The natural history of carotid arterial disease in asymptomatic patients with cervical bruits

A prospective study was initiated in January 1980 to follow with Duplex scanning a consecutive series of 167 asymptomatic patients with cervical bruits. Patients were seen at six month intervals for the first year and yearly thereafter. Based on previously validated criteria, disease at the carotid bifurcation was classified into 6 categories: Normal, 1-15% diameter reduction, 16-49%, 50-79%, 80-99%, and occlusion. Patients were evaluated to assess: the occurrence of new neurological symptoms, the stability of the lesions at the carotid bifurcation, and the possible role of risk indicators on disease changes. During follow-up, ten patients became symptomatic (6 with TIA's and 4 with stroke). The development of symptoms was accompanied by disease progression in 8 patients. By life table analysis, the annual rate occurrence of symptoms was 4%. The mean annual rate of disease progression to a greater than 50% stenosis was 8%. When progression in all categories was considered, 60% of the sides showed some disease aggravation. The presence of or progression to a greater than 80% stenosis was highly correlated (p = 0.00001) with either the development of a total occlusion of the internal carotid artery or new symptoms. The major risk factors associated with disease progression were cigarette smoking, diabetes mellitus, and age. Those patients under 65 years of age were most likely to show progression. Despite high rates of disease progression, this study further supports the contention that it is prudent to follow a conservative course in the management of asymptomatic patients presenting with a cervical bruit.(ABSTRACT TRUNCATED AT 250 WORDS)     

Combining carotid endarterectomy with off-pump coronary artery bypass graft surgery is safe and effective

Background:

We, as neurologists, are frequently consulted to give neurological clearance for surgery in patients who are undergoing coronary artery bypass graft (CABG) surgery and have suffered from stroke or transient ischemic attack (TIA) in past. Similarly clearance is also sought in another group of patients who, though have not suffered from stroke or TIA, but found to have significant carotid stenosis on routine screening prior to surgery. Cardiac surgeons and anesthetists want to know the risk of perioperative stroke in such patients and should carotid endarterectomy (CEA) be done along with CABG. In absence of any clear-cut guideline, neurologists often fail to give any specific recommendation.

Aim:

To find out safety and efficacy of synchronous CEA in patients undergoing CABG.

Design:

Retrospective study.

Materials and Methods:

Out of 3,700 patients who underwent CABG, 150 were found to have severe carotid stenosis of >70%. Out of this, 46 patients with >80% stenosis (three symptomatic and 43 asymptomatic) and one patient with >70% symptomatic carotid stenosis (TIA within last 2 weeks) were taken for simultaneous CEA along with CABG. These three symptomatic carotid patients had suffered from stroke within last 6 months.

Results:

One patient with asymptomatic near total occlusion of carotid artery suffered from hyperperfusion syndrome. None suffered from ischemic stroke, myocardial infarction (MI), or death during perioperative period.

Conclusion:

Combining CEA along with CABG is a safe and effective procedure.     

Cerebrovascular reactivity in carotid artery occlusion: possible implications for surgical management of selected groups of patients

OBJECTIVES: The aim of this study was to use transcranial Doppler ultrasonography to investigate cerebrovascular reactivity to hypercapnia in the middle cerebral arteries of patients with carotid occlusion with different outcomes. PATIENTS AND METHODS: Cerebrovascular reactivity to hypercapnia was calculated with the breath-holding index (BHI). Patients with unilateral carotid occlusion were divided as follows: asymptomatic (20 patients), transient ischemic attack (TIA) (20 patients), minor (20 patients) and major stroke (14 patients). Values of BHI homolateral to the carotid occlusion were compared with those of 25 healthy subjects and 34 stroke patients without significant carotid stenosis. RESULTS: BHI values were comparable in healthy controls, non stenotic stroke patients and asymptomatic occluded patients. BHI values of patients with symptomatic occlusion were significantly lower than those of the above-mentioned groups (P<0.0001). Moreover, the reduction of BHI was significantly associated with the extent of the neurological impairment. In fact, BHI values were significantly higher in TIA than in minor and major stroke (P<0.0001) and in minor than in major stroke patients (P<0.02). Finally, we found that a BHI value homolateral to carotid occlusion of 0.69 can be considered the cut-point for distinguishing between symptomatic and asymptomatic patients. CONCLUSION: Prospective studies are needed to demonstrate if the presence of this threshold value may help in selecting a subset of patients with asymptomatic carotid occlusion or with transient or mild neurological deficit with the highest probability of benefiting from surgical therapy.     

