New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature

BACKGROUND AND PURPOSE: Against the background of a relatively low rate of clinical events during carotid angioplasty and stenting (CAS) or carotid endarterectomy (CEA), diffusion-weighted imaging (DWI) is increasingly being used to compare the incidence of new ischemic lesions after both procedures. In addition, DWI may also provide a means of defining the role of different CAS techniques on this adverse outcome. Therefore, we performed a PubMed search and systematically analyzed all peer-reviewed studies published between January 1990 and June 2007 reporting on the occurrence of new DWI lesions after CAS or CEA. Summary of Review- In 32 studies comprising 1363 CAS and 754 CEA procedures, the incidence of any new DWI lesion was significantly higher after CAS (37%) than after CEA (10%) (P<0.01). Similar results were obtained in a meta-analysis focusing on those studies directly comparing the incidence of new DWI lesions after either CEA or CAS (OR, 6.1; 95% CI, 4.19 to 8.87; P<0.01). The use of cerebral protection devices (33% vs 45% without; P<0.01) and closed-cell designed stents during CAS (31% vs 51% with open-cell stents; P<0.01), as well as selective versus routine shunt usage during CEA (6% vs 16%; P<0.01) significantly reduced the incidence of new ipsilateral DWI lesions. CONCLUSIONS: New DWI lesions occur more frequently after CAS than after CEA. However, technical advances mainly in the field of endovascular therapy potentially reduce the incidence of these adverse ischemic events. In this scenario, DWI appears to be an ideal tool to compare and further improve both techniques.     

Effect of body size on operative risk of carotid endarterectomy

Many studies have found that women have a higher risk of perioperative stroke or death from carotid endarterectomy. Other vascular surgical procedures have demonstrated that body size and morphology impact on operative risk. We correlated the 30 day operative risk of stroke and death in the European Carotid Surgery Trial (ECST) with height, weight, body surface area (BSA), and body mass index using single variable analyses and multivariable logistic regression. Women were at significantly higher risk of perioperative stroke and death in the ECST. Both height and BSA confounded the effect of sex, implying that the generally smaller size of women may contribute to their increased risk. This finding should be validated in other large datasets.     

Association between asymptomatic carotid stenosis and cognitive function: A systematic review

Background

Asymptomatic carotid stenosis (CS), traditionally considered clinically silent, may be an independent risk factor for a cognitive impairment.

Methods

To determine whether an association exists between asymptomatic CS and cognitive function, we systematically reviewed the literature in the Cochrane Library, MEDLINE, EMBASE and the China National Knowledge Infrastructure databases.

Results

A total of 8 cross-sectional studies and 2 community-based cohort studies were included, comprising 763 participants in the CS group and 6308 participants in the non-CS group. All but one study supported the association between asymptomatic CS and cognitive impairment. Pooled analysis identified older age (2 studies) and cerebral hypoperfusion (2 studies) as additional factors in patients with asymptomatic CS that may linked to cognitive decline.

Conclusions

These results suggest that rather than being clinically silent, asymptomatic CS may be associated with cognitive impairment, and this should be further investigated in high-quality studies.     

Diagnostic accuracy of various EEG changes during carotid endarterectomy to detect 30-day perioperative stroke: A systematic review

ObjectivesWe assessed whether significant intraoperative electroencephalography (EEG) changes have predictive value for perioperative stroke within 30 days after carotid endarterectomy (CEA) procedures for carotid stenosis (CS) patients. We also assessed the diagnostic accuracy of various EEG changes in predicting perioperative stroke.MethodsWe searched databases for reports with outcomes of CS patients who underwent CEA with intraoperative EEG monitoring. We calculated the sensitivity, specificity, and diagnostic odds ratio (DOR) of EEG changes for predicting perioperative stroke. Sensitivity and specificity were presented with forest plots and a summary receiver operating characteristic (ROC) curve.ResultsThe meta-analysis included 10,672 patients. Intraoperative EEG changes predicted 30-day stroke with a sensitivity of 46% (95% CI, 38–54%) and specificity of 86% (95% CI, 83–88%). The estimated DOR was 5.79 (95% CI, 3.86–8.69). The estimated DOR for reversible and irreversible EEG changes were 8.25 (95% CI, 3.34–20.34) and 70.84 (95% CI, 36.01–139.37), respectively.ConclusionIntraoperative EEG changes have high specificity but modest sensitivity for predicting perioperative stroke following CEA. Patients with irreversible EEG changes are at high risk for perioperative stroke.SignificanceIntraoperative EEG changes can help surgeons predict the risk of perioperative stroke for CS patients following CEA.     

