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Delay from symptoms to carotid endarterectomy
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.ORCID iD: 0000-0003-0394-5096
2008 (English)In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 263, no 4, 404-411 p.Article in journal (Refereed) Published
Abstract [en]

Objectives.  To investigate the time between cerebrovascular symptom and carotid endarterectomy (CEA), what prolongs this time and if and when the patients suffer additional cerebrovascular events.

Design.  Observational.

Setting.  Single Centre study at a specialized Stroke Centre.

Subjects.  A total of 275 patients with ≥50% symptomatic carotid stenosis (according to the NASCET-criteria) between 1 January 2004 and 31 March 2006.

Main outcome measures.  Time between cerebrovascular symptom and CEA, time between different parts of the investigation, additional cerebrovascular symptoms before CEA and as perioperative complication.

Results.  A total of 128 patients underwent CEA. The median time between symptom and CEA was 11.7 weeks in the beginning and 6.9 weeks at the end of the study. Seven per cent were operated within 2 weeks and 11% between 2 and 4 weeks after their cerebrovascular symptom. The time delays were most pronounced between symptom onset and arrival at the Umeå Stroke Centre from the secondary hospitals and between the decision to recommend CEA and the CEA. Twenty-eight per cent of the patients who were intended for surgery suffered additional cerebrovascular events, 1.4% suffered a major stroke which excluded the indication of CEA and 3.0% of the CEA patients suffered a stroke with functional dependence within 30 days of the operation.

Conclusions.  The delay between symptom and CEA was substantially longer than the desired 2 weeks. Many patients suffered additional cerebrovascular events before CEA. The risk of a severe additional stroke before CEA was about the same as the risk of a severe complication from the CEA.

Place, publisher, year, edition, pages
2008. Vol. 263, no 4, 404-411 p.
Keyword [en]
Adult, Aged, Aged; 80 and over, Carotid Artery; Internal/*surgery, Carotid Stenosis/complications/*surgery, Endarterectomy; Carotid/*adverse effects/statistics & numerical data, Female, Humans, Intraoperative Complications/*prevention & control, Male, Middle Aged, Risk Factors, Stroke/prevention & control, Time Factors
National Category
Family Medicine
URN: urn:nbn:se:umu:diva-9515DOI: 10.1111/j.1365-2796.2007.01908.xPubMedID: 18266661OAI: diva2:149186
Available from: 2008-04-14 Created: 2008-04-14 Last updated: 2015-06-11Bibliographically approved
In thesis
1. Carotid stenosis
Open this publication in new window or tab >>Carotid stenosis
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Abstract [en]

Carotid stenosis is one of several causes of ischemic stroke and entails a high risk of ischemic stroke recurrence. Removal of a carotid stenosis by carotid endarterectomy results in a risk reduction for ischemic stroke, but the magnitude of risk reduction depends on several factors. If the delay between the last symptom and carotid endarterectomy is less than 2 weeks, the absolute risk reduction is >10%, regardless of age, sex, or if the degree of carotid stenosis is 50–69% or 70–99%. Thus, speed is the key. However, if many patients suffers an ischemic stroke recurrence within the first 2 weeks of the presenting event, an additional benefit is likely be obtained if carotid endarterectomy is performed even earlier than within 2 week after the presenting event.

Carotid endarterectomy for asymptomatic carotid stenoses carries a small risk reduction for stroke. Screening for asymptomatic carotid stenosis requires a prevalence of >5% in the examined population, i.e., higher than in the general population; however, directed screening in groups with a prevalence of >5% is beneficial.

The aims of this thesis were to investigate the length of the delay to carotid endarterectomy, determine the risk of recurrent stroke before carotid endarterectomy, and determine if a calcification in the area of the carotid arteries seen on dental panoramic radiographs is a valid selection method for directed ultrasound screening to detect asymptomatic carotid stenosis.

Consecutive patients with a symptomatic carotid stenosis who underwent a preoperative evaluation aimed at carotid endarterectomy at Umeå Stroke Centre between January 1, 2004–March 31, 2006 (n=275) were collected retrospectively and between August 1, 2007–December 31, 2009 (n=230) prospectively. In addition, 117 consecutive persons, all preliminarily eligible for asymptomatic carotid endarterectomy and with a calcification in the area of the carotid arteries seen on panoramic radiographs, were prospectively examined with carotid ultrasound.

The median delay between the presenting event and carotid endarterectomy was 11.7 weeks in the first half year of 2004, dropped to 6.9 weeks in the first quarter year of 2006, and had dropped to 3.6 weeks in the second half year of 2009.

The risk of ipsilateral ischemic stroke recurrence was 4.8% within 2 days, 7.9% within 1 week, and 11.2% within 2 weeks of the presenting event. For patients with a stroke or transient ischemic attack as the presenting event, this risk was 6.0% within 2 days, 9.7% within 1 week, and 14.3% within 2 weeks of the presenting event. For the 10 patients with a near-occlusion, the risk of ipsilateral ischemic stroke recurrence was 50% at 4 weeks after the presenting event.

Among the 117 persons with a calcification in the area of the carotid arteries seen on panoramic radiographs, eight had a 50–99% carotid stenosis, equalling a prevalence of 6.8% (not statistically significantly over the pre-specified 5% threshold). Among men, the prevalence of 50–99% carotid stenosis was 12.5%, which was statistically significantly over the pre-specified 5% threshold.

In conclusion: The delay to carotid endarterectomy was longer than 2 weeks. Additional benefit is likely to be gained by performing carotid endarterectomy within a few days of the presenting event instead of at 2 weeks because many patients suffer a stroke recurrence within a few days; speed is indeed the key. The finding that near-occlusion entails an early high risk of stroke recurrence stands in sharp contrast to previous studies; one possible explaination is that this was a high-risk period missed in previous studies. The incidental finding of a calcification in the area of the carotid arteries on a panoramic radiograph is a valid indication for carotid ultrasound screening in men who are otherwise eligible for asymptomatic carotid endarterectomy.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2011. 101 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1446
Carotid stenosis, Risk, Recurrence, Stroke, TIA, Near-occlusion, Carotid Endarterectomy, Delay, Panoramic Radiographs
National Category
Other Clinical Medicine Neurology
Research subject
Internal Medicine; Neurology; Odontology
urn:nbn:se:umu:diva-46396 (URN)978-91-7459-289-4 (ISBN)
Public defence
2011-10-27, Bergasalen, Norrlands Universitetssjukhus, Umeå, 13:00 (Swedish)
Available from: 2011-10-06 Created: 2011-08-31 Last updated: 2015-06-11Bibliographically approved

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