Crescendo Transient Ischemic Attacks Research Articles

Elective or Urgent Carotid Endarterectomy in Symptomatic Patients: Analysis Based on the Type and Timing of Neurological Symptoms

The aim of this study was to retrospectively analyse perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in symptomatic patients in a high-volume academic vascular centre, stratifying them according to the type of preoperative symptoms and the timing of surgery with respect to the indexed neurological event. From January 2014 to December 2020, 1,369 consecutive CEAs were performed at our institution. Data concerning these interventions were prospectively collected in a dedicated database including data concerning preoperative assessment, surgical details, perioperative (<30days) outcomes, and long-term outcomes. A retrospective analysis of the database was performed, and 213 interventions performed in symptomatic patients were found. We identified 2 subgroups of patients: patients with stable neurological symptoms (not recent transient ischemic attack (TIA) or stable major disabling stroke, stable group, and 157 patients) and patients with unstable neurological symptoms (recent TIA, crescendo TIAs, stroke in evolution, acute/recent minor stroke, unstable group, and 56 patients). Perioperative outcomes were analysed in terms of mortality, major neurological events, and local or systemic complications The results were compared using the χ2 test; these were also analysed on the basis of the presenting symptom (isolated TIA, crescendo TIA, stroke in evolution, acute/recent minor stroke, stabilized stroke) and the timing of the intervention relative to the onset of the symptom. Long term results were analysed using the life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. Overall, 30-day stroke and death rate were 4.2%. (3.1% vs. 7%, P=0.2). Two deaths occurred at 30days, both in the stable group (mortality 1.2%, P=0.4 compared to the unstable group), but no fatal strokes were recorded in the overall sample. No differences were found in terms of new perioperative neurological events and local complications between the 2 groups. We found a trend toward poorer perioperative results in patients operated on within 48hr from the indexed event and in patients operated on for stroke in evolution or acute/recent stroke, whereas we found a trend toward better results in favour of patients operated on between 8 and 14days (P=0.08). The median duration of follow-up was 24.8months (range 1-78); at 5years we did not find significant differences in terms of survival and stroke-free survival rates between 2 groups. In our experience, carotid surgery in symptomatic patients provided satisfactory results, particularly in patients with stable neurological status. Among unstable patients, the rate of complications significantly increases, mainly among treated in the very early (<48hr) period for stroke in evolution or acute/recent stroke. Once the perioperative risk is overcome, the results in the long-term setting are similarly good, both in stable and in unstable patients.

‘Crescendo transient ischemic attack’—an uncommon presentation of a very common disease: a case report on capsular warning syndrome

ABSTRACTCapsular warning syndrome is a rare presentation of transient ischaemic attack, which described as recurrent episodes of motor and/or sensory deficits which typically sparring the cortical function. It has a significant risk to progress into a massive stroke with permanent disability, thus important to be recognise early. Here, we report a middle-age gentleman with no known medical illness presented with eight episodes of transient ischaemic attack within the span of 24 h. He was treated with double anti-platelet for 21 days and was not subjected to thrombolysis at time of presentation because it was outside the window period of 4.5 h, and has fully recovered after each episode. The purpose of this case report is to share the uncommon clinical presentation of transient ischaemic attack, which is still not fully understood and warrant more studies especially on the treatment that can affect the progression of the disease.

Stroke Risk in Patients with Suspected Transient Ischemic Attacks with Focal and Nonfocal Symptoms: A Prospective Study

