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Risk of recurrent stroke before carotid endarterectomy: the ANSYSCAP study
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. (Umeå Stroke Centre)
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. (Umeå Stroke Centre)ORCID iD: 0000-0003-0394-5096
2013 (English)In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 8, no 4, 220-227 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Carotid endarterectomy yields greater risk reduction for ipsilateral ischemic stroke when performed within two-weeks of the last cerebrovascular symptom than when performed two-weeks or more after the last symptom. However, additional benefit might be gained if carotid endarterectomy is performed earlier than within two-weeks. AIMS: To investigate the 90-day risk of ipsilateral ischemic stroke recurrence after amaurosis fugax, retinal artery occlusion, transient ischemic attack, or minor ischemic stroke in patients with 50-99% carotid stenosis before carotid endarterectomy, with emphasis on the first 14 days. METHODS: Prospective cohort study. 230 consecutive patients with symptomatic 50-99% carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial grading method) who underwent evaluation before carotid endarterectomy. Of these, 183 underwent carotid endarterectomy; the median delay to carotid endarterectomy was 29 days. Blood pressure lowering medication was used by 93% and lipid-lowering medication by 90%. RESULTS: The risk of ipsilateral ischemic stroke recurrence before carotid endarterectomy was 5·2% (n = 12) within two-days, 7·9% (n = 18) within seven-days, 11·2% (n = 25) within 14 days, and 18·6% (n = 33) within 90 days of the presenting event. The risk of ipsilateral ischemic stroke recurrence was higher if the presenting event was a stroke (adjusted hazard ratio 12·4, P = 0·015) or transient ischemic attack (adjusted hazard ratio 10·2, P = 0·026) compared with an amaurosis fugax. DISCUSSION: The risk of recurrent ipsilateral ischemic stroke was high within the first days of the presenting event. Many recurrences would likely have been avoided if carotid endarterectomy had been performed within the first days of the presenting event.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2013. Vol. 8, no 4, 220-227 p.
Keyword [en]
Stroke, Carotid Stenosis, Risk, Recurrence
National Category
Neurology Cardiac and Cardiovascular Systems
Research subject
Neurology
Identifiers
URN: urn:nbn:se:umu:diva-46712DOI: 10.1111/j.1747-4949.2012.00790.xISI: 000319398900012PubMedID: 22494778OAI: oai:DiVA.org:umu-46712DiVA: diva2:440060
Note

Originally published in thesis in submitted form.

First published online: April 12, 2012.

Available from: 2011-09-12 Created: 2011-09-12 Last updated: 2017-12-08Bibliographically 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]
Karotisstenos
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1446
Keyword
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
Identifiers
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)
Opponent
Supervisors
Available from: 2011-10-06 Created: 2011-08-31 Last updated: 2015-06-11Bibliographically approved

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Johansson, EliasArnerlöv, ConnyWester, Per

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