11例颈动脉盗血综合征临床分析

目的分析11例颈动脉盗血综合征(CSS)的临床表现和影像学特点,评估其侧支循环建立与代偿方式及不同治疗方式的预后,为CSS的诊治提供依据。方法纳入2016年1月~2016年5月住院治疗的CSS患者11例。所有患者均进行颈部血管彩超、头颅CT血管造影(CTA)或磁共振血管成像(MRA)、数字剪影血管造影(DSA)等检查明确CSS诊断,进行侧支循环代偿评估。11例CSS患者中,4例患者行颈动脉内膜剥除术(CEA),5例行颈动脉内支架植入术(CAS),2例颈动脉闭塞患者药物保守治疗。对11例患者在治疗3个月、6个月和1年后进行随访,并评估缺血性脑血管事件及改良RANKIN量表评分(mRs)。结果 11例CSS患者中,单侧颈内动脉病变7例,双侧颈内动脉病变4例。临床表现为短暂性脑缺血发作7例,分水岭梗死3例,腔隙性脑梗死1例;其中后循环缺血7例,前循环缺血4例。DSA评估侧支循环建立单以一级侧支循环(11例)和二级侧支循环(4例)开放为主。ASITN评分大部分为3~4级。治疗后随访,有2例行CAS的患者出院后出现不同时期卒中样症状,4例行CEA的患者随访期内均未发生卒中。CAS和CEA术后3个月、6个月和1年的mRs评分均有不同程度改善。结论 CSS患者多发生于颈动脉狭窄严重患者,其侧支循环开放良好,以一、二级侧支循环开放为主,临床表现以后循环缺血症状多见。CAS及CEA能改善颈动脉狭窄,可能成为CSS的治疗手段。     

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.     

Recent concepts in the management of extracranial carotid stenosis: carotid endarterectomy versus carotid artery stenting

Carotid stenosis is seen in 10% of patients with ischemic stroke, and carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the two invasive treatments options available. Pooled analysis of the three largest randomized trials of CEA involving more than 3000 symptomatic patients estimated 30-day stroke and death rate at 7.1% after CEA. Some subgroups among the symptomatic patients appeared to have more benefit from CEA. These include patients aged 75 years or more, patients with ulcerated plaques, and patients with recent transient ischemic attacks within 2 weeks of randomization. Selection of asymptomatic patients for carotid revascularization should be guided by an assessment of comorbid conditions, life expectancy, and other individual factors, and should include a thorough discussion of the risks and benefits of the procedure with an understanding of patient preferences. The recent trials comparing CEA with CAS has not established its superiority over CEA. The carotid revascularization endarterectomy versus stenting (CREST) study showed that CAS is still associated with a higher periprocedural risk of stroke or death than CEA. In patients over 70 years of age, CEA is clearly superior to CAS. The increased risk of nonfatal myocardial infarction in the CREST group subjected to CEA clearly suggests that patients being considered for CEA or CAS require a careful preliminary cardiac evaluation. CAS can be justified for patients whose medical comorbidities or cervical anatomy make them questionable candidates for CEA. The benefit of revascularization by either method versus modern aggressive medical therapy has not been established for patients with asymptomatic carotid stenosis.     

颈部夹层动脉导致缺血性脑卒中17例临床分析

目的:探讨颈部夹层动脉(CAD)缺血性脑卒中的临床表现。方法:收集我中心前瞻性登记数据库中的17例(共18支病变血管)经DSA全脑血管造影证实的、因CAD所致缺血性脑卒中患者的资料,对其归纳分析。结果:CAD所致缺血性脑卒中和短暂性脑缺血发作(TIA)占同期该年龄段缺血性脑卒中和TIA的7.49%(17/227)。所有患者均因TIA或局灶神经功能缺损就诊;头颅MRI和DSA均发现特征性征象,颈内动脉夹层(ICAD)与椎动脉夹层(VAD)的构成比为16/2;所有患者均接受抗凝、抗血小板聚集治疗,其中6例行支架置入术。随访2个月所有患者均获得一定程度的神经功能恢复。结论:ICAD较VAD常见,TIA或局灶神经功能缺损症候结合特征性的影像学改变是诊断CAD的主要线索和依据。     

Strategy for management of carotid arterial stenosis: analysis of 293 consecutive patients in a Japanese cerebrovascular center]