ObjectivesThe aim was to investigate triage methods for suspected transient ischemic attacks (TIAs) with focal or nonfocal symptoms. Materials and methodsIn total, 350 patients with suspected TIAs were enrolled and followed for one year. Potential high-risk factors for TIAs, such as atrial fibrillation, carotid artery stenosis, crescendo TIA, and ABCD2 score ≥ 4, were evaluated. Patients were classified into 3 groups according to the initial neurological symptoms: focal, nonfocal, and mixed (both focal and nonfocal) groups. Stroke-free survival rates were compared via Kaplan-Meier analysis. ResultsDiffusion-weighted MRI (DWI) was performed for 89.8% of the patients within 7 days, and the frequency of acute brain infarction on DWI was significantly lower in the nonfocal group (focal, 24.1%; nonfocal, 7.2%; mixed, 22.2%; P < .01). There was no significant difference in the one-year event-free survival rates across the groups.Significantly higher stroke risk was observed in patients with one or more high-risk categories or the ABCD2 score (≥ 4) in the focal group (P = .021 and .26, respectively), whereas no significant difference was observed in the other groups. Across all symptom groups, significantly higher stroke risk was observed in patients showing acute infarcts on DWI evaluated within 7 days. ConclusionsBoth high-risk categorization (≥ 1 potential high-risk factors) and ABCD2 score (≥ 4) alone were useful tools for identifying higher stroke risk in patients with focal symptom but not with nonfocal symptoms in isolation. Further studies are warranted in triage methods for TIA with nonfocal in isolation in conjunction with DWI.

Contribution of Endoplasmic Reticulum Stress to the Clinical Instability of Carotid Plaques in Human Carotid Stenosis.

Endoplasmic reticulum (ER) stress is an important process during the progression of atherosclerosis. The aim of this study was to elucidate the association of ER stress and clinical instability of carotid plaque. One hundred ninety-three patients with carotid stenosis undergoing carotid endarterectomies (CEAs) were enrolled. We classified the patients into 3 groups: the asymptomatic, symptomatic, and cTIA (crescendo transient ischemic attack)/SIE (stroke in evolution) groups. Immunohistological staining was performed to assess ER stress and apoptosis. The correlation between ER stress marker expression and clinical instability was analyzed by Tukey-Kramer test and ordinal logistic regression. From the 193 CEAs, 24 asymptomatic plaques and 24 symptomatic plaques were randomly selected, and all 7 plaques in the cTIA/SIE group were selected. Glycophorin A staining demonstrated significant correlation between intraplaque hemorrhage and clinical instability (odds ratio [OR], 1.27; 95%CI, 1.14-1.41). The expression of ER stress markers (glucose-regulated protein 78 [GRP78] and C/EBP homologous protein [CHOP]) exhibited a significant correlation with clinical instability (GRP78: OR, 1.25; 95%CI, 1.14-1.38, CHOP: OR, 1.39; 95%CI, 1.16-1.66). Double-label immunofluorescence demonstrated ER stress markers were detected in CD68-positive cells and smooth muscle actin (SMA)-positive cells. The coexpression of the ER stress markers exhibited a significant correlation with clinical instability (CD68/GRP78: OR, 1.13; 95%CI, 1.05-1.20, CD68/CHOP: OR, 1.092; 95%CI, 1.04-1.14, SMA/CHOP: OR, 1.082; 95%CI, 1.04-1.13). However, the colocalization of CHOP and cleaved caspase-3 (apoptosis marker) did not correlate with clinical instability. These findings indicated that the ER stress pathway may be a potential therapeutic target in the prevention of stroke.

Emergency STA-MCA bypass surgery for symptomatic progressive ischemic stroke

BackgroundIntravascular acute thrombectomy is recommended for acute cerebral infarction within 8 h of onset, based on several randomized controlled trials. However, standard treatment for cases outside these indications has not been established. ObjectiveEmergent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed within 72 h of onset for non-cardiogenic cerebral artery occlusive disease and the surgical outcomes are discussed. MethodsRetrospective review of 18 consecutive patients with non-cardiac cerebrovascular occlusive stroke who underwent emergent bypass surgery from September 2010 to August 2018. Surgical indications were determined as symptomatic ICA or MCA occlusive disease within 8–72 h after onset, and crescendo and/or progressive frequent transient ischemic attack, or impending stroke despite aggressive medical treatment with National Institutes of Health Stroke Scale (NIHSS) at 4 points or more, small cortical infarction (1/3 or less), and observed perfusion-diffusion mismatch. ResultsSurgical outcome was good recovery in 2 patients, moderate disability in 8, severe disability in 6, and death in 2 patients. Favorable outcome was achieved in 55.6%, and poor outcome in 44.4%. No patient showed enlargement of the area of cerebral infarction. The value of the BRS significantly improved after surgery in favourable outcome group. No patient suffered any complication related to surgical intervention including hemorrhagic complications. ConclusionsEmergent STA-MCA bypass surgery can improve clinical outcome and reduce the risk of morbidity under strict surgical indications, so could be an option for acute stage revascularization after ineffective thrombolytic therapy for non-cardiac acute cerebrovascular stroke.