Carotid artery blood flow velocity related to transient ischemic attack and stroke in a population study of 69-year-old men

A population-based sample of 478 men aged 69 years living in Malm?, Sweden, underwent Doppler ultrasonic examination of their carotid arteries; cerebrovascular symptoms and signs were recorded independently. Among 471 men with complete examinations, 117 (25%) showed significant abnormalities in carotid blood flow velocity (moderate stenoses [30-60% diameter reduction] in 20%, severe stenosis [greater than or equal to 60% reduction] or occlusion in 5%). The latter seemingly formed a group separate from the main distribution curve. Stroke was reported in 28 men (6%), during the year before examination in nine (2%). Carotid transient ischemic attack (TIA) was clinically confirmed in one man during this year, while unconfirmed symptoms were reported in 63 (13%). There was a relation between ipsilateral hemispheric stroke/TIA and severe carotid disease (p less than 0.001). Four of seven men with total occlusion had a stroke or a clinically confirmed TIA. Nevertheless, the majority of carotid stenoses (including severe stenoses) were asymptomatic. Cerebrovascular symptoms were not significantly more frequent among the men having moderate stenosis than among those having healthy arteries.     

Benign outcome of carotid occlusion

We followed 40 patients with unilateral carotid occlusion by serial clinical and Doppler evaluation for over 6 years. Two groups were identified: 19 patients had already occluded their arteries on entry to the study, and 21 progressed to occlusion during the course of the study. No strokes occurred in the first group during follow-up, and the annual stroke rate in the second group was 3.8% for the territory of the occluded artery and 5.7% for all vascular territories. Death rate was 6.6% annually for both groups, mainly cardiac. Transcranial Doppler with digital compression of each carotid artery demonstrated middle cerebral artery (MCA) dependent on the patent carotid being total in 50% and partial in 30%. There was no correlation between degree of stenosis and MCA dependency (r = -0.24). Our data on stroke risk in asymptomatic patients with unilateral carotid artery occlusion indicate a benign outcome.     

Clinical significance of the ophthalmic artery in carotid artery disease

A total of 141 subjects with tight stenosis (≥75%) or occlusion of internal carotid artery were followed up at intervals 3–6 months regularly for 40 ± 16 months. The direction of ophthalmic artery flow was used as a parameter of risk indicator on cerebral ischemic events. Eleven patients with bilateral carotid tight stenosis/occlusion were excluded in the analysis. Thus, the 130 carotid arteries were divided into three groups: (1) carotid artery with ipsilateral hemispheric TIA or stroke (85 patients), (2) carotid arteries with contralateral hemispheric TIA/stroke or VBI (15 patients), and (3) carotid arteries of asymptomatic patients (30 patients). The symptomatic carotid artery group (group 1) had significantly more often reversed ophthalmic flow than the other two groups (group 2 and 3, p < 0.001). During follow-up prospectively for four years, 41 patients had cerebral ischemic events, three had cardiac ischemic events and six died of malignancy. Patients with reversed OA flow had more often subsequent cerebral ischemic events than those with forward flow (27 vs 14, p = 0.010). However, the difference remained significant only in the asymptomatic patients (group 3, 4 vs 0, P < 0.001), not for groups 1 and 2, after further analysis. Our work supported that the clinical role of ophthalmic artery collateral varied between asymptomatic and symptomatic patients.     