Carotid arterial stenosis is a major risk factor for ischemic stroke and is increasing in Japan as the life-style has been westernized. The purpose of this study was to clarify the detailed process of diagnosis and treatment of patients with carotid arterial stenosis. Of the consecutive 1,889 hospitalized patients in our cerebrovascular center during 2001 and 2003, 293 patients had carotid stenosis 50% or more in diameter by the NASCET method; 82 patients were hospitalized during the acute stage of ischemic stroke and 211 patients with or without past history of ischemic stroke were admitted in the chronic stage. Among acute ischemic stroke patients, 62 patients (76%) had mild neurological symptoms of NIH Stroke Scale score < or = 4 on admission. As the initial treatment during the acute phase, all patients underwent antithrombotic medication; 33 of them underwent carotid endarterectomy (CEA) or carotid arterial stenting (CAS) in the chronic stage. Of 211 chronic patients, 123 (58%) did not have a history of symptomatic ischemic stroke, and instead had nonspecific symptoms, including carotid bruit, headache, and vertigo, or were diagnosed as having carotid artery stenosis by examinations of preoperative screenings. One hundred and thirty-five chronic patients underwent CEA/CAS and all the others except for a patient with serious gastrointestinal bleeding underwent anti-thrombotic medication. Statin treatment was chosen for 59 acute patients and 66 chronic patients. Because many patients with carotid arterial stenosis had mild symptoms during the acute phase or did not have ischemic episodes, we might overlook carotid lesions unless we performed screening examinations using ultrasound or magnetic resonance angiography.     

颈动脉粥样硬化斑块无创性高分辨力磁共振成像研究进展

颈动脉粥样硬化性狭窄与脑卒中复发密切相关。目前颈动脉狭窄的治疗方法主要包括药物治疗和外科手术(颈动脉支架成形术和颈动脉内膜切除术)。脑卒中预防在于识别颈动脉狭窄危险因素,筛查脑卒中复发高危患者,从而使其从药物治疗或外科手术中获益,然而目前仅根据颈动脉狭窄程度制定治疗方案,缺乏个体化治疗。近年来,新型影像学技术如无创性高分辨力磁共振成像(HRMRI)等,可以检测出颈动脉易损斑块。与传统数字减影血管造影术测量的颈动脉狭窄程度相比,无创性HRMRI可以根据颈动脉斑块特征准确预测同侧脑卒中风险,从而指导个体化治疗。     

Carotid artery stenting: Current state of evidence and future directions

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long‐term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in‐stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.     

Consensus and controversy in the treatment of ischemic cerebrovascular diseases]

Surgical and endovascular revascularization for ischemic cerebrovascular diseases (CVD) should be strictly indicated based on medical treatment. In this report, we describe current consensus and controversy in the treatment of ischemic CVD, and perspectives. 1) Local intra-arterial fibrinolytic therapy for acute cerebral embolism; intra-venous t-PA can be beneficial when given within 3 hours of stroke onset (NINDS), but many patients present later after stroke onset and alternative treatments are needed. Despite an increased frequency intracranial hemorrhage, treatment with intra-arterial proUK within 6 hours for MCA occlusion significantly improved clinical outcome at 90 days (mRS 40% >25%, PROACT-II). MELT-Japan are going now and waiting for results. 2) Carotid stenting; Carotid angioplasty and stenting (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) in those considered at high risk for CEA. SAPPHIRE study confirmed CAS is an excellent option for patients with coexisting coronary artery disease, congestive heart failure, and other comorbid conditions that make them poor candidates for CEA. Now, CREST in USA and CSSA in Europe are going for randomized trial compared with CEA and CAS in any risk for CEA patients. 3) Stenting for intracranial arteries; Stroke rates in patients with symptomatic intracranial stenosis may be high on medical therapy. Although there is no clinical evidence and appropriate devices for intracranial vessels, it seems to be a potentially effective in the future.     

Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are used to prevent ischaemic stroke in patients with stenosis of the internal carotid artery. Better knowledge of risk factors could improve assignment of patients to these procedures and reduce overall risk. We aimed to assess the risk of stroke or death associated with CEA and CAS in patients with different risk factors. METHODS: We analysed data from 1196 patients randomised to CAS or CEA in the Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE) trial. The primary outcome event was death or ipsilateral stroke (ischaemic or haemorrhagic) with symptoms that lasted more than 24 h between randomisation and 30 days after therapy. Six predefined variables were assessed as potential risk factors for this outcome: age, sex, type of qualifying event, side of intervention, degree of stenosis, and presence of high-grade contralateral stenosis or occlusion. The SPACE trial is registered at Current Controlled Trials, with the international standard randomised controlled trial number ISRCTN57874028. FINDINGS: Risk of ipsilateral stroke or death increased significantly with age in the CAS group (p=0.001) but not in the CEA group (p=0.534). Classification and regression tree analysis showed that the age that gave the greatest separation between high-risk and low-risk populations who had CAS was 68 years: the rate of primary outcome events was 2.7% (8/293) in patients who were 68 years old or younger and 10.8% (34/314) in older patients. Other variables did not differ between the CEA and CAS groups. INTERPRETATION: Of the predefined covariates, only age was significantly associated with the risk of stroke and death. The lower risk after CAS versus CEA in patients up to 68 years of age was not detectable in older patients. This finding should be interpreted with caution because of the drawbacks of post-hoc analyses.     