标准式与外翻式颈动脉内膜切除术治疗颈动脉狭窄

目的 探讨标准式与外翻式颈动脉内膜切除术治疗颈动脉狭窄的临床应用.方法 总结颈动脉内膜切除术治疗颈动脉粥样硬化狭窄81例患者的临床资料,共90侧,标准术式25侧,外翻术式65侧,分析两种术式的特点,评价其应用价值及疗效.结果 手术均获成功,动脉阻断时间为:标准式为13.4 -48.2 min,外翻式为14.5 - 31.2 min.术后患者均复查颅颈CTA,必要时复查颅脑CT,显示手术侧颈动脉形态正常.采用标准式中2例2侧术后出现术侧脑梗死灶,另有2例2侧术后11个月出现吻合口区域粥样斑块形成、再狭窄;外翻式中1例1侧术后14个月出现再狭窄;8例8侧颈内动脉狭窄伴扭曲者采用外翻式后扭曲消失.结论 标准式及外翻式颈动脉内膜切除术可以有效地治疗颈动脉狭窄,预防脑卒中.两种手术方式各有特点,应根据手术者的习惯、熟练程度以及患者病变、影像、解剖特点等选择合适的手术方式.     

A clinico-pathologic study of carotid endarterectomy plaques

Carotid endarterectomy specimens surgically removed in one piece were kept intact, processed pathologically, and serially sectioned at 8 microns. There were 34 cases with multiple hemispheric transient ischemic attacks (TIAs), 23 cases with multiple episodes of transient monocular blindness (TMBs), 33 asymptomatic cases, and 51 cases with prolonged or persisting neurologic deficits. The occurrence of TIAs and TMBs correlated best with severe carotid stenosis (1 mm. or less), less well with the presence of mural thrombus, and not at all with ulceration of plaque and intraplaque hemorrhage. The residual lumen in asymptomatic cases was wider. The persistence of neurologic deficits correlated best with carotid occlusion or near-occlusion (37 of 51). In only 3 cases was there evidence of embolism from ulceration with minor stenosis. There were many variations in the size, form, composition, site, and number of mural thrombi, ulcerations, and hemorrhages; to provide an accurate picture, serial sections are necessary. Large rounded cavities in plaques sometimes were empty, smooth-lined cul-de-sacs rather than eroding ulcerations (16 cases). Mural thrombi are probably not an important source of embolism. Ulceration and hemorrhage into plaque posed little or no threat in the present series. Using the pathologic and clinical data, inferences have been made concerning the relative frequency of embolism and hemodynamic failure in the mechanism of the varied events associated with carotid occlusion. Observations have been made on a few additional points--selective involvement of the lower extremity, prolonged TIAs, the onset of symptoms during sleep, unusual motor disorders, the occurrence of headache, retinal embolism and progression of stenosis.     

Quality of life after carotid endarterectomy: a review of the literature

Strokes are one of the leading causes of death, morbidity, and disability worldwide, mainly among elderly people. It is also the third most common cause of years of life being lost, indicating a high risk of premature mortality. Revascularisation with endarterectomy (CEA) is effective in reducing the risk of death and strokes in patients with carotid artery stenosis, but the effect of invasive treatment on quality of life (QoL) still needs attention. To shed more light on the patients’ perspective on this health condition, we carried out a review of the literature which aimed to analyze the level of health-related QoL among stroke survivors, with special attention to patients who had been treated with CEA. Strokes significantly reduce the level of QoL, which may subsequently be improved in the course of treatment with CEA. Patients experience a reduced level of QoL in the early postoperative period, but at 1 year following CEA, the level of QoL remains stable and is similar to that of chronically ill patients. The domains of QoL which are most affected are physical and emotional functioning, which also serve as markers for decreased QoL in the long term. Older age and comorbidities are predictors of worse QoL. Stroke survivors require proper care both immediately after a stroke happens and during the long-term rehabilitation. Measurement of QoL and of the determining factors that contribute to a reduced level of QoL, as well as focusing on determinants of QoL in stroke survivors may help to reduce patients’ disability and improve their daily functioning in society as well as reducing the cost of health care.     

