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

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, 66.1Ϯ8 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.

Associations of Brachial-Ankle Pulse Wave Velocity and Carotid Atherosclerotic Lesions with Silent Cerebral Lesions

“…Past cross-sectional and prospective studies have indicated that the ultrasound-detected carotid atherosclerotic lesions were associated with ischemic stroke (1, 2) and coronary heart diseases (22,23), and that these lesions can help to estimate the risk of ischemic stroke (3)(4)(5)(6)(7)(8). Our study showed the two types of carotid lesion were related with SCI.…”

“…Increased intima-media thickness (IMT) and atherosclerotic plaques in the carotid arteries have been reported to have associations with ischemic stroke (1)(2)(3)(4)(5)(6)(7)(8), and therefore have been recognized as useful risk assessment tools for cerebrovascular diseases (9,10). Similarly, brachialankle pulse wave velocity (baPWV) has been investigated as a new method of assessing systemic atherosclerosis.…”

Quantitative mapping of cerebrovascular reactivity using resting-state BOLD fMRI: Validation in healthy adults

“…Clinically, impaired CVR has been associated with risk for stroke and transient ischemic attacks (Liu et al, 2012;Zirak et al, 2014). Given similar diagnoses, individuals with CVR impairment have a much higher risk of disabling stroke than those without (Blaser et al, 2002;Bokkers et al, 2011;Kuroda et al, 2004;Mandell et al, 2011;Mandell et al, 2008;Markus and Cullinane, 2001;Schoof et al, 2007;Silvestrini et al, 2000 ;Tsivgoulis and Alexandrov, 2008). In addition, reduced CVR has also been cited as a marker for lacunar infarction (Birns et al, 2009;Mandell et al, 2011), microbleeding (Birns et al, 2009;Conijn et al, 2012), as well as cortical atrophy (Fierstra et al, 2010) and cognitive decline in individuals at risk of stroke (Hurford et al, 2014;Kovács et al, 2010).…”

Effect of Stenting on Cerebral CT Perfusion in Symptomatic and Asymptomatic Patients with Carotid Artery Stenosis

“…24 Also patients with symptomatic stenosis and ipsilateral hemodynamic compromise are at higher risk of disabling stroke than patients with normal cerebral perfusion. 4 It is important to evaluate individual perfusion parameters and relate these to the different stages of hemodynamic compromise. MTT is considered the most sensitive perfusion parameter because it directly relates to cerebral perfusion pres- The significance of the difference between relative perfusion parameters was tested using the paired-samples t test in symptomatic patients and the Wilcoxon signed rank test in asymptomatic patients.…”

“…Collateral circulation, on the other hand, can maintain normal cerebral perfusion pressure and normal flow in many patients with carotid artery stenosis. 3 In symptomatic patients with severe carotid stenosis and occlusion, [4][5][6] the association of cerebral hemodynamics with the risk of stroke has been described. In asymptomatic patients with severe carotid stenosis, less proof of this association is available.…”