Identification of Patients at Risk for Ischaemic Cerebral Complications After Carotid Endarterectomy with TCD Monitoring

Horn, Jeffrey A.; Naylor, A. Ross; Laman, D.M.; Chambers, Brian R.; Stork, Jacinda L.; Schroeder, Torben V.; Nielsen, Marius; Dunne, Victoria G.; Ackerstaff, R.G.A.

doi:10.1016/j.ejvs.2005.04.033

Cited by 29 publications

(17 citation statements)

References 30 publications

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“…This threshold is similar to rates reaching clinical significance in other studies [22, 23, 32]. Approximately 13–18% of our cohort were identified with >10 ES/30 min over the first 24–36 post-operative hours, depending on the number of monitoring sessions.…”

Section: Discussionsupporting

confidence: 58%

“…This is a lower threshold than first suggested by our group using a smaller sample [21]. However, this rate is similar to the best overall figure of 14 ES/h for anticipation of post-operative stroke/TIA derived from a meta-analysis of 991 subjects studied for variable intervals during the first three post-operative hours [23]. These authors also found that a threshold of ≥8 emboli/h correlated with ischaemic cerebral complications using multivariate analysis.…”

Section: Discussionmentioning

confidence: 80%

“…High rates of transcranial Doppler (TCD) detected embolic signals (ES) soon after CEA are predictive of peri-operative ipsilateral carotid stroke or TIA [21,22,23]. Horn et al [23], using a meta-analysis of 991 patients studied for varying time intervals during the first 3 post-operative hours, identified 14 ES/h as the best overall microembolic rate for anticipation of ischaemic stroke or TIA (sensitivity 84%, specificity 76%). However, the clinical applicability of TCD ES detection after CEA remains uncertain because the most efficient monitoring protocol to identify those at risk is unclear.…”

Section: Introductionmentioning

confidence: 99%

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Timing of Clinically Significant Microembolism after Carotid Endarterectomy

et al. 2007

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Purpose: Post-operatively detected transcranial Doppler (TCD) embolic signals (ES) are associated with an increased risk of carotid endarterectomy (CEA) stroke/TIA. The aims here were to quantify this risk and determine the most efficient monitoring protocol. Methods: Sequential patients undergoing CEA (enrolled in a randomised, blinded, placebo-controlled trial of peri-operative dextran therapy) had 30-min TCD monitoring in the first post-operative hour. 30-min monitoring was also performed 2–3, 4–6 and 24–36 h post-operatively. First post-operative hour ES counts were correlated with peri-operative ipsilateral carotid stroke/TIA to determine the size of a clinically significant ES load and the magnitude of the associated risk. The exact Cochran-Armitage test for trend in proportions was used to determine when a clinically significant ES load was first detected. Results: 141 patients (mean age 69.3 years, 72% male) were monitored during the first post-operative hour. An ES count >10 per recording was identified as the best overall predictor of ipsilateral stroke/TIA (sensitivity 72%, specificity 89%). 3/119 (2.5%) patients with 0–10 ES had ipsilateral carotid events compared to 8/22 (36.4%) patients with 11–115 ES (OR = 22.1, 95% CI 4.5, 138.4, p < 0.0001). 13/18 (72%) of subjects with >10 ES were identified in the first post-operative hour with no significant increase in the number of new cases over the subsequent 24–36 post-operative h (p = 0.354). Conclusion: Patients with clinically significant post-operative microembolism had an approximately 15 times higher risk of ipsilateral stroke/TIA and most were identified during a 30-min study in the first post-operative hour.