Femoral Highway: Next Stop The Brain

A 66 year old heavy smoking male, presented with upper body cyanosis and crescendo transient ischaemic attacks. Computed tomography angiography (A, arrows) revealed near occlusion of the bifurcated graft from the ascending aorta, eight years after zone 0 arch aneurysm exclusion (maintained on aspirin). Native supra-aortic trunks remained patent through collaterals. Bilateral axillary artery revascularisation from the femoral route was accomplished successfully. Cerebral perfusion was achieved by retrograde flow to the right carotid and vertebral arteries (B, arrows) through a complete circle of Willis. The patient is still smoking on dual antiplatelet therapy and remains asymptomatic at five year follow up.Image 1

Carotid Endarterectomy Using a Flow-Reversal Technique in the Acute Period: A Novel Approach That May Reduce Intraoperative Cerebral Events

Lesion manipulation during internal carotid artery (ICA) surgical dissection is the most crucial stage of carotid endarterectomy (CEA); a friable part of the carotid plaque or a thrombus may detach from the arterial wall, leading to cerebral embolism. Proximal protection devices used in carotid artery stenting reverse the blood flow to the brain eliminating, at least after their deployment, the chance of cerebral embolism. Based on the working principle of these devices, we propose a new approach to CEA making use of a flow-reversal technique, and we report its successful application in 2 high-risk patients with a soft and friable type 4 ICA plaque: a 62-year-old male patient presenting with crescendo transient ischemic attacks and a 61-year-old male patient presenting with a major stroke. Both were operated in the acute period. Once the reverse flow has been established, the surgeon can freely manipulate the carotid and perform a fast blunt dissection without the risk that the disturbance of the arterial wall may lead to cerebral embolism. A video recording of the procedure has been made and presented with this article. Despite the various limitations, including increased clamping time, transient intolerance to reverse flow, and increased blood loss, this technique may improve clinical outcomes, especially in symptomatic patients with friable plaque. A clinical trial is warranted to further study the results of the flow-reversal CEA.

Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systemic Review

Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systemic Review

Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systemic Review

Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks: A Systemic Review

Cerebral glucose metabolism changes in chronic ischemia patients following subcranial-intracranial bypass.

The use of the internal maxillary artery (IMA) in intracranial artery bypass or subcranial-intracranial (SC-IC) bypass has recently been described as an alternative to traditional bypass. This study explores cerebral glucose metabolism characteristics of SC-IC bypass. Ten crescendo transient ischemic attack (TIA) patients with chronic occlusion of the middle cerebral artery (MCA) received bypass surgery of IMA with the radial artery graft (RAG) to the branch of MCA. The graft's flow volume (FV) was measured by operative intraoperative duplex ultrasonography. Positron emission tomography (PET)/computed tomography (CT) was used to calculate the preoperational and postoperational average of the standard uptake value (SUVavg) of the 18-fluoro-2-deoxy-D-glucose (18F-FDG) in the region of interest (ROI). The asymmetric index (AI) is recommended to reflect the SUVavg changes, and subsequently, cerebral glucose metabolism changes are supposedly clarified. Patent IMA-RAG-MCA bypass in ten chronic ischemia patients was confirmed by angiography after surgery. The intraoperative FV measurement value was 65.64 ± 10.52 (58.11-73.17) ml/min. Before the operation, the SUVavg of the ROI in the ischemic hemisphere (4.76 ± 2.35 (3.08-6.04)) clearly decreased compared to the one (5.99 ± 2.63 (4.11-7.87)) in the contralateral mirror region (P = 0.003). The result of AI of preoperation minus AI of postoperation was more than 10% (P = 0.031), which indicated suspicious significant changes in cerebral metabolism. All symptoms of study patients having crescendo ischemia were resolved in 1month after the operation. In the cerebral hypoperfusion territory, uptake of 18F-FDG deceased. Improving the flow volume via SC-IC bypass makes available an elevated uptake of 18F-FDG.