双侧颈动脉重度狭窄/闭塞患者的临床干预研究

目的评价血管内支架置入术和内科药物治疗双侧重度颈动脉狭窄/闭塞病人的疗效.方法一侧颈动脉闭塞,对侧颈动脉重度狭窄病人21例,随机分成两组：A组8例,接受颈动脉血管内支架置入治疗;B组13例,接受内科药物治疗.临床和超声波随访1年半.结果A组患者术前颈动脉狭窄程度为70%～98%,颈内动脉支架放置成功,术后狭窄程度小于10%,除1例偶发一次一过性脑出血（TI）外,其他病人未再出现TIA和中风发作,颈动脉超声随访1年半,未见明显的管腔再狭窄（狭窄＜30%）.B组病人9例再次卒中（5例发生脑梗塞,其中2例死亡,4例反复TIA）,另4例病情无变化.超声波检查发现7例病人颈动脉内中膜增厚、动脉粥样斑块增多增大,管腔进一步狭窄.结论血管内支架置入术是治疗双侧颈动脉重度狭窄/闭塞安全有效的治疗手段,其短-中期疗效优于内科药物治疗.     

Operative versus nonoperative management of asymptomatic high-grade internal carotid artery stenosis: improved results with endarterectomy

In a 4-year period, 129 asymptomatic high-grade (80-99%) internal carotid artery stenoses were identified in 115 patients. Because we previously demonstrated a strong relation between degree of carotid stenosis and subsequent development of ipsilateral related events (stroke, transient ischemic attack, and carotid occlusion), we changed our previous policy and began to offer carotid endarterectomy to good surgical risk patients referred to us with asymptomatic high-grade carotid stenosis. A total of 56 carotid endarterectomies were performed while 73 lesions were followed nonoperatively. Operated and nonoperated groups were similar with regard to age, prevalence of hypertension, cardiac disease, diabetes, and aspirin use. Life table analysis to 24 months revealed a higher rate of stroke (19 vs. 4%, p = 0.08), transient focal neurologic deficits (28 vs. 5%, p = 0.008), and carotid occlusion (29 vs. 0%, p = 0.003) in the nonoperated group. Eight of the 9 strokes in the nonoperated group occurred within 9 months of diagnosis of the high-grade lesion; none were preceded by a transient ischemic attack. There was 1 perioperative stroke (1.8%) but no in-hospital operative deaths and no difference in the late death rates of the two groups. This suggests that the preservation of neurologic status in patients with asymptomatic high-grade internal carotid artery stenosis can be improved by carotid endarterectomy.     

Carotid endarterectomy for prevention of stroke: comparison of surgical and conservative therapy

The incidence of TIA, stroke and death among 689 patients with a narrowing of the internal carotid artery exceeding 50% was investigated in a follow-up study. Patients were assigned according to their initial status to one of the following groups: asymptomatic, transient ischemic attacks (TIA) and minor stroke. Patients subjected to carotid endarterectomy (n = 206) were compared to those treated by oral medication only. The follow-up time averaged 2.1 years. The incidence of stroke and death among the initially asymptomatic persons was not significantly different in those who underwent surgery (n = 46) and those who did not (n = 234). The incidence of TIA however was significantly higher in the operated patients. Among patients with TIA the incidence of repeated TIA, stroke and death was similar in those who were operated (n = 90) and those who were not (n = 61). The same was true for subsequent TIA and strokes in patients who had suffered from a first stroke prior to the initial examination. Patients who underwent surgery (n = 70) did not differ in this respect from the 188 patients who were not operated on. The death rate, however, was significantly higher in the non-operated patients (24.5% versus 7.2%). Due to the retrospective character of the study, operated and non-operated groups of patients were not directly comparable. We therefore selected comparable groups of patients by a stratification procedure. These subgroups showed no differences in the incidence of TIA and stroke between operated and non-operated patients. The result indicates, that the decision to perform carotid endarterectomy should be made with great caution.     