高龄颈动脉狭窄患者颈动脉内膜切除术和颈动脉支架成形术的安全性比较简

目的回顾接受颈动脉内膜切除术和颈动脉支架成形术的高龄（≥70岁）颈动脉狭窄患者的临床资料,分析手术安全性。方法共691例颈动脉狭窄患者,121例行颈动脉内膜切除术、570例行颈动脉支架成形术,分析两组患者危险因素、临床特征和术后并发症发生率,评价两种手术方法之安全性。结果术后30d时,两组患者病死率（0．83％对1．05％,P=1．000）、脑卒中（4．13％对1．93％,P=0．258）和心肌梗死（0．83％对0,P=0．175）发生率差异均无统计学意义;但颈动脉内膜切除术组患者术后心脏不良事件（8．26％对1．05％,P=0．000）和脑神经损伤（4．96％对0,P=0．000）发生率高于颈动脉支架成形术组,而窦性心动过缓或低血压发生率低于颈动脉支架成形术组（0对7．54％,P=0．002）。结论高龄患者接受颈动脉内膜切除术或颈动脉支架成形术均有较高的安全性,术前应全面评价患者基础情况,以减少术后并发症发生率。     

Time trends in the published risks of stroke and death due to endarterectomy for symptomatic carotid stenosis

BACKGROUND: Large randomised trials performed in the 1980s and early 1990s showed that carotid endarterectomy (CEA) is beneficial for patients with recently symptomatic severe stenosis. Some surgeons have argued that the operative risk of stroke and death has fallen over the last decade due to refinements in operative technique, and that the indications for surgery should therefore now be broadened. Yet, studies of routinely collected data report higher operative mortality than in the trials, and surgical case series without independent post-operative assessment by a neurologist may not provide reliable data on stroke risk. METHODS: We performed a systematic review of all studies published between 1994 and 2001 inclusive that which reported the risks of stroke and death for symptomatic carotid stenosis, and compared the reported risks and patient characteristics with those in the ECST and NASCET and with our previous review of studies published prior to 1995. Pooled estimates of the operative risk of stroke and death were obtained by Mantel-Haenszel meta-analysis. RESULTS: Of 383 studies published between 1994 and 2001, only 45 reported operative risks for patients with symptomatic stenosis separately. The pooled operative risk of stroke and death reported in studies published by surgeons only (4.2%, 95% CI = 2.9-5.5, 34 studies) was significantly lower (p < 0.0001) than that in the ECST and NASCET combined (7.0%, 95% CI = 6.2-8.0), whereas the pooled risk reported in studies that involved neurologists was similar (6.5%, 95% CI = 4.3-8.7, 11 studies, p = 0.6). In contrast, operative mortality in ECST and NASCET was significantly lower than in other studies published between 1994 and 2001. By comparison with our previous review, when stratified according to involvement of neurologists, we found no evidence of a reduction in published risks of death or stroke and death due to CEA between 1985 and 2001. CONCLUSIONS: There is no evidence of a systematic reduction over the last decade in the published risks of stroke and death due to CEA for symptomatic stenosis. Operative risks in studies with comparable outcome assessment are similar to ECST and NASCET. The surgical data from the large trials are still likely therefore to be applicable to routine clinical practice.     

Multicenter retrospective review of results and complications of carotid endarterectomy in 1981

A multicenter retrospective audit of carotid endarterectomies performed during 1981 was completed with 46 institutions contributing 3,328 cases. Overall, there was a 2.5% risk of transient neurological dysfunction following surgery and a 6% risk of stroke or death. The intra-institutional combined major morbidity and mortality varied from 21% to 0. Those institutions with greater than 700 beds had a statistically lower incidence of stroke or death than did other institutions. The incidence of stroke or death postoperatively was significantly lower for patients who were operated on for amaurosis fugax or for unspecified reasons. Those patients who were operated on for a progressing stroke had a higher incidence of stroke but this group was at greatest risk for stroke without surgery. The incidence of postoperative stroke or death was related to the type of arterial repair; vein patch grafting was statistically better than both fabric patch grafting and primary closure. When all patients who were not monitored during surgery were compared to all patients who had electroencephalographic (EEG) monitoring, there was found to be a significant statistical difference in favor of the EEG group. Endarterectomy combined with coronary artery bypass or simultaneous bilateral endarterectomies had a statistically significant higher incidence of stroke or death than did unilateral carotid endarterectomy.