Outcomes of Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke in Evolution

Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE). A retrospective analysis was performed using prospectively collected data fromall consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI),surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale(NIHSS) score variation, and functional outcome at 90days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE). A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85±5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31±6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS≤2). Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.

Cholesterol Crystals in Embolic Debris are Associated with Postoperative Cerebral Embolism after Carotid Artery Stenting

Object: We investigated possible associations among the presence of cholesterol crystals in embolic debris, the proportions of debris components, and postoperative cerebral embolism in patients undergoing carotid artery stenting (CAS). Methods: Sixty-seven consecutive procedures were performed for internal carotid artery stenosis with CAS at our hospital between November 2015 and February 2018. Procedures for emergency CAS for stroke in evolution or crescendo transient ischemic attack were excluded (n = 12). The embolic debris from remaining procedures (n = 55) was stained with hematoxylin-eosin and the red blood cells, white blood cells, and fibrin were quantified by color-based segmentation. Cholesterol crystals and calcification were examined histopathologically. Diffusion-weighted imaging (DWI) was performed 1–3 days after CAS, and the images were used to classify procedures according to the presence of new lesions. Results: Of the 55 CAS procedures, new DWI lesions were identified after 32. One patient had symptomatic cerebral embolism. Higher proportions of patients with cholesterol crystals in embolic debris (17 vs. 78%, p < 0.001) and higher proportion of white blood cells (mean 2.3 [0–9.9] vs. 4.2% [0–29.9%], p < 0.01) were observed in the embolic debris of procedures with and without new DWI lesions. Conclusions: Cholesterol crystals were common in the embolic debris from patients with postoperative ischemic lesions after CAS. These results suggest that inflammatory destabilization of the intraplaque lipid component is related to postprocedural DWI lesions.

PP28 Tia prehospital referral feasibility trial (TIER): recruitment and intervention usage

BackgroundEarly specialist assessment of Transient Ischaemic Attack (TIA) can reduce the risk of stroke and death. This study assessed feasibility of undertaking a multi-centre randomised trial to evaluate clinical and cost effectiveness of referral of patients attended by emergency ambulance paramedic with low-risk TIA directly to specialist TIA clinic for early review.MethodsWe developed a protocol and referral pathway for paramedics to assess and refer patients directly to TIA clinic, including provision of aspirin. We randomly allocated volunteer paramedics to intervention or control group. Intervention paramedics were trained to deliver the intervention during the patient recruitment period. Control paramedics continued to deliver care as usual. Patients with TIA were identified from hospital records. We aimed to recruit 86 patients and pre-defined progression criteria related to feasibility of intervention delivery and trial methods.ResultsDevelopment and recruitment phases are complete, with outcome follow up ongoing. Eighty nine of 134 (66%) paramedics participated in TIER. Of 1377 patients attended by trial paramedics during the patient recruitment period, 53 (3.8%) were identified as eligible for trial inclusion. Three of 36 (8%) patients attended by intervention paramedics were referred to the TIA clinic. Of the others, only one appeared to be a missed referral; in one case there was no prehospital record of TIA; one was attended by a paramedic who was not TIER trained; one patient record was missing; all others were recorded with contraindications: FAST positive (n=13); ABCD2 score &gt;3 (n=5); already taking warfarin (n=2); crescendo TIA (n=1) other clinical factors (n=8).ConclusionsPreliminary Results indicate challenges in recruitment and low referral rates. The low-risk 999 TIA population suitable for Emergency Department avoidance may be smaller than previously thought. Further analyses will focus on whether progression criteria for a definitive trial were met, and clinical outcomes from this feasibility trial.

Transient ischaemic attack pre-hospital referral feasibility trial (TIER): recruitment and intervention usage.