Angioplasty and stenting of symptomatic and asymptomatic vertebral artery stenosis: to treat or not to treat

Background and purpose: Comprehensive indications for treatment of symptomatic vertebral stenosis remain unavailable. Even less is known about endovascular treatment of asymptomatic cases. We treated symptomatic and asymptomatic vertebral ostium stenosis with angioplasty and stenting and investigated the long term outcome. Methods: Consecutive patients with two different indications were included. Group 1 (G1) had symptomatic >50% stenosis. Group 2 (G2) had asymptomatic >50% stenosis and severe lesions of anterior circulation and were expected to benefit from additional cerebral blood supply. Results: Twenty nine vertebral origin stenoses in 28 patients (75% men, mean age 64 ± 9 years) were treated. There were 16 G1 and 13 G2 cases. Technical success rate was 100%. Immediate neurological complications rate was 3.4% (one G1 patient with vertebral TIA due to release of emboli). Two further strokes were seen during follow up (32 ± 24 months): vertebrobasilar stroke in a G2 patient with permeable stent in V1 segment, new ipsilateral V3 occlusion and high‐risk cardioembolic source, and carotid stroke in a G1 patient who had had ipsilateral carotid stenting. There were no deaths of any cause. Asymptomatic restenosis was observed in one out of 19 patients from both groups who underwent a follow up angiography. Conclusions: Angioplasty and stenting appears to be technically feasible and safe in asymptomatic and symptomatic vertebral stenosis. More studies are needed in order to clarify its role in primary and secondary prevention of vertebrobasilar stroke. High risk anterior circulation lesions should be taken into account as a possible indication in patients with asymptomatic vertebral stenosis.     

Immediate and long-term results of carotid endarterectomy

We review the long-term results of carotid endarterectomy in 200 consecutive patients operated on from 1980 to 1987. The patients were part of an ongoing study using duplex scanning to assess the status of the carotid bifurcation before and after endarterectomy. The average follow-up for the patients was 31 months. The indications for surgery were transient ischemic attacks in 87 (43.5%) and stroke in 36 (18%) patients; 77 patients (38.5%) were asymptomatic. In 176 sides (88%), the degree of stenosis exceeded 50% in terms of diameter reduction. The perioperative stroke rate was 2.3% in patients with transient ischemic attacks, 2.8% in patients with strokes, and 1.3% in asymptomatic patients. There was one perioperative death (0.5%). There were five occlusions of the internal carotid artery, one during the perioperative period and four after discharge; in three patients the occlusion was associated with the development of a stroke. There was a restenosis rate of 19.7% secondary to myointimal hyperplasia; such lesions did not appear to contribute to new ischemic events during or after their development. The mean stroke incidence after the decision was made for carotid endarterectomy was 2.8%/yr in the patients with transient ischemic attacks, 6.2%/yr in the patients with stroke, and 0.65%/yr in the asymptomatic patients. The annual death rate was 6% for the entire group, 5.5%/yr in the patients with transient ischemic attacks, 9.2%/yr in the patients with stroke, and 4.6%/yr in the asymptomatic patients.     

Gender-specific risk of perioperative complications in carotid endarterectomy patients with contralateral carotid artery stenosis or occlusion

Carotid endarterectomy (CEA) has been shown to be effective in stroke prevention in selected patients. Some studies, however, identified gender as an independent risk factor for perioperative CEA complications demonstrating an increased rate of perioperative stroke or death in women. Furthermore, contralateral internal carotid artery (ICA) occlusion has been associated with higher rates of perioperative CEA complications. Therefore, we sought to analyse the gender-specific risk of perioperative CEA complications between patients with or without contralateral ICA stenosis or occlusion. We retrospectively analysed 212 consecutive CEA patients (male = 156, Female = 56) for their gender-specific, perioperative risk of stroke, transient ischemic attack (TIA), restenosis and cardiac complications in the presence (62%) or absence (38%) of a contralateral ICA stenosis/occlusion. In women but not in men, risk of perioperative ischemic events (stroke, TIA) or re-stenosis (p = 0.036) and combined perioperative complications (ischemic events, re-stenosis or cardiac complications; 38.2 % vs. 9.1%; p = 0.028) was significantly increased in the presence of a contralateral ICA stenosis or occlusion. Furthermore, in the presence of a contralateral ICA stenosis/occlusion the number of perioperative ischemic events (p = 0.008) and combined perioperative complications (38.2 % vs. 14.3%; p = 0.006) was significantly higher in female than in male patients. Our study suggests that women with contralateral ICA stenosis or occlusion may have a significantly higher risk for perioperative CEA complications than other subgroups of CEA patients. This risk increase seems to be gender-specific and, if confirmed in larger prospective studies, may influence ICA stenosis therapy in the presence of a contralateral ICA stenosis/occlusion in female patients.     

