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, 66.1Ϯ8 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; Pϭ0.003). 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; Pϭ0.002), poststenotic arterial narrowing (OR, 22.7; 95% CI, 3.6 to 141.6; Pϭ0.001), and very severe stenosis (OR, 13.6; 95% CI, 2.2 to 83.7; Pϭ0.005). 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.

Objectives: To evaluate the reduction of embolic signals after the initiation of an antithrombotic secondary prevention in patients with recent arterioembolic stroke and to determine the predictive value of decreased microembolism on the risk of early stroke recurrence. Methods: Eighty six consecutive patients (55 men, 31 women; mean age 60.6 years) with a non-disabling arterioembolic ischaemic event in the anterior circulation within the last 30 days and a medium grade or high grade stenosis (>50%) of the ipsilateral carotid or middle cerebral artery underwent 1 hour transcranial Doppler monitoring as part of the admission examinations. Antithrombotic secondary prevention was started after completion of admission. Patients in whom embolic signals were detected underwent a second monitoring within 4 days (mean time 1.8 days). All patients were followed up prospectively to evaluate the relation between presence and persistence of embolic signals and the risk of recurrent transient ischaemic attack (TIA) and stroke within the next 6 weeks. Results: In 44 patients, embolic signals were detected at admission, a mean 5.4 days (range 0 to 21 days) after the initial event. Twenty five were positive for embolic signals also at the second monitoring, in 19 signals had ceased. Forty two patients without embolic signals at admission served as controls. During follow up, six ischaemic events (two stroke, three TIA, one amaurosis fugax) occurred in 25 patients with persisting embolic signals but none in 19 patients in whom signals had ceased by the second monitoring. One patient in the control group had a TIA. The incidence of a recurrent event was 0.45 per 30 patient-days if embolic signals persisted compared with 0.015 if signals could not be detected or had ceased. Persistence of embolic signals was an independent predictor of a recurrent TIA or stroke (adjusted odds ratio 37.0; 95% confidence interval (95% CI) 3.5 to 333; p<0.003). Cessation and decrease of embolic signals was associated with the administration of antiplatelet agents but not with anticoagulation with intravenous heparin (p<0.001). Conclusions: Rapid cessation of embolic signals detected in patients with recently symptomatic arterial stenosis decreases increased risk of an early ischaemic recurrence. Effect of antithrombotic agents on embolic signals might serve as a marker for their efficacy on preventing stroke recurrence. I n patients with symptomatic arterial stenosis, stroke is most likely caused by emboli arising from the stenotic lesion. Subsequent antithrombotic therapy aims to prevent recurrent thromboembolism. However, even in the presence of an antithrombotic prevention, recurrence of an ischaemic event within the first month has been described in 10% to 15% of patients.1 2 Presence of microemboli as detected by transcranial Doppler sonography (TCD) after an initial event has been reported as an independent predictor of an early ischaemic recurrence with a ninefold increase of risk, 2 and was associated with the absence of an antiplatelet medic...