Early specialist assessment of transient ischaemic attack (TIA) can reduce the risk of stroke and death. This study assessed the feasibility of undertaking a multi-centre randomised trial to evaluate clinical and cost effectiveness of referral of patients attended by emergency ambulance paramedics with low-risk TIA directly to specialist TIA clinics for early review. We developed a protocol and referral pathway for paramedics to assess and refer patients directly to a TIA clinic, and administer aspirin. We randomly allocated volunteer paramedics to intervention or control groups. Intervention paramedics were trained to deliver the intervention during the patient recruitment period. Control paramedics continued to deliver care as usual. Patients with TIA were identified from hospital records. We aimed to recruit 86 patients and pre-defined progression criteria related to feasibility of intervention delivery and trial methods. Development and recruitment phases are complete, with outcome follow-up ongoing. Of 134 (66%) paramedics, 89 participated in TIER. Of 1377 patients attended by trial paramedics during the patient recruitment period, 53 (3.8%) were identified as eligible for trial inclusion. Of 36 (8%) patients attended by intervention paramedics, three were referred to the TIA clinic. Of the others, only one appeared to be a missed referral; in one case there was no pre-hospital record of TIA; one was attended by a paramedic who was not TIER trained; one patient record was missing; and all others were recorded with contra-indications: FAST positive (n = 13); ABCD2 score > 3 (n = 5); already taking warfarin (n = 2); crescendo TIA (n = 1); and other clinical factors (n = 8). Preliminary results indicate challenges in recruitment and low referral rates. The low-risk 999 TIA population suitable for emergency department avoidance may be smaller than previously thought. Further analyses will focus on whether progression criteria for a definitive trial were met, and clinical outcomes from this feasibility trial.

Safety of urgent endarterectomy in acute non-disabling stroke patients with symptomatic carotid artery stenosis: an international multicenter study.

International recommendations advocate that carotid endarterectomy (CEA) should be performed within 2weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2days) in comparison to early (3-14days) CEA in patients with sCAS. Consecutive patients with non-disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a 6-year period. The primary outcome events included stroke, myocardial infarction or death during the 30-day follow-up period. A total of 311 patients with sCAS underwent urgent (n=63) or early (n=248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo transient ischaemic attacks (21% in urgent vs. 7% in early CEA; P=0.001). The 30-day rates of stroke did not differ (P=0.333) between patients with urgent (7.9%; 95% confidence interval 3.1%-17.7%) and early (4.4%; 95% confidence interval 2.4%-7.9%) CEA. The mortality and myocardial infarction rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6days (interquartile range 4-6) vs. 10days (interquartile range 7-14); P<0.001]. Our findings highlight that urgent CEA performed within 2days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets.

IP121. Early Carotid Endarterectomy in Symptomatic Patients∗

The objective of this study was to evaluate whether early carotid endarterectomy (CEA) in symptomatic patients is associated with higher rates of stroke or death in the postoperative period. A retrospective study from 2016 to 2017 was conducted in our institution. In the indexed period, 68 patients matched the inclusion criteria. Patients’ characteristics and results were recorded in a dedicated database. All patients were submitted to a preoperative and postoperative clinical examination by an independent neurologist and were divided into four groups based on the surgical timing (0-7 days; 7-15 days; 15-30 days; >30 days). National Institutes of Health Stroke Scale score was also calculated in all cases. In all patients, the level of serologic and intraplaque ST2 (suppression of tumorigenicity) was evaluated as a potential marker of plaque instability. Data were analyzed with χ2 test and Kaplan-Meier curves (SPSS 24.0 statistical software; IBM Corp, Armonk, NY). Of 68 patients treated, 47 were male (69%), with a median age of 70 years (range, 48-83 years); 82% suffered from hypertension, and 29% were diabetic patients. Preoperative symptoms consisted of transient ischemic attack (43%), minor stroke (32%), major stroke (23%), and crescendo transient ischemic attack (2%). Degree of stenosis was between 60% and 80% in 63% of the patients, between 80% and 99% in 27%, and near occlusion in 10%. CEA was performed in 100% of cases with a National Institutes of Health Stroke Scale score between 0 and 8: 8 (12%) eversion CEAs and 60 (88%) CEAs with patch. Eleven patients (16%) were treated within 7 days; 24 (35%) were assigned to the second group (7-15 days), 12 (18%) to the third group (15-30 days), and 21 (31%) to fourth group. No neurologic events or deaths were recorded at 30 days. There was no statistical difference between the four groups regarding ST2 marker levels. In the median follow-up of 12 months (range, 1-24 months), stroke-free survival rate was 100%. The time between neurologic event and CEA did not influence the early and midterm results in our series. Early CEA may be safely proposed also in patients with major stroke.