Progression of carotid disease after endarterectomy: A Doppler ultrasound study

The clinical prognosis and evolution of carotid lesions after unilateral endarterectomy were determined in 64 patients examined 1 to 13 years after surgery (mean observation period, 6 years). Surgery mainly was confined to symptomatic patients with a stenosis only on the appropriate side. Average annual stroke rate was 1.6% on the operated and 0.8% on the nonoperated side. Direct Doppler examination at follow-up revealed a recurrent stenosis (≥50%) or occlusion in 36% of the operated carotid arteries, not significantly different from the proportion of progressive carotid lesions on the nonoperated side (27%). In total, 43.8% of the patients had developed new lesions in one or both carotid arteries, as compared to previous angiographic findings. About 30% of the progressive lesions were associated with symptoms of transient ischemic attacks or stroke, as opposed to 5.5% of vessels without progression of lesions (p < 0.001). The incidence of recurrent stenosis on the operated side is considerably higher than that previously reported for symptomatic recurrent stenosis, but may represent the natural course of carotid disease in this population, in which carotid surgery thus should not be regarded as definitive treatment.     

Carotid artery occlusion: acute symptoms and long-term prognosis

Fifty-nine patients with carotid artery occlusion diagnosed during 1968-1977 were studied. The presenting symptoms were ipsilateral TIA in 12 patients, stroke in 41, 9 of whom died in the acute phase, and TIA or stroke from other vascular territory in 6 patients. Thirty-nine percent of the patients had preceding TIA. At the time of follow up (mean 48 months), only 2 cases with TIA and 2 with stroke on the occluded side were found. Seven patients had recurrent symptoms from other vascular regions. Twelve patients died during follow up because of diseases unrelated to stroke. Thus the annual incidence of ipsilateral stroke (approximately 1%) and TIA (approximately 1%) was low. Anticoagulant treatment of 20 of the patients might have contributed to the low recurrence rate.     

Outcome in patients with symptomatic occlusion of the internal carotid artery or intracranial arterial lesions: a meta-analysis of the role of baseline characteristics and type of antithrombotic treatment

OBJECTIVES: We performed a systematic review of the literature to assess the impact of potential risk factors of recurrent stroke other than a compromised cerebral blood flow in patients with carotid occlusion or intracranial arterial lesions. In addition, we investigated the effect of treatment with aspirin or oral anticoagulation on recurrent stroke rate and assessed whether the incidence of recurrent stroke has decreased over the years. METHODS: We searched Medline (1966 and onwards) and reference lists of identified articles for papers reporting on the recurrent stroke risk in patients with carotid occlusion or intracranial arterial lesions. Two authors independently extracted information from all papers. The influence of study characteristics on the risk of the endpoints 'recurrent stroke', 'ipsilateral stroke' and 'vascular death' was determined by Poisson regression analysis. Rate ratios were calculated per 10 percentage points increase of a characteristic. RESULTS AND CONCLUSIONS: Patients with intracranial carotid stenosis or occlusion had a higher rate of recurrent stroke (rate ratio 1.09; 95% CI 1.05-1.14) than patients with extracranial carotid occlusion or middle cerebral artery stenosis or occlusion. In patients with bilateral carotid occlusion the rate was lower (rate ratio 0.82; 95% CI 0.68-0.98). No other vascular risk factors than hypertension (rate ratio 1.23; 95% CI 1.07-1.41) could be shown to increase the rate of recurrent stroke. Oral anticoagulation but not aspirin had a protective effect on the incidence of recurrent stroke (rate ratio 0.86; 95% CI 0.79-0.93). The reported rates of recurrent stroke in patients with symptomatic occlusion of the internal carotid artery or intracranial arterial lesions have not decreased over the years.     

