Spontaneous Cerebral Embolisation in Asymptomatic and Recently Symptomatic Patients with TIA/Minor Stroke

Abstract

Objectives: Spontaneous embolisation (SE) detected using Transcranial Doppler (TCD) after a Transient Ischaemic Attack (TIA)/Minor stroke is an independent predictor of recurrent stroke. There are, however limited data on the differential prevalence of SE in the first few days/weeks after onset of symptoms.Method: 156 consecutive patients (symptomatic n ϭ 123, asymptomatic n ϭ 33) underwent Carotid Endarterectomy (CEA) during an 18 month period and had an accessible window permitting 30 min of preoperative TCD monitoring. A prospective study was conducted with assessors blinded to clinical status.Results: Spontaneous embolisation was detected in 31 symptomatic patients (25%) of which 1/1 (100%), 14/35 (40%), 8/37 (22%) and in 8/50 (16%) patients presented within 48 h, 3-7 days, 8 -14 days and Ͼ14 days respectively from the index clinical event. SE occurred in only 6% of asymptomatic patients. Out of 31 symptomatic patients with SE, seven (22.6%) suffered recurrent cerebrovascular events following admission as opposed to 11/92 patients (11.9%) who had no evidence of spontaneous embolisation after admission (OR 2.2 (95% CI 0.8 -6.1))(P ϭ 0.2) Conclusion: Patients presenting for CEA in the hyperacute period after onset of TIA/Minor stroke have a high incidence of SE. Patients with SE had a 23% risk of recurrent cerebrovascular events. These data support the current drive towards expedited CEA in recently symptomatic patients. Proximal Common Carotid Artery Lesions: Endovascular and Open RepairLinni K., Aspalter M., Ugurluoglu A., Hölzenbein T.Eur J Vasc Endovasc Surg 2011;41:728-34.

Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without Significantly Increasing Peri-operative Bleeding Complications

“…In the 2011 audit, Salem reported that 18/123 patients (15%) suffered recurrent symptoms in the (median) 3-day time period between transfer from the TIA clinic and undergoing CEA. 9 None, however, were strokes. In a second (2013) audit, Ali observed that 10/89 patients (11%) suffered recurrent neurological events (TIA ¼ 8;…”

“…12 Similar data (regarding spontaneous embolization rates) were available from the two preceding audits in 2010 and 2011. 9,10 In addition, the time from flow restoration to removal of drapes was used as a surrogate for the delay to achieving haemostasis. In view of the temporal changes in patch type (and the effect/bias this might have had on haemostasis), three consecutive patient cohorts were analyzed: (i) January 1, 2011 to December31, 2011: polyester patch with regular aspirin þ 75 mg clopidogrel the night before surgery (n ¼ 96); (ii) January 1, 2012 to May 31, 2013: bovine pericardial patch with regular aspirin þ 75 mg clopidogrel the night before surgery (n ¼ 122); and (iii) August 17, 2013 to July 27, 2014 (the current audit): bovine pericardial patch with regular aspirin þ 75 mg clopidogrel starting once ICH was excluded in the TIA clinic (n ¼ 100).…”

“…8 This protocol was associated with a reduction in the delay from symptom to CEA to a median of 9 days (95% CI 7e 10). 9 Following transfer from the TIA clinic, patients underwent CEA within a median of 3 days. However, two sequential audits showed that during this 3-day time period (between transfer from the TIA clinic and undergoing CEA), 11% and 15% of patients (respectively) suffered recurrent TIAs or strokes, 9,10 emphasizing just how unstable underlying carotid plaques were during this early time period.…”

Prognostic Value of Preoperative Border-zone (Watershed) Infarcts on the Early Postoperative Outcomes of Carotid Endarterectomy after Acute Ischemic Stroke

“…15 The latest evidence suggests that CEA could also be performed during the hyper acute period without significantly increasing the operative risk in neurologically stable patients. 18,19,35 The operative risk remains high however for CEA performed in cases of neurological instability (associated brain hemorrhage, large volume cerebral infarctions with persistent disabling massive deficit, stroke-in-evolution). 19 For this reason, we decided to operate only on neurologically stable patients regardless of the time at which they reached stability.…”

Part One: For the Motion. Carotid Endarterectomy is Safer than Stenting in the Hyperacute Period After Onset of Symptoms

“…In 1977, Harrison and Marshall showed that when CEA was performed within 4 weeks of the index TIA, 66% of patients had thrombus overlying their plaque compared with only 21% when CEA was performed thereafter. 10 Surgeons who have regularly been performing CEA within 7 days of symptom onset increasingly encounter grossly disrupted plaques with large amounts of overlying thrombus (Fig. 1), which is associated with higher rates of spontaneous embolization being detected on transcranial Doppler in the early time period after symptom onset (42% prevalence at < 7 days of symptom onset, 22% at 8e14 days, and 16% for > 14 days).…”