Outcome of patients with symptomless carotid bruits: a prospective study

Abstract

Knowledge of the natural history of symptomless carotid artery disease is important in determining the best preventative treatment for symptom-free patients. To document the progression of carotid artery disease and the clinical course of a symptomless population, 336 patients with symptom-free carotid bruits were prospectively followed up initially with oculoplethysmography and subsequently with duplex scanning. During a mean follow-up of 4.87 years, eight patients (2.4%) suffered a stroke. Thirtyseven (11.0%) experienced transient ischaemic attacks (TIAs). The cumulative event rate (TIA plus stroke) was 13.4% ( 45 336 ). The annual event rates were 0.48% for stroke, 2.26% for TIA and 2.75% for all ischaemic events. In a subgroup of 69 high-grade carotid stenoses (80–99%), 31 carotid endarterectomies were performed before the development of a TIA or stroke and 21 after the development of symptoms, while 17 lesions were followed-up non-operatively. The total event rate (TIA and stroke) was significantly greater in the non-operated compared with the operated arteries (51.0% versus 6.4% at 5 years, P = 0.0034). However, most of the events which occurred in the non-operated group were TIAs (85.7%) rather than stroke. There was no difference in the death rate of the two groups ( P>0.05). Review of serial duplex studies performed on 540 carotid arteries revealed that 382 arteries (70.7%) remained unchanged and 158 (29.3%) showed disease progression. Forty-four of the 540 arteries became symptomatic (TIA or stroke). In 29 of the 44, the event occurred without any change in diameter of the artery, while in 15 there was a change of at least one category greater stenosis. In 39 patients, the stenosis was at least 40% and in five the stenosis was under 40%. Nine events occurred in the patients with severe contralateral carotid stenoses (>60%). The incidence of TIA (32.2%), stroke (6.8%) and death (18.6%) was higher in patients with internal carotid artery stenoses in excess of 80% than in those with lesions between 0 and 79% stenosis ( P < 0.0001, P = 0.0367 and P = 0.0236, respectively). In this study the incidence of cerebrovascular events was higher in patients with high-grade internal carotid artery disease, and the preservation of neurological status in patients with symptomless high-grade carotid artery stenosis was improved by carotid endarterectomy, although the overall mortality remained unchanged.