Improved prognosis for asymptomatic carotid stenosis with prophylactic carotid endarterectomy.

BACKGROUND AND PURPOSE: The value of carotid endarterectomy in asymptomatic patients with high-grade stenosis is controversial. The objective of this study is to compare the immediate and long-term outcome of patients after carotid endarterectomy for asymptomatic carotid stenosis (greater than 75%) with the reported natural history of patients followed nonoperatively to determine whether carotid endarterectomy reduces the subsequent neurological event rate. METHODS: The data from 141 carotid endarterectomies performed in 123 patients between January 1980 and December 1986 were reviewed from the perspective of perioperative results and long-term follow-up to January 1990, providing a follow-up ranging from 3 to 10 years. The mean follow-up was 56.6 months (range 27-117 months). RESULTS: There were no perioperative deaths. There were two postoperative stokes: one in the cerebellar distribution and one in the middle cerebral distribution. During the course of follow-up, no patient suffered a stroke in the hemisphere ipsilateral to carotid endarterectomy. One patient developed ipsilateral transient ischemic attacks 24 months after surgery associated with carotid restenosis. A total of three patients developed four recurrent carotid stenoses, for an incidence of 2.8%. All four recurrences were corrected surgically. CONCLUSIONS: These findings are in marked contrast to the reported natural history of patients with greater than 75% stenosis in which the 1-year neurological event rate is 18% and the 1-year stroke rate is 5%. Although final proof of efficacy for prophylactic carotid endarterectomy in asymptomatic patients will await the outcome of randomized trials, until these data are available, prophylactic carotid endarterectomy is justified in centers of excellence that can perform the surgery with low perioperative risk.     

Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis.

BACKGROUND AND PURPOSE: Improved methods of identifying patients at high risk of thromboembolism would allow improved targeting of therapy. One such situation is carotid artery stenosis. This is associated with an increased risk of stroke, which can be reduced by carotid endarterectomy. However, the risk-benefit ratio is low in patients with tight asymptomatic stenosis and moderate symptomatic stenosis. Most stroke in patients with carotid stenosis is believed to be embolic. Therefore, the detection of asymptomatic cerebral emboli using Doppler ultrasound may allow identification of a high-risk group. METHODS: Transcranial Doppler ultrasound was used to record for 1 hour the ipsilateral middle cerebral artery in 111 patients with >60% carotid artery stenosis (69 symptomatic, 42 asymptomatic). The Doppler audio signal was recorded onto digital audio tape for later analysis for embolic signals (ES) by an individual blinded to clinical details. In 67 subjects the relationship between ES and angiographically determined plaque ulceration was investigated. All subjects were followed up prospectively, and the relationship between ES and risk of future ipsilateral carotid artery territory ischemic events (TIA and stroke) was determined. RESULTS: ES were detected in 41(36.9%) subjects. In symptomatic patients there was a significant inverse relationship between the number of ES per hour and time elapsed since last symptoms (Spearman's rho=-0.2558, P=0.034). ES were more common in subjects with plaque ulceration, with a relative risk of 4. 94 (95% CI, 1.23 to 19.84; P=0.025) after controlling for both symptomatic status and degree of stenosis. The presence of ES at entry was predictive of TIA and stroke risk during follow up in both symptomatic (P=0.02) and asymptomatic patients (P=0.007). Considering all 111 patients, the presence of asymptomatic embolization was predictive of a further ischemic event, with an adjusted OR of 8.10 (95% CI, 1.58 to 41.57; P=0.01) after controlling for other cardiovascular risk factors, degree of stenosis, symptomatic status, and aspirin or warfarin use. CONCLUSIONS: Asymptomatic embolization in patients with carotid artery stenosis correlates with known markers of increased stroke risk and is an independent predictor of future stroke risk in patients with both symptomatic and asymptomatic carotid stenosis. It may allow identification of a high-risk group of patients who will particularly benefit from carotid endarterectomy. A large multicenter study is now required to confirm these findings.     