Abstract WMP47: Cholesterol Crystals in Embolic Debris Correlate Postoperative Silent Cerebral Embolism in Carotid Artery Stenting

Introduction: Very few studies have investigated the relationship between the histopathology of the embolic debris in embolic protection devises and postoperative cerebral embolism in carotid artery stenting (CAS). The aim of this study was to evaluate embolic debris and its association with clinical, laboratory, and neurointerventional findings in patients treated by CAS due to internal carotid stenosis. Hypothesis: Cholesterol crystals in embolic debris are associated with postoperative cerebral embolism in CAS. Methods: All embolic debris was stained with hematoxylin-eosin. Embolic debris underwent quantitative analysis to quantify three main components: red blood cells, white blood cells and fibrin, by color based segmentation. Histopathological assessment included presence of calcifications, cholesterol crystals, foamy cells, and endothelial cells. Diffusion weighted image (DWI) was evaluated 1 to 3 days after CAS, and patients were classified by presence of new lesions on DWI after CAS. Exclusion criteria were emergency CAS for stroke in evolution or crescendo transient ischemic attack. Results: From November 2015 to April 2017, 40 patients were treated in our hospital by CAS due to internal carotid artery stenosis. Exclusion criteria were fulfilled in 5 patients. 24 patients had new lesions on DWI after CAS and 11 patients did not have those. Single patient had symptomatic cerebral embolism. Patients with new lesions on DWI after CAS had higher rate of cholesterol crystal in embolic debris (80% vs 18%, p&lt;0.01) and higher rate of patients taking strong statin on admission (71% vs 18%, P=0.02) than those without new lesions on DWI after CAS. There is no significant difference with blood levels of LDL-cholesterol [111 mg/dl (79-197) vs 108 mg/dl (62-167); p=0.85]. Main components of embolic debris were not significantly different between two groups. Conclusion: Cholesterol crystals in embolic debris and treatment history of dyslipidemia were significantly associated with post-operative high intensity lesion on DWI in CAS.

