-year follow-up period.

CONCLUSIONS

Solitaire stents deployment may reduce ischemic events in staged angioplasty for severe carotid stenosis.

Diet and Lifestyle as Risk Factors for Carotid Artery Disease: A Prospective Cohort Study

BACKGROUND

Stroke is one of the leading causes of death, and out of all stroke cases, 10-15% originate from a previously asymptomatic stenosis in the internal carotid artery.

AIMS

The aim of the study was to investigate whether dietary and lifestyle habits were associated with future risk of incident carotid artery disease (CAD).

METHODS

Baseline examinations on middle-aged individuals (n = 30,447) in the Malmö Diet and Cancer study (MDCS), a prospective cohort study, took place between 1991 and 1996 in Malmö, Sweden. Individuals with cardiovascular disease and diabetes mellitus were excluded at baseline, resulting in a total study population of 25,952 patients. Information on dietary intake was gathered through a 7-day food diary, a detailed questionnaire, and a 1-h interview. A diet quality index was calculated from adherence to recommended intake of 6 dietary components (saturated fat, polyunsaturated fat, fish and shellfish, fiber, vegetables and fruit, and sucrose). Individuals with a first registered diagnosis of CAD were identified from the Swedish National Patient register.

RESULTS

During a median follow-up of 21.8 years, 469 participants (1.8%) developed CAD. The diagnosis of incident CAD was validated and confirmed in 99% of a random sample of 100 individuals. Higher intake of vegetables and fruit was associated with a trend of decreased risk of CAD in a Cox regression analysis (hazard ratio of 0.76, 95% confidence interval 0.56-1.03; p = 0.080).

CONCLUSIONS

In conclusion, the present study found a trend toward a protective effect of higher intake of vegetables and fruit against incident CAD. More prospective studies investigating the association between diet and CAD and stroke are needed in order to give firm recommendations.

Evolution of surgical treatment of carotid artery stenosis: a single center observational study

Background: In 2009 and 2011 respectively ESVS and AHA/ASA guidelines recommended to operate patients with a symptomatic carotid artery stenosis within 14 days. This study aimed primarily to determine if an academic hospital has implemented these international guidelines about indication and timing of surgical treatment of carotid stenosis. Second, the influence of referral from another hospital on time from symptoms to surgery and the influence of time between neurological event and surgery on 30-day complication rate was studied. Third, the number of asymptomatic carotid artery lesions treated surgically was also evaluated in both periods.Methods: Retrospective study to compare patients with significant atherosclerotic carotid stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) in 2005-2006 versus patients treated in 2014-2016. Demographic data, treatment characteristics, interval between symptom and surgery and 30-day outcomes were collected.Results: In 2005-2006 38.1% (59/155) of the patients were treated for symptomatic carotid artery stenosis, in 2014-2016 this increased to 66.5% (121/182) (p < .001, 95% CI: 0.179-0.383). Median time from neurological symptom to surgery in symptomatic patients decreased from 30 to 13 d (p <.001, 95% CI: 1.476-2.763). Early surgery did not increase the 30-day postoperative complications (p = .19, 95% CI: 0.987-1.003). Referral from another hospital almost doubled the time interval between symptoms and surgery in 2014-2016 (p <.001, 95% CI: 1.386-2.827).Conclusions: Since the publication of the international guidelines, patients with symptomatic carotid artery stenosis were preferably surgically treated within 2 weeks at an academic institution. The number of treated asymptomatic carotid stenoses was drastically reduced.

The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence

Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.

Endarterectomy with "systematized" resection anastomosis of carotid bulb, about 240 cases

OBJECTIVE

Carotid endarterectomy has traditionally been the strategy for the surgical management of carotid stenosis. Alongside the usual techniques, this study presents another technique: endarterectomy with systematized resection-anastomosis.