Age and gender disparities in the risk of carotid revascularization procedures

The potential effect of age and gender stratification in the outcome of patients with carotid artery stenosis undergoing carotid revascularization procedures (CRP) may have important implications in clinical practice. Both European Stroke Organization and American Heart Association guidelines suggest that age and sex should be taken into account when selecting a CRP for an individual patient. We reviewed available literature data through Medline and Embase. Our search was based on the combination of terms: age, gender, sex, carotid artery stenosis, carotid artery stenting (CAS) and carotid endarterectomy (CEA). Postoperative stroke and mortality rates increased with age after any CRP (CEA or CAS), especially in patients aged over 75 years. Older patients with carotid artery stenosis undergoing CAS were found to have a nearly double risk of stroke or death compared with CEA, while CEA was found to benefit more patients aged over 70 years with symptomatic carotid artery stenosis. Male patients with symptomatic or asymptomatic carotid artery stenosis had lower stroke/mortality rates and benefited more from CEA compared with females. For the periprocedural risk of stroke or death in patients with carotid artery stenosis after CAS no sex differences were found. Therefore, CEA appears to have lower perioperative risks than CAS in patients aged over 70 years, and thus should be the treatment of choice if not contraindicated. The periprocedural risk of CEA is lower in men than in women, while there was no effect of gender on the periprocedural risk of CAS.     

Treatment of carotid artery disease: Stenting or surgery?

Carotid endarterectomy (CEA) is the only form of cerebral revascularization for which Level 1 evidence of effectiveness has been reported. Recent studies demonstrate the feasibility of carotid artery stenting (CAS) as an alternative to CEA. Its popularity is due to the perceived advantages of a less invasive treatment for carotid occlusive disease. Two randomized trials have reported no difference in the composite stroke, death, and myocardial infarction rate between CAS and CEA. However, these trials were not powered to identify superiority between the two procedures. A trial sponsored by the National Institutes of Health is currently underway to make that determination. The lead-in phase of this trial noted low complication rates with CAS. These results have encouraged the US Food and Drug Administration to approve the use of CAS in patients with neurologic symptoms (ie, ipsilateral stroke, transient ischemic attacks, and amaurosis fugax) in association with severe medical co-morbidities. Patients with carotid restenosis after previous CEA, anatomically inaccessible lesions above C2, and radiation-induced stenoses may also benefit from preferential treatment with CAS. The National Institutes of Health have now expanded the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) to include asymptomatic patients, and resulting data will help to clarify the role of CAS in this subset as well.     

血管成形术治疗症状性重度颈动脉狭窄的临床研究

目的 探讨颈动脉内膜剥脱术(carotid endarterectomy,CEA)和颈动脉支架成形术(carotid artery stenting,CAS)治疗症状性重度颈动脉狭窄的近期和中期临床效果.方法 回顾性地分析了2016年1月至2018年12月在我院接受CEA或CAS治疗的203例症状性重度颈动脉狭窄患者的...     

颈动脉内膜切除术临床研究进展简

经过半个多世纪的发展,颈动脉内膜切除术已成为治疗颈动脉狭窄、预防缺血性卒中的金标准手术技术。但是对于颈动脉内膜切除术与颈动脉支架成形术的选择、手术前后认知功能的变化、补片与转流管的应用,以及性别对围手术期和术后并发症的影响等尚存争议,有待更多的大样本前瞻性随机对照试验进一步阐明。     

Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?

Purpose of Review

Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.

Recent Findings

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.

Summary

‘Average surgical risk’ patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed ‘high risk’ for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.

     

CEA治疗伴对侧颈内动脉闭塞的颈动脉重度狭窄的疗效

目的评价颈动脉内膜剥脱术治疗一侧颈内动脉重度狭窄伴对侧颈内动脉闭塞的疗效。方法回顾性分析11例患者的临床资料,包括围手术期并发症及近远期疗效;并比较术前及术后3个月颈部及大脑中动脉血管血流峰值。结果即刻成功率为100%,术后患者脑缺血症状均得到改善,围手术期无病例死亡或缺血性脑卒中等严重并发症发生,仅有1例出现皮下血肿、1例出现短暂声音嘶哑,经积极治疗后均好转。随访率100%,随访时间6~61(32.5±17.2)个月。患者均无术侧颈动脉再狭窄,其中1例再发对侧缺血性脑卒中。术后患者颈动脉血流峰值及大脑中动脉收缩期血流峰值与术前比较差异有统计学意义(均P0.05)。结论对于一侧颈内动脉重度狭窄伴对侧颈动脉闭塞的高危患者,颈动脉内膜剥脱术具有满意的围手术期结果和较好的远期脑卒中预防疗效。     

Carotid endarterectomy: a review

BACKGROUND: Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEA results. INVESTIGATION: Brain imaging with CT or MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRA or CT angiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment. INDICATIONS: Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50-69% symptomatic stenosis, and those with asymptomatic stenosis > or = 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions. TECHNIQUES: Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. "Eversion" endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis. CAROTID ANGIOPLASTY AND STENTING: Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA. AUDITING: It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.     