Invited commentary

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) concluded that carotid surgery for symptomatic stenosis is better than medical therapy, and the conferred benefit of surgery is proportional to the degree of stenosis.1North American Symptomatic Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7865) Google Scholar The European Carotid Surgery Trial (ECST) came to a similar conclusion and that “on average, the immediate risk of surgery was worth trading off against the long-term risk of stroke without surgery when the stenosis was greater than 80% diameter.”2European Carotid Surgery Trialists Collaborative GroupRandomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (2966) Google Scholar The preceding and other studies leave little room for doubt that endarterectomy is beneficial to symptomatic patients; what is still being debated is the exact timing of surgery. Most clinicians agree that patients presenting with crescendo transient ischemic attacks or a mobile plaque on imaging deserve to be considered for an emergent endarterectomy to prevent a severe stroke. What is not clear is what type of patient ought to have an urgent (ie, during the same hospitalization and as promptly as possible) carotid endarterectomy. Avgerinos et al attempt to answer the question, When is it optimal to perform endarterectomy for symptomatic patients? They queried the Vascular Study Group of New England database of 14,864 carotid endarterectomies and identified 4076 performed for symptomatic stenosis. Of the latter cases, 989 carotid endarterectomies were performed within a month of symptom onset. They analyzed outcomes based on timing of surgery: same day, <48 hours, 2-5 days, and >6 days. They found that the postoperative stroke rate was highest if surgery was performed <48 hours after presenting stroke or transient ischemic attack, whereas postoperative stroke rates were similar in the other time frames. In a similar analysis from a single center and spanning the same time period, Tsantilas et al found a combined stroke and mortality rate for symptomatic patients of 2.5% and no significant difference in stroke rates in the various time periods of 48 hours, 3-7 days, 8-14 days, and 15-180 days.3Tsantilas P. Kuhnl A. Kallmeyer M. Pelisek J. Poppert H. Schmid S. et al.A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery.J Vasc Surg. 2017; 65: 12-20Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Other authors have strongly emphasized the need for prompt carotid endarterectomy, provided symptoms are stable, to prevent a recurrent stroke.4Bond R. Rerkasem K. Rothwell P.M. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery.Stroke. 2003; 34: 2290-2303Crossref PubMed Scopus (246) Google Scholar In performing an urgent carotid endarterectomy, there are many factors that need to be taken into consideration. By the time the surgeon sees the consult, proper imaging is obtained, and the patient is prepared for surgery, several hours would have passed. Adding to the complexity, a patient admitted on a Friday or Saturday may experience longer delays. This paper concludes that there is no major penalty in waiting a few days. Until we have more sophisticated imaging capabilities to detect which plaques are likely to disintegrate and cause recurrent symptoms, it is a guessing game.5Rothwell P.M. Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient.Eur J Vasc Endovasc Surg. 2008; 35: 255-263Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The prudent approach, though, is to avoid delays in removing the offending plaque. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Early carotid endarterectomy performed 2 to 5 days after the onset of neurologic symptoms leads to comparable results to carotid endarterectomy performed at later time pointsJournal of Vascular SurgeryVol. 66Issue 6PreviewTiming of carotid endarterectomy (CEA) after onset of neurologic symptoms remains controversial. We assessed the association of CEA timing with postoperative outcomes. Full-Text PDF Open Archive

Abstract 304: Association Between Plaque Morphology and Time Interval After the Neurologic Index Event in Patients With Symptomatic Carotid Stenosis

Objectives: Instable plaques are more common in patients with symptomatic carotid stenosis compared to asymptomatic patients. Clinically symptomatic patients are at high risk for a recurrent stroke in the first days after a neurologic index event. Histopathologic plaque stabilisation or remodelling mechanisms of symptomatic plaques are unclear. Therefore, our study aimed to find changes of plaque morphology in dependence of time interval between neurologic index event and plaque removal. Methods: Plaques of patients that were removed from surgically treated patients with symptomatic carotid stenosis between 2004 and 2016 were included. Histological analyses of those carotid plaques were performed to assess the type of plaque (American Heart Association classification), the stability of plaque (thickness of the fibrous cap &lt;/&gt;200μm), the extent of calcification, inflammation, neovascularization and the deposition of collagen and elastin. Statistical analysis was applied in form of an ordinal regression analysis, adjusted for common risk factors of atherosclerosis. Results: Out of 348 included plaques, the patients’ median age was 71 (Q1-Q3, 65 - 77) years and 69% were male. Median time interval between index event and plaque removal was 10 days (Q1-Q3, 4-28 days). Most common index event was a transient ischemic attack with 37% (128 of 348), followed by stroke in 28% (97 of 348), amaurosis fugax in 22% (76 of 348) and instable symptoms (crescendo transient ischemic attack, stroke in evolution) in 12% (43 of 348), respectively. The ordinal regression analysis revealed, that the time interval as continuous independent variable had no significant influence on plaque type, plaque stability, extent of calcification, inflammation or neovascularization and the deposition of collagen and elastin. Conclusions: The examined plaque morphology features of patients with symptomatic carotid stenosis showed no differences in relation to the time interval between neurologic index event and plaque removal. To find potential symptomatic plaque remodelling mechanisms, currently ongoing molecular and histomorphological analysis aim at identifying novel markers of apoptosis and cell fate-driven mechanisms in fibrous cap-enriched vascular smooth cells.

Location of Cerebral Microbleeds May Predict Subsequent Stroke after Transient Ischemic Attack

Location of Cerebral Microbleeds May Predict Subsequent Stroke after Transient Ischemic Attack