MATERIAL AND METHODS

A retrospective study from January 2006 to December 2018, included all patients managed for carotid stenosis at Meaux hospital with the "endarterectomy with systematized resection-anastomosis" technique. The perioperative death and stroke rate were evaluated according to the judgment criterion "homolateral ischemic stroke and any stroke or perioperative death". Statistical analysis of the data was performed using SPSS software.

RESULTS

For 415 carotids operated, we identified 240 managed with this technique. The average age was 71.7±9.6 years, 70% men and 30% women. The main cardiovascular risk factor was hypertension (76.7%), 24.2% of patients had an ischemic heart disease history, 43.7% homolateral ischemic stroke and 29% transient ischemic attack. Bilateral lesions were diagnosed in 6.2% of patients and 7.5% had contralateral occlusion. Carotid stenosis was symptomatic in 52.9% of patients. The average stenosis rate observed was 82.9±8.1% on computed tomography angiogram and 83.7±7.7% on magnetic resonance angiogram. The shunt was used in 45.4% of procedures. The average length of stay was 5.9±2.3 days. All patients had satisfactory results in terms of patency and anatomical appearance on the 1st check. In the post-operative period during the first month, complications occurred in 12.5% of patients (1.6% acute coronary syndrome, 0.8% neurological event, 0.8% death, 0.4% infection, 12.1% hematoma, 1.6% recovery for bleeding). The overall perioperative death and stroke rate was 2.6%. Myocardial infarction and sepsis were the causes of death for the 2 patients in the peri operative period. The mean duration of follow-up was 21.2 months, without any restenosis or occurrence of neurological complications. One patient died beyond the 1st month of follow-up without established cause, and the overall mortality rate was 1.3%.

CONCLUSION

Thromboendarterectomy with "systematized" anastomosis resection represents an angioplasty method for carotid stenosis surgical management under visual control.

Long-term stroke risk with carotid endarterectomy in patients with severe carotid stenosis

OBJECTIVE

Informed debate regarding the optimal use of carotid endarterectomy (CEA) for stroke risk reduction requires contemporary assessment of both long-term risk and periprocedural risk. In this study, we report long-term stroke and death risk after CEA in a large integrated health care system.

METHODS

All patients with documented severe (70%-99%) stenosis from 2008 to 2012 who underwent CEA were identified and stratified by asymptomatic or symptomatic indication. Those with prior ipsilateral interventions were excluded. Patients were followed up through 2017 for the primary outcomes of any stroke/death within 30 days of intervention and long-term ipsilateral ischemic stroke; secondary outcomes were any stroke and overall survival.

RESULTS

Overall, 1949 patients (63.2% male; mean age, 71.3 ± 8.9 years) underwent 2078 primary CEAs, 1196 (58%) for asymptomatic stenosis and 882 (42%) for symptomatic stenosis. Mean follow-up was 5.5 ± 2.7 years. Median time to surgery was 72.0 (interquartile range, 38.5-198.0) days for asymptomatic patients and 21.0 (interquartile range, 5.0-55.0) days for symptomatic patients (P < .001). Most of the patients' demographics and characteristics were similar in both groups. Controlled blood pressure rates were similar at the time of CEA. Baseline statin use was seen in 60.5% of the asymptomatic group compared with 39.9% in the symptomatic group (P < .001), and statin adherence by 80% medication possession ratio was 19.3% asymptomatic vs 12.4% symptomatic (P < .001). The crude overall 30-day any stroke/death rates were 0.9% and 1.5% for the asymptomatic group and the symptomatic group, respectively. The 5-year risk of ipsilateral stroke and a combined end point of any stroke/death by Kaplan-Meier survival analysis were 2.5% and 28.7% for the asymptomatic group and 4.0% and 31.4% for the symptomatic group, respectively. Unadjusted cumulative all-cause survival was 74.2% for the asymptomatic group and 71.8% for the symptomatic group at 5 years.

CONCLUSIONS

In a contemporary review of CEA, outcomes for either operative indication show low adverse events perioperatively and low long-term stroke risk up to 5 years. These results are well within consensus guidelines and published trial outcomes and should help inform the discussion around optimal CEA use for severe carotid stenosis.