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Section: Discussionsupporting

confidence: 58%

Section: Discussionmentioning

confidence: 80%

Section: Introductionmentioning

confidence: 99%

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Timing of Clinically Significant Microembolism after Carotid Endarterectomy

et al. 2007

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“…It is worth mentioning that none of the above-mentioned studies analyze more than 1 factor simultaneously. [19][20][21][22][23][24][25][26][27][28][29] However, the overall evidence for outcome differences by gender-specific characteristics in the literature is limited. 30 Mantese et al found that sex did not modify the treatment effect.…”

Section: Discussionmentioning

confidence: 99%

Gender-related risk factors for perioperative stroke after carotid endarterectomy in symptomatic patients

et al. 2017

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“…Thus, a reduction of flow in the MCA suggests cerebral ischemia, considering that different ranges have been proposed to be considered clinically significant. Besides this, it is the only effective technology in detecting micro-emboli during CEA [19][20][21][22] …”

Section: Transcranial Dopplermentioning

confidence: 99%

Carotid Stenosis and Anaesthesia

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et al. 2016

Int J Surg Surgical Proced

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EpidemiologyThe importance of carotid stenosis approach lies in the relationship it has with ischemic stroke, since it is present in 10-20% of all of them. This is of magnitude when we know that in Western countries, stroke is the third leading cause of death, behind only heart disease and cancer, with a mortality ranging from 10 to 30%, having survivors risk of recurring ischemic cardiac or neurologic events, so much so that is the leading cause of disability. The prevalence of stenosis in the internal carotid artery (ICA) is high and furthermore increases with age, in fact more than 50% stenosis rises from 0.5% in people aged between 50 and 59 years to 10% in those over 80 years. The primary mechanism involved in stroke in patients with carotid stenosis is embolism of atherosclerotic or thrombotic waste material from the plate to the distal cerebral vasculature. Infiltration of inflammatory cells on the surface of carotid plaques can play a key role in causing plaque rupture and embolization or occlusion of the carotid and also hemodynamic factors are correlated with increased risk of stroke in patients with carotid stenosis [1,2,3]. Of all the factors studied, the degree of arterial stenosis has emerged as the most directly related to the increased risk of stroke. Any diagnostic strategy, whatever the technique used, should have as its primary objective to determine, in the most accurate way, the amount of this stenosis [4].In the NASCET study the risk of ipsilateral recurrent stroke in patients with symptomatic carotid stenosis treated conservatively was 4.4% per year for patients with stenosis between 50 and 69% and 13% per year for those with 70% stenosis. The risk in patients with asymptomatic stenosis of 60% was around 1-2%, but could rise to 3-4% per year in elderly patients or in the presence of stenosis or occlusion of the contralateral artery, evidence of silent embolization in an imaging test, heterogeneity of the carotid plaque, poor collateral circulation, generalized inflammatory state or peripheral or coronary artery disease associated [5]. Treatment Medical versus interventional treatmentGiven the above discussion, we will assume that the main objective in the treatment of carotid stenosis is the prevention of ischemic stroke and its aftermath, regardless of the type of patient, the presence or absence of symptoms and the degree of stenosis. However, despite the clarity of the target it is unclear what therapeutic option to choose among only medical treatment or revascularization and, in the latter case, between endoluminal or surgical treatment. We will be guided in this review [6], considering that these guidelines place more emphasis on stroke prevention in the prevention of ischemic heart disease, on the grounds that according to the CREST study, stroke has shown greater impact on quality of life of the patient than nonfatal myocardial ischemia [7].The major determinants of the clinical course are the presence or absence of neurological symptoms and the degree of stenosis. The threat of isc...

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Identification of Patients at Risk for Ischaemic Cerebral Complications After Carotid Endarterectomy with TCD Monitoring

Abstract: These results support the use of TCD monitoring for MES shortly after CEA in order to identify patients at risk of developing ischaemic cerebral complications.

Cited by 29 publications

References 30 publications

Timing of Clinically Significant Microembolism after Carotid Endarterectomy

Timing of Clinically Significant Microembolism after Carotid Endarterectomy

Gender-related risk factors for perioperative stroke after carotid endarterectomy in symptomatic patients

Carotid Stenosis and Anaesthesia

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