Carotid Artery Occlusion: Acute Symptoms and Long-term Prognosis

Abstract

Fifty-nine patients with carotid artery occlusion diagnosed during 1968-1977 were studied. The presenting symptoms were ipsilateral TIA in 12 patients, stroke in 41, 9 of whom died in the acute phase, and TIA or stroke from other vascular territory in 6 patients. Thirty-nine percent of the patients had preceding TIA. At the time of follow up (mean 48 months), only 2 cases with TIA and 2 with stroke on the occluded side were found. Seven patients had recurrent symptoms from other vascular regions. Twelve patients died during follow up because of diseases unrelated to stroke. Thus the annual incidence of ipsilateral stroke (～1 %) and TIA (～1 %) was low. Anticoagulant treatment of 20 of the patients might have contributed to the low recurrence rate.     

High rate of restenosis after carotid artery stenting in patients with high-grade internal carotid artery stenosis

OBJECTIVE: Carotid endarterectomy (CEA) is the gold-standard procedure for the majority of patients with high-grade symptomatic internal carotid artery stenosis and also for specified high-grade asymptomatic stenoses; however, a proportion of patients are treated with carotid endovascular therapy. We aimed to document medium-term clinical and neurosonographical outcome after carotid artery stenting (CAS). METHODS: 53 patients (mean age: 65 +/- 8 years) with high-grade (> or = 70 % by means of duplex sonography) carotid artery stenosis were enrolled into the study. Nineteen patients had asymptomatic, 34 patients had symptomatic stenoses. All patients had a pre-interventional CT, Doppler and duplex sonography, and digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) prior to the procedural DSA. All patients were offered CEA as the gold-standard procedure and as an alternative to CAS. Both clinical and Duplex sonographical follow-up was obtained at day 1 and 7, month 1, month 3, month 6, month 12, and every subsequent 6 months after the procedure. Mean follow-up time was 22 +/- 1.6 months (+/- SEM). RESULTS: 2/53 patients suffered from stroke. A further 2 patients suffered from carotid artery occlusion shortly after CAS. The cumulative rate of restenosis during follow-up was 24.5 % (13/53). Four of these (7.5 %) were of high-grade and led to further interventional or surgical therapy. CONCLUSIONS: A high rate of restenosis was found during follow-up after CAS. Our analysis of non-selected patients emphasizes that CEA remains the gold-standard procedure for the treatment of symptomatic internal carotid artery stenosis. The frequently performed endovascular treatment of carotid stenosis outside the setting of a randomized controlled trial is not supported by our data.     

Outcome of surgical treatment of 110 patients with transient ischemic attack

Between 1980 and 1982, 227 consecutive patients with transient ischemic attack (TIA) or ischemic brain infarction (IBI) were evaluated as possible candidates for carotid surgery in the Department of Neurology, University of Helsinki. One hundred and ten patients (mean age 58, range 41-72 years) were selected for surgery; 82 of them had had TIA and 28 IBI as the presenting symptom. After a total of 128 operations (84 unilateral and 18 bilateral endarterectomies, and 8 arterial reconstructions), 16 patients (14.5%) developed neurological deficits. In 7 patients (6.4%), the deficit was severe and 4 of them (3.6%) died within the first four days after surgery. Ten patients had occlusion of the contralateral internal carotid artery and/or severe hypertension. Five of them suffered ischemic brain infarction after the operation and two died. Operation on an occluded internal carotid artery in 7 patients was complicated by hemiparesis in two patients, one of whom died. Patients with surgical complications more often had severe hypertension (p less than .001), total occlusion of the contralateral internal carotid artery, (n.s.) and severe angiographic changes (n.s.) compared with patients without complications. During the follow-up the annual rate for IBI was 3.3% and for acute myocardial infarction (AMI) 4.4%. Vascular death occurred with a frequency of 1.7% per year. The results emphasize that patients with TIA or IBI should be carefully evaluated before recommending surgical treatment for prevention of threatened stroke. Patients with severe risk factors may fare better on medical treatment than with surgical intervention.