Usefulness of carotid ultrasonography and treatment of carotid disease

Carotid stenosis is an important etiology of ischemic stroke. Most of the strokes associated with carotid stenosis are caused by artery-to-artery embolism. The risk of embolism highly depends on the stenosis degree and the vulnerability of the carotid plaque. Carotid ultrasonography is useful for evaluating the characteristics of carotid plaque. This review aims to provide information on performing and interpreting the result of carotid ultrasonography and the treatment of carotid artery disease based on the current guidelines. The degree of stenosis can be measured by the diameter reduction and flow velocity criteria. The risk of embolism is highest when the stenosis degree is around 70% to 80%. A heterogeneous echolucent plaque with an irregular surface or an ulcer shows a high risk of embolism. Appropriate treatment is important for the patients with carotid stenosis. In symptomatic patients, a potent antiplatelet treatment, especially during the acute stage, is beneficial. Patients with asymptomatic stenosis over 50% can also be considered for antiplatelet treatments. The associated risk factors should be managed according to the targets. Medically intractable cases or patients with high risk of embolism may receive carotid endarterectomy or carotid artery stenting depending on the concomitant disease and the degree of carotid stenosis. Considering the safety of ultrasound imaging, treatment may be followed-up by carotid ultrasonography.

Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment

BACKGROUND

Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT).

METHODS

Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months followup periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only.

RESULTS

Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period.

CONCLUSION

Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.

Choosing the right therapy for a patient with asymptomatic carotid stenosis

Introduction: Most patients with asymptomatic carotid stenosis (ACS) now have a lower risk with intensive medical therapy than with stenting (CAS) or endarterectomy (CEA); the annual risk of stroke or death with intensive medical therapy is ~ 0.5%, vs. a periprocedural risk with CAS of ~ 2.5-4.1% with CAS, and ~ 1.4-1.8% with CEA. The excess risk of CAS is greater in older patients.Areas covered: Discussed are the need for intensive medical therapy, the nature of intensive medical therapy, approaches to identifying the few patients with ACS who could benefit from CEA or CAS, and which patients would be better suited to CEA vs. CAS.Expert opinion: All patients with ACS are at high risk of cardiovascular events, soshould receive intensive medical therapy including lifestyle modification, intensive lipid-lowering, B vitamins to lower homocysteine (using methylcobalamin rather than cyanocobalamin), and appropriate antithrombotic therapy. High-risk patients who could benefit from intervention can be identified by clinical and imaging features including transcranial Doppler embolus detection, ulceration, intraplaque hemorrhage, reduced cerebrovascular reserve, plaque echolucency, silent infarction on brain imaging, and progression of stenosis. Most patients whose risk of stroke warrants intervention would be better treated with CEA than with CAS.

Management of Asymptomatic Carotid Artery Stenosis

PURPOSE OF REVIEW

The goal of this paper is to provide the reader with a review of the evidence supporting the surgical and medical management of patients with asymptomatic internal carotid artery (ICA) stenosis.

RECENT FINDINGS

Based on the results of earlier clinical trials, surgical intervention with carotid endarterectomy (CEA) has long been the preferred method of management for patients with asymptomatic severe carotid stenosis. Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term. However, more recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA. As a result, medical management alone is advocated as well for patients with asymptomatic carotid stenosis. In addition to stenosis severity, there are a number of features of plaque morphology associated with vulnerable plaque that predict future stroke risk. Rates of stroke in patients with asymptomatic severe carotid stenosis with modern surgical techniques, CEA and CAS, are similar to modern medical therapy alone. Both surgery and medical therapy are good treatment options but it is not known which treatment is superior. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), an NIH-sponsored, multicenter, randomized trial that aims to answer this important management decision.

