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Brain Trauma Stroke


Table 1: Symptomatic Carotid Disease—What Do the Guidelines Recommend?


Symptomatic Carotid Artery Stenosis


1. For patients with recent TIA or ischemic stroke within the past six months and ipsilateral severe (70–99 %)


carotid artery stenosis, CEA is recommended if the peri-operative morbidity and mortality risk is estimated to be <6 %


2. For patients with recent TIA or ischemic stroke and (Class I; level of


ipsilateral moderate (50–69 %) carotid stenosis, CEA is evidence B) recommended depending on patient-specific factors, such as age, sex, and comorbidities, if the peri-operative morbidity and mortality risk is estimated to be <6 % 3. When the degree of stenosis is <50 %, there is no indication for carotid revascularization by either CEA or CAS


4. When CEA is indicated for patients with TIA or stroke, surgery within two weeks is reasonable, rather than


delaying surgery, if there are no contraindications to early revascularization


5. CAS is indicated as an alternative to CEA for symptomatic (Class I; level of patients at average or low risk of complications associated evidence B) with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by >70 % by non-invasive imaging or >50 % by catheter angiography


6. Among patients with symptomatic severe stenosis (>70 %) (Class IIb; level of in whom the stenosis is difficult to access surgically,


evidence B)


medical conditions are present that greatly increase the risk for surgery, or when other specific circumstances exist, such as radiation-induced stenosis or restenosis after CEA, CAS may be considered


7. CAS in the above setting is reasonable when performed (Class IIa; level of


by operators with established peri-procedural morbidity evidence B) and mortality rates of 4–6 %, similar to those observed in trials of CEA and CAS


8. For patients with symptomatic extracranial carotid occlusion, EC/IC bypass surgery is not routinely recommended


9. Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor


modification, is recommended for all patients with carotid artery stenosis and a TIA or stroke as outlined elsewhere in this guideline


The revised American Heart Association/American Stroke Association (AHA/ASA) guidelines published in 2011 for the prevention of stroke make the above recommendations for the management of symptomatic carotid stenosis. CAS = carotid angioplasty and stenting; CEA = carotid endarterectomy; EC/IC = extracranial/intracranial; TIA = transient ischemic attack. Source: Furie et al., 2011.41


After two years follow-up, there was no statistically significant difference between CAS and CEA in the composite endpoint of any peri-procedural stroke or death and ipsilateral ischemic stroke up to two years after the procedure in both intention-to-treat (9.5 versus 8.8 %) and per-protocol (9.4 versus 7.8 %) analyses. The incidence of recurrent carotid stenosis ≥70 % at two years, as defined by ultrasound, was significantly higher after carotid artery stenting in both analyses


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predefined threshold. Thus, the study failed to prove the non-inferiority of CAS compared with CEA for the peri-procedural complication rate. In a post hoc analysis, older age in the CAS group (but not the CEA group) was significantly associated with an increased risk of ipsilateral stroke or death.22


(Class III; level of evidence A)


(Class I; level of evidence B)


Level of Evidence (Class I; level of


evidence A)


(10.7 versus 4.6 % by intention-to-treat). However, it cannot be excluded that the degree of in-stent stenosis is slightly overestimated by conventional ultrasound criteria.23


(Class III; level of evidence A)


(Class IIa; level of evidence B)


The Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) was a French multicenter clinical trial that randomized 527 patients to endarterectomy (n=262) or CAS (n=265) to prove non-inferiority of CAS to CEA in low-risk patients with symptomatic carotid stenosis of ≥60 %. The 30-day incidence of any stroke or death, the composite primary outcome measure, was significantly higher with CAS than with CEA (9.6 versus 3.9 %, relative risk [RR] 2.5, 95 % CI 1.2–5.1) and the incidence of disabling stroke or death was 1.5 versus 3.4 % for the CEA and CAS groups, respectively. The trial was stopped prematurely due to an excess number of deaths in the CAS group.24


At four years of


follow-up, it was found that the cumulative probability of peri-procedural stroke or death and non-procedural ipsilateral stroke was higher with stenting than with endarterectomy (11.1 versus 6.2 %, hazard ratio [HR] 1.97, 95 % CI 1.06–3.67, p=0.03). There were more major local complications after stenting and more systemic complications (mainly pulmonary) after endarterectomy, but the differences were not significant. Cranial nerve injury was more common after endarterectomy than after stenting.24


The International carotid stenting study (ICSS) was a multicenter European trial, in which 1,713 patients (age >40 years) with recently symptomatic carotid artery stenosis were randomly assigned to receive carotid artery stenting (n=855) or CEA (n=858).25


The 30-day risk of stroke,


death, or myocardial infarction (MI) was significantly higher after CAS than after CEA (7.4 versus 4.0 %, RR 1.8, 95 % CI 1.2–2.8, p=0.003). The 120-day risk of stroke, death, or MI was still higher in the stenting cohort (8.5 versus 5.2 %; p=0.006). Moreover, in a subset of 231 patients in the ICSS who had brain magnetic resonance imaging (MRI), the proportion of patients with new ischemic brain lesions on diffusion-weighted MRI at a median of one day after treatment was significantly higher in the stenting group than in the endarterectomy group (50 versus 17 %, odds ratio 5.2, 95 % CI 2.8–9.8, p<0.0001).26


It is important to note that, relative to CEA, CAS is a less mature procedure and, as with any intervention, experience and improvements in techniques and devices have an impact on the potential risk and efficacy. Many proponents of CAS have argued that EVA-3S, SPACE, and ICSS did not insure that the interventionists had adequate experience with CAS prior to enrolling patients in the study. That said, analyses of the experience of interventionists in these studies did not show a relationship with peri-procedural events.27–30


Most recently, the Carotid revascularization endarterectomy versus stenting trial (CREST) was published.31


CREST was a North American


randomized multicenter trial comparing CAS with CEA in both symptomatic and asymptomatic patients. The primary endpoint was the occurrence of stroke, death, or MI during the peri-procedural period and ipsilateral stroke up to four years. About half of the patients enrolled had an asymptomatic >60 % stenosis and half were symptomatic with >50 % stenosis. The CREST study attempted to address the issue of inexperienced interventionists by enforcing a credentialing lead-in period of up to 20 CAS procedures prior to enrolling patients in the study. Overall, there was no significant difference in the rates of the primary endpoint


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