Risk of Stroke, Transient Ischemic Attack, and Vessel Occlusion Before Endarterectomy in Patients With Symptomatic Severe Carotid Stenosis

Author:

Blaser Till1,Hofmann Katrin1,Buerger Thomas1,Effenberger Olaf1,Wallesch Claus-Werner1,Goertler Michael1

Affiliation:

1. From the Departments of Neurology (T.B., K.H., C.-W.W., M.G.), Surgery and Vascular Surgery (T.B.), and Diagnostic Radiology (O.E.), University of Magdeburg, Magdeburg, Germany.

Abstract

Background and Purpose We aimed to identify and determine the clinical relevance of parameters predictive of stroke recurrence and vessel occlusion before carotid endarterectomy. Methods One hundred forty-three consecutive patients (105 men; mean age, 66.1±8 years) with symptomatic severe carotid artery stenosis were prospectively followed up until carotid endarterectomy. Patients had suffered an ischemic vascular event in the ipsilateral anterior circulation 9.6 days (median; range, 0 to 92 days) before presentation and assessment of stenosis. Admission examination included medical history, neurological status, extracranial and transcranial Doppler/duplex sonography, CT/MRI, ECG, and routine laboratory examination. All patients were reevaluated in the same way the day before surgery (without CT/MRI) and at recurrence of an ischemic event (including CT/MRI). Results The end point of follow-up after 19.0 days (median; range, 0 to 118) was carotid endarterectomy in 120 patients, ipsilateral recurrent ischemia in 15 patients (7 transient events and 8 disabling strokes, with carotid occlusion in 4), and (asymptomatic) carotid occlusion in 8 patients. An exhausted cerebrovascular reactivity as determined by a Doppler CO 2 test in the middle cerebral artery ipsilateral to the stenosis was the only independent predictive parameter for disabling stroke (odds ratio [OR], 9.7; 95% confidence interval [CI], 2.1 to 44.1; P =0.003). Stroke rate in patients with exhausted reactivity was 27% per month compared with 5.2% in those with normal reactivity. Progression of stenosis toward occlusion was observed in 12 patients and correlated with decreased poststenotic peak systolic velocity (OR, 0.75; 95% CI, 0.62 to 0.90; P =0.002), poststenotic arterial narrowing (OR, 22.7; 95% CI, 3.6 to 141.6; P =0.001), and very severe stenosis (OR, 13.6; 95% CI, 2.2 to 83.7; P =0.005). In patients without hemodynamic compromise, occlusion was not associated with increased stroke risk. Conclusions Patients with recently symptomatic high-grade carotid artery stenosis and ipsilateral hemodynamic compromise are at high risk for early disabling stroke. Assessment of the hemodynamic status is recommended after diagnosis of severe carotid stenosis in symptomatic patients to further investigate and evaluate whether these patients may benefit from early endarterectomy.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Advanced and Specialised Nursing,Cardiology and Cardiovascular Medicine,Clinical Neurology

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