Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence.Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362.

Renal dysfunction predicts mortality in patients with myocardial infarction but less is known about the impact of renal dysfunction on in-hospital mortality after ischaemic stroke. All 361 patients (185 men, 176 women; mean age 72.1 years) with ischaemic stroke and glomerular filtration rate (GFR) <90 ml/min/1.73 m2 were followed-up. GFR was calculated according to abbreviated modification of diet in renal disease (MDRD) formula. Stroke severity was determined by National Institutes of Health Stroke Scale (NIHSS). The mean GFR was 61.5 +/- 16.6 ml/min/1.73 m2. There were 49 (13.6%) in-hospital deaths. Patients who died had higher NIHSS (P = 0.0001), were older (P = 0.024), had lower GFR (P = 0.028), higher hs-C-reactive protein (P = 0.001) and lower albumin (P = 0.048). No differences in presence of diabetes and hypertension, cholesterol (total, HDL and LDL), triglycerides and BMI between patients who died or survived were found. With univariate analysis association between in-hospital mortality and NIHSS (P = 0.0001), GFR (P = 0.041), total cholesterol (P = 0.021) and LDL cholesterol (P = 0.034) was found. With Cox multivariable regression analysis of risk factors, NIHSS (P = 0.0001), GFR (P = 0.018), total cholesterol (P = 0.008) and LDL cholesterol (P = 0.011) were only predictors of in-hospital mortality. In patients with ischaemic stroke, decreased GFR was associated with higher in-hospital mortality.

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Transcranial Doppler monitoring of intracranial blood flow during carotid endarterectomy, carotid angioplasty with stenting, surgical management of intracranial aneurysms, coronary artery bypass grafting, and thrombolysis of middle cerebral artery (MCA) occlusions is important because it enables recording of the flow in the MCA in real time. An adequate blood flow through the MCA during carotid endarterectomy allows for selective use of an intraluminal shunt (or the decision to operate without it) and timely identification of cerebral hyperperfusion, vasospasm, hypoperfusion, and cerebral microembolisms as well as recanalization of the cerebral artery, thus minimizing postoperative neurologic complications such as stroke or cognitive dysfunction.