Early outcome of carotid angioplasty and stenting versus carotid endarterectomy in a single academic center

BACKGROUND: Evidence is accumulating that carotid angioplasty and stenting (CAS) might become an alternative to carotid endarterectomy (CEA) for the treatment of high-grade carotid artery disease (CAD). Evaluating the efficacy of this novel technique in single institutions in addition to performing further large trials can help to guide optimal patient management in everyday practice. METHODS: In this study we compared the early outcome of 100 prospectively followed patients who underwent CAS with a retrospectively reviewed group of 142 patients that underwent CEA over the same time period. Only patients who had received pre- and postsurgical evaluations by a neurologist were included. According to the criteria set forth by the large trials the occurrence of minor or major strokes, myocardial infarction and death within 30 days was analysed. RESULTS: Both groups had similar age and sex distributions, as well as cerebrovascular risk factors. In the group of CAS patients 63 (63%) and in the group of CEA patients 92 (65%) had a symptomatic carotid stenosis, respectively. For symptomatic patients the overall complication rate (any stroke or death) was 6.5% (3 minor and 3 major strokes) in the surgical and 8% (2 minor strokes, 2 major strokes, and 1 death) in the non-surgical group (n.s.). For asymptomatic patients there was one minor stroke (2%) in the surgical and no stroke or death in the non-surgical group. As a frequent non-neurological complication the post-procedural course was complicated by groin hematoma requiring surgery in 3 CAS patients, and neck hematoma requiring additional surgery in 3 CEA patients. CONCLUSIONS: Within our academic institution we found comparable complication rates for CAS and CEA in patients with symptomatic or asymptomatic high-grade CAD. Although these early results are promising and support the notion that CAS may become an alternative treatment option for CAD in everyday practice, the long-term efficacy of CAS has to be evaluated critically by means of further prospective studies.     

Time delay between symptom and surgery in patients with carotid artery stenosis

Andgren S, Sjöberg L, Norrving B, Lindgren A. Time delay between symptom and surgery in patients with carotid artery stenosis.
Acta Neurol Scand: 2011: 124: 329–333.
© 2011 John Wiley & Sons A/S. Objectives – Many severe strokes are preceded by warning signs such as a transient ischemic attack or stroke with minor deficits. Carotid endarterectomy (CEA) of a symptomatic carotid artery stenosis can prevent future strokes, but should be performed within 2 weeks after the initial symptom to maximize the benefit. The aim of this study was to determine the time delays between symptom and CEA. Methods – We performed a single center observational retrospective study at a tertiary stroke center. A total of 142 carotids in 139 patients with symptomatic stenoses between 2002 and 2006 were included. The main outcome measure was time between qualifying cerebrovascular symptom and CEA. Results – The median time between symptom and CEA was 26 days. The longest delays were between the last diagnostic examination and carotid conference, and between carotid conference and surgery. The median time was shorter for those who received emergency medical care (median 21 days) and for those who were admitted immediately to hospital (median 20 days). Conclusions – The time between symptom and surgery is often longer than desirable. There are several measures to improve the chain of procedures for patients with carotid artery stenosis. These may include omitting the formal carotid conference for uncomplicated cases and minimizing waiting time for surgery.     

The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.     

Neurological complications of carotid revascularisation

Carotid endarterectomy (CEA) is an effective treatment for patients with recently symptomatic severe carotid stenosis and in selected patients with symptomatic moderate carotid stenosis. Carotid artery angioplasty and stenting (CAS) is emerging as an alternative to CEA, and randomised controlled trials suggest comparable efficacy to CEA in prevention of non-perioperative stroke. Neurovascular complications can result from both procedures, usually from thromboembolism from the operated vessel, cerebral hypoperfusion causing ischaemia and, rarely, intracerebral haemorrhage. The overall incidence of perioperative strokes complicating CEA and CAS is approximately 4% and 6%, respectively, and represents a devastating outcome that the procedure was designed to prevent. Other neurological sequelae complicating carotid revascularisation include cerebral hyperperfusion syndrome, cranial and peripheral nerve injuries, and contrast encephalopathy in patients undergoing CAS. In this review, we analyse the incidence, mechanisms and perioperative management of neurological complications for patients undergoing carotid revascularisation.