Carotid endarterectomy for asymptomatic carotid stenosis

Ischemic stroke. How to keep the first one from happening

The prevention of stroke has undenied merit. Recognition of stroke-inducing conditions (eg, cardiac diseases associated with embolism, polycythemia) provides opportunities for specific prevention strategies. For a larger number of patients, however, risk factors for degenerative vascular disease should be addressed. The evidence for efficacy is strongest for treatment of hypertension, and smoking cessation also reduces the risk of stroke. The value of treatment of hyperlipidemia in reducing the incidence of a first stroke remains to be demonstrated. Optimal management of carotid bruit and asymptomatic stenosis will be clarified by results of ongoing clinical trials. On the basis of available data, use of aspirin by healthy persons without risk factors cannot be recommended as a method for preventing a first ischemic stroke.

Neuropsychological deficits in asymptomatic carotid artery stenosis

A total of 20 subjects with asymptomatic carotid artery stenosis (ACAS) and a group of healthy controls were compared as to their cognitive performance. Subjects with ACAS showed substantial deficits on tasks of mental speed, learning, visuospatial abilities, verbal processing and deductive reasoning. The cognitive profile of ACAS--subjects indicated non-specific impairment, possibly related to widespread cerebral vascular disease, of which the presence of ACAS may be one indicator.

Perioperative stroke. Part I: General surgery, carotid artery disease, and carotid endarterectomy

Although stroke, defined as a focal neurological deficit lasting more than 24 hr, is uncommon in the perioperative period, its associated mortality and long-term disability are high. No large-scale data are available to identify the importance of recognized risk factors for stroke in the perioperative period. A review of the literature shows that the incidence and mechanism of its occurrence are influenced by the presence of cardiovascular disease and the type of surgery. The most common cause of perioperative stroke is embolism. In non-cardiac surgery, the incidence of perioperative stroke is higher among the elderly. Properly administered, controlled hypotension is associated with minimal risk of stroke. Cerebral vasospasm may be the cause of focal cerebral ischaemia in eclamptic patients, and the aggressive treatment of hypertension may exacerbate the neurological damage. The risk of stroke associated with carotid endarterectomy is closely related to the preoperative neurological presentation, and the experience of the surgical/anaesthetic team. Symptomatic cerebrovascular disease, acute stroke, asymptomatic carotid lesions, preoperative assessment of risk, local and general anaesthesia, cerebral protection and monitoring during carotid endarterectomy are discussed with reference to reducing the risk of perioperative stroke. Adequate monitoring and protection have minimized the risk of ischaemia from carotid clamping, and the major mechanism of stroke is embolization.

Carotid endarterectomy for asymptomatic carotid stenosis: a ten-year experience with 120 procedures in a fellowship training program

Performance of carotid endarterectomy for asymptomatic carotid stenosis has been restricted during recent years because of concern of reported complications in as high as 10-15% of patients, as well as limited long-term data on stroke protection. During the last 10 years, we have studied immediate and long-term results of carotid endarterectomy for asymptomatic disease in 120 patients. Operations were performed by a clinical vascular fellow with a staff surgeon in attendance in 113 (94%) cases with the remainder performed by the staff surgeon. Patients' mean age was 66 years; 82% were men. Risk factors included hypertension (56%), smoking (52%), coronary artery disease (32%), diabetes (24%), and hypercholesterolemia (6%). Arteriographic severity of stenoses was 80-99% in 74%, 60-79% in 22%, and 40-59% in 4% of cases. Postoperative complications included two transient neurological events (1.7%). No permanent strokes or deaths occurred. Using the life table method, cumulative stroke rate was 4.5% for ipsilateral events and 7.3% for contralateral events, confirming the high degree of stroke protection afforded by carotid endarterectomy in this population. Since these results were accomplished in a fellowship training program, we regard adequacy of this experience as the most influential factor in accomplishing this record. Surgeons who are unable to achieve comparable results should consider abandonment of the procedure or an extended period of additional training.

Screening of the internal carotid arteries in patients with peripheral vascular disease by colour-flow duplex scanning

The prevalence of internal carotid arterial disease was assessed in 416 consecutive patients with peripheral arterial disease (PAD). Colour-flow duplex scanning was performed to determine the extent of the disease. Major internal carotid artery disease (MICAD), meaning 75% stenosis and/or occlusion, was found in 14.9% (62) of the patients; 12.5% (52) had unilateral disease and 2.4% (10) had bilateral disease. In 7.7% (32) there was a stenosis of 75-99%. An occlusion was seen in 7.2% (30). No correlation was found between the severity of the internal carotid artery disease and the severity of the peripheral arterial disease. The 16.0% (60) prevalence in MICAD in patients with obstructive disease was significantly higher than the 4.7% (2) in aneurysm patients (p less than 0.05). The results show that there was no correlation between MICAD and the risk factors: hypertension, gender, age, diabetes mellitus, hypercholestolaemia, smoking and ischaemic heart disease. The high prevalence of MICAD in patients with PAD suggests that it would be useful to start a screening programme to determine if high grade stenosis should be operated upon.