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Brain Trauma Stroke


Ischemic Stroke—Stenting versus Surgery for Carotid Disease Swaroop Pawar, MD, MPH1


and Steven R Messé, MD2 1. Fellow, Vascular Neurology; 2. Assistant Professor of Neurology, Department of Neurology, Hospital of the University of Pennsylvania


Abstract


Extracranial internal carotid artery stenosis is one of the most common and best studied causes of stroke. Revascularization with carotid endarterectomy (CEA) has been shown to be beneficial for patients with severe stenosis associated with stroke or transient ischemic attack (TIA) and for many patients with moderate stenosis associated with stroke or TIA. CEA has also been shown to be beneficial for patients with asymptomatic severe stenosis if they have a reasonable expected lifespan and surgical risk, but the benefit is greater for men compared with women. Carotid angioplasty and stenting (CAS) has become a viable alternative procedure for carotid revascularization with less risk of major bleeding complications and cranial nerve injury. Randomized studies of CEA versus CAS have found that the endovascular approach is associated with a lower risk of myocardial infarction but a higher risk of peri-procedural stroke which has a greater impact on long-term quality of life. Thus, recommending CEA or CAS must be based upon individual patient characteristics and their preferences, but at this point it appears that most patients should still be receiving CEA if an intervention is required.


Keywords Stroke prevention, carotid stenosis, carotid endarterectomy, carotid angioplasty and stenting, carotid revascularisation


Disclosure: The authors have no conflicts of interest to declare. Received: November 18, 2011 Accepted: December 22, 2011 Citation: US Neurology, 2011;7(2):120–5 Correspondence: Steven R Messé, MD, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 West Gates Building, Philadelphia, PA 19104. E: messe@mail.med.upenn.edu


The purpose of this article is twofold: first, to review the studies comparing carotid endarterectomy (CEA) with medical treatment to help decide who should undergo revascularization; and secondly, to review studies comparing carotid angioplasty and stenting (CAS) versus CEA to see how they should be revascularized.


Extracranial internal carotid artery stenosis is a leading cause of ischemic strokes and transient ischemic attacks (TIAs). It is estimated that extracranial atherosclerotic carotid disease is responsible for 15–20 % of strokes and treatments for extracranial internal carotid artery stenosis are among the best-studied interventions for preventing stroke.1–3


Several


groundbreaking studies in the 1990s confirmed the benefit of surgical revascularization for most patients with hemodynamically significant carotid stenosis. At this point, CEA is considered to be the gold standard treatment for symptomatic carotid stenosis and many patients with asymptomatic carotid stenosis also undergo revascularization.4–10 With advances in endovascular techniques, CAS has evolved into a viable alternative to CEA and considerable interest has been shown in determining whether endovascular treatment is comparable to surgery for the treatment of carotid stenosis.


Determining whether a carotid stenosis has been symptomatic or asymptomatic is essential to deciding whether an individual patient would benefit from a revascularization procedure, as well as the urgency required to undertake such an intervention. Carotid artery stenosis is


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considered symptomatic if the patient has experienced focal neurologic symptoms related to ischemia in the ipsilateral retina causing monocular blindness, or in the ipsilateral cerebral hemisphere, potentially causing contralateral hemiparesis, hemianesthesia, a visual field cut, and neglect in the non-dominant hemisphere, or aphasia in the dominant hemisphere.


Carotid Endarterectomy in Symptomatic Carotid Stenosis


In the 1990s, two large randomized controlled trials, namely the North American symptomatic carotid endarterectomy trial (NASCET)4,6 European carotid surgery trial (ECST),5,7


and the established that patients with symptomatic carotid stenosis benefit from CEA.


NASCET was a randomized prospective multicenter trial carried out to assess the efficacy of CEA versus medical treatment in patients with symptomatic carotid atherosclerotic disease. The study enrolled 659 patients who had a hemispheric or retinal TIA or a non-disabling stroke within the 120 days before entry. The result showed a significant benefit of CEA in patients with 70–99 % symptomatic stenosis. The two-year ipsilateral stroke risk was 26 % in the medically treated patients versus 9 % in the surgical group (p<0.001). The absolute risk reduction (ARR) was 17.0 % and the number needed to treat (NNT) was found to be six at two years. In patients with 50–69 % symptomatic stenosis, the benefit was more modest; the five-year rate of ipsilateral stroke was 15.7 % in patients treated with surgery and 22.2 % in patients who received


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