Carotid endarterectomy after systemic thrombolysis in a stroke population

OBJECTIVE

Vascular specialists are increasingly being requested to perform carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) for stroke patients, raising concerns about hemorrhagic complications. Few case series and registry reports have assessed the question, and even fewer studies have included a control group. The aim of this study was to evaluate the overall outcome of patients undergoing CEA after IVT and to compare them with contemporary patients with CEA after simple stroke (non-IVT group). It also aimed to evaluate the differences in outcomes of stroke patients requiring CEA between nonvascular and vascular centers.

METHODS

The data of 169 consecutive patients who have undergone CEA after stroke in a single center was analyzed from January 2011 to December 2016, 27 of them (16%) having undergone previous IVT. A comparative analysis between the non-IVT and the IVT groups was performed. The time between stroke diagnosis and referral to a vascular specialist was also studied.

RESULTS

Age, sex, and cardiovascular comorbidities were similar in both groups. Median time between stroke and CEA was 13 days (Q1-Q3, 8-23 days), with 16 of the 27 patients (59%) in the IVT group undergoing CEA less than 14 days after the initial event. There were three intracranial hemorrhages (2.1%) in the non-IVT group versus one (3.7%) in the IVT group (P = NS). The overall 30-day combined stroke and death rate was 7.1% (6.3% in the non-IVT group vs 11.1% in the IVT group; P = .70). The incidence of postoperative cervical hematoma requiring reoperation was similar in both groups (2.1% vs 3.7%; P = NS). The median time between diagnosis of stroke and referral to a vascular specialist was higher for patients in nonvascular centers compared with vascular centers (3.5 days vs 1.0 day; P < .001), which translated to fewer patients referred from nonvascular centers undergoing surgery in the 14-day window period (38% vs 67%; P < .001).

CONCLUSIONS

In this retrospective analysis, CEA after IVT showed similar outcomes when compared with the overall CEA after stroke population. Stroke patients diagnosed in nonvascular centers were referred later than those in vascular centers and, although postoperative outcomes were similar, that was correlated with fewer patients undergoing surgery in a timely fashion.

Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers

Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.

Combining morphological and biomechanical factors for optimal carotid plaque progression prediction: An MRI-based follow-up study using 3D thin-layer models

Plaque progression prediction is of fundamental significance to cardiovascular research and disease diagnosis, prevention, and treatment. Magnetic resonance image (MRI) data of carotid atherosclerotic plaques were acquired from 20 patients with consent obtained. 3D thin-layer models were constructed to calculate plaque stress and strain. Data for ten morphological and biomechanical risk factors were extracted for analysis. Wall thickness increase (WTI), plaque burden increase (PBI) and plaque area increase (PAI) were chosen as three measures for plaque progression. Generalized linear mixed models (GLMM) with 5-fold cross-validation strategy were used to calculate prediction accuracy and identify optimal predictor. The optimal predictor for PBI was the combination of lumen area (LA), plaque area (PA), lipid percent (LP), wall thickness (WT), maximum plaque wall stress (MPWS) and maximum plaque wall strain (MPWSn) with prediction accuracy = 1.4146 (area under the receiver operating characteristic curve (AUC) value is 0.7158), while PA, plaque burden (PB), WT, LP, minimum cap thickness, MPWS and MPWSn was the best for WTI (accuracy = 1.3140, AUC = 0.6552), and a combination of PA, PB, WT, MPWS, MPWSn and average plaque wall strain (APWSn) was the best for PAI with prediction accuracy = 1.3025 (AUC = 0.6657). The combinational predictors improved prediction accuracy by 9.95%, 4.01% and 1.96% over the best single predictors for PAI, PBI and WTI (AUC values improved by 9.78%, 9.45%, and 2.14%), respectively. This suggests that combining both morphological and biomechanical risk factors could lead to better patient screening strategies.

Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2

BACKGROUND

Treatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria.

METHODS

SPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported.

FINDINGS

It was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates.

INTERPRETATION

The low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.

A nomogram for the prediction of cerebrovascular disease among patients with brain necrosis after radiotherapy for nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

This study sought to develop and validate a nomogram to predict cerebrovascular disease (CVD) among patients with brain necrosis after radiotherapy for nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

A total of 346 eligible patients with brain necrosis after radiotherapy for NPC were divided into a training set (n = 231) and a validation set (n = 115). A multivariate Cox proportional hazards regression model was used to select the significant variables for CVD prediction in the training set. Then, a nomogram was developed based on the regression model. The performance of the nomogram was assessed with respect to discrimination and calibration. All patients were classified into high- or low-risk groups based on the risk scores derived from the nomogram. Moreover, a decision curve analysis was performed with the combined training and validation sets to evaluate the clinical usefulness of the nomogram.

RESULTS

Four significant predictors were identified: hypertension, statin treatment, serum level of high-density lipoprotein, and interval between radiotherapy and brain necrosis. The nomogram incorporating these four predictors showed favorable calibration and discrimination regarding the training set, with a C-index of 0.763 (95% CI, 0.694 to 0.832), which was confirmed using the validation set (C-index 0.768; 95% CI, 0.675 to 0.861). Furthermore, the nomogram successfully stratified patients into high- and low-risk groups. The decision curve indicated that our nomogram was clinically useful.

CONCLUSION

The nomogram showed favorable predictive accuracy for CVD among patients with brain necrosis after radiotherapy for NPC and might aid in clinical decision making.

Risk-Benefit Assessment of Carotid Revascularization

Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Reproducibility of Transcranial Doppler ultrasound in the middle cerebral artery

BACKGROUND

Transcranial Doppler ultrasound remains the only imaging modality that is capable of real-time measurements of blood flow velocity and microembolic signals in the cerebral circulation. We here assessed the repeatability and reproducibility of transcranial Doppler ultrasound in healthy volunteers and patients with symptomatic carotid artery stenosis.

METHODS

Between March and August 2017, we recruited 20 healthy volunteers and 20 patients with symptomatic carotid artery stenosis. In a quiet temperature-controlled room, two 1-h transcranial Doppler measurements of blood flow velocities and microembolic signals were performed sequentially on the same day (within-day repeatability) and a third 7-14 days later (between-day reproducibility). Levels of agreement were assessed by interclass correlation co-efficient.

RESULTS

In healthy volunteers (31±9 years, 11 male), within-day repeatability of Doppler measurements were 0.880 (95% CI 0.726-0.950) for peak velocity, 0.867 (95% CI 0.700-0.945) for mean velocity, and 0.887 (95% CI 0.741-0.953) for end-diastolic velocity. Between-day reproducibility was similar but lower: 0.777 (95% CI 0.526-0.905), 0.795 (95% CI 0.558-0.913), and 0.674 (95% CI 0.349-0.856) respectively. In patients (72±11 years, 11 male), within-day repeatability of Doppler measurements were higher: 0.926 (95% CI 0.826-0.970) for peak velocity, 0.922 (95% CI 0.817-0.968) for mean velocity, and 0.868 (95% CI 0.701-0.945) for end-diastolic velocity. Similarly, between-day reproducibility revealed lower values: 0.800 (95% CI 0.567-0.915), 0.786 (95% CI 0.542-0.909), and 0.778 (95% CI 0.527-0.905) respectively. In both cohorts, the intra-observer Bland Altman analysis demonstrated acceptable mean measurement differences and limits of agreement between series of middle cerebral artery velocity measurements with very few outliers. In patients, the carotid stenoses were 30-40% (n = 9), 40-50% (n = 6), 50-70% (n = 3) and > 70% (n = 2). No spontaneous embolisation was detected in either of the groups.

CONCLUSIONS

Transcranial Doppler generates reproducible data regarding the middle cerebral artery velocities. However, larger studies are needed to validate its clinical applicability.

TRIAL REGISTRATION

ClinicalTrial.gov (ID NCT 03050567), retrospectively registered on 15/05/2017.