Ipsilateral Ischemic Stroke Research Articles

Risk of stroke recurrence after intravenous thrombolysis in patients with symptomatic carotid stenosis.

To assess if intravenous thrombolysis (IVT) affects the risk of recurrent preoperative cerebrovascular events before carotid surgery or stenting in patients with symptomatic ≥ 50% carotid stenosis. Three cohorts of symptomatic ≥ 50% carotid stenosis patients were merged. To make the control group relevant, we excluded patients not presenting with stroke on the day of symptom onset. The risk of preoperative cerebrovascular events up to 30 days was compared between the IVT-treated and non-IVT-treated. In total, 316 patients were included, 64 (20%) treated with IVT. Those treated with IVT had similar risk of recurrent ipsilateral ischemic stroke or retinal artery occlusion (12% at day 7, 12% at day 30) as those not treated (9% at day 7, 15% at day 30; adjusted HR 0.9, 95% CI 0.4-2.2). There was a tendency (p = 0.09) towards time-dependency in the data where the recurrence risk was higher in IVT-treated at day 0 (6% in IVT-treated, 1% in non-IVT-treated, OR 5.5, 95% CI 1.2-25.4, p = 0.03). This was not significant when adjusting for co-factors (adjusted OR 4.4, 95% CI 0.9-21.8, p = 0.07) and was offset by a later risk decrease, with no remaining risk difference between IVT-treated and non-IVT-treated at day 7. Intravenous thrombolysis treatment does not seem to affect the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic ≥50% carotid stenosis: The risk is high in both IVT-treated and non-IVT-treated. However, there might be a risk increase on the day of IVT treatment that is offset by a risk decrease during the first week.

Effect of Internal Carotid Artery Doppler Peak-Systolic Velocity Thresholds for Classifying Ipsilateral Ischemic Stroke Due to Large Artery Atherosclerosis According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) System for CME Credit September 2023

Effect of Internal Carotid Artery Doppler Peak-Systolic Velocity Thresholds for Classifying Ipsilateral Ischemic Stroke Due to Large Artery Atherosclerosis According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) System for CME Credit September 2023

Extracranial Carotid Plaque Calcification and Cerebrovascular Ischemia: A Systematic Review and Meta-Analysis.

Although coronary calcification quantification is an established approach for cardiovascular risk assessment, the value of quantifying carotid calcification is less clear. As a result, we performed a systematic review and meta-analysis to evaluate the association between extracranial carotid artery plaque calcification burden and ipsilateral cerebrovascular ischemic events. A comprehensive literature search was performed in the following databases: Ovid MEDLINE(R) 1946 to July 6, 2022; OVID Embase 1974 to July 6, 2022; and The Cochrane Library (Wiley). We performed meta-analyses including studies in which investigators performed a computed tomography assessment of calcification volume, percentage, or other total calcium burden summarizable in a single continuous imaging biomarker and determined the association of these features with the occurrence of ipsilateral stroke or transient ischemic attack. Our overall meta-analysis consisted of 2239 carotid arteries and 9 studies. The presence of calcification in carotid arteries ipsilateral to ischemic stroke or in stroke patients compared with asymptomatic patients did not demonstrate a significant association with ischemic cerebrovascular events (relative risk of 0.75 [95% CI, 0.44-1.28]; P=0.29). When restricted to studies of significant carotid artery stenosis (>50%), the presence of calcification was associated with a reduced risk of ischemic stroke (relative risk of 0.56 [95% CI, 0.38-0.85]; P=0.006). When the analysis was limited to studies of patients with mainly nonstenotic plaques, there was an increased relative risk of ipsilateral ischemic stroke of 1.72 ([95% CI, 1.01-2.91]; P=0.04). Subgroup meta-analyses of total calcium burden and morphological features of calcium showed wide variability in their strength of association with ischemic stroke and demonstrated significant heterogeneity. The presence of calcification in carotid plaque confers a reduced association with ipsilateral ischemic events, although these results seem to be limited among carotid arteries with higher degrees of stenosis. Adoption of carotid calcification measures in clinical decision-making will require additional studies providing more reproducible and standardized methods of calcium characterization and testing these imaging strategies in prospective studies.

Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion

Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. ClinicalTrials.gov Identifier: NCT01758614.

Effect of Internal Carotid Artery Doppler Peak Systolic Velocity Thresholds for Classifying Ipsilateral Ischemic Stroke Due to Large Artery Atherosclerosis According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) System

Background: A Doppler peak systolic velocity (PSV) of 125 cm/s has been used to indicate an internal carotid artery 50% stenosis, a marker of large artery atherosclerosis (LAA) when classifying ischemic stroke according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Shifting this cut point to 180 cm/s might affect the classification of ischemic stroke. Methods: Color Doppler–assisted measurements of PSV were performed at the baseline visit of a large longitudinal cohort study in the United States: the Cardiovascular Health Study (CHS). Incident ischemic stroke within the following 6 years was ascertained by adjudicated review of medical records. The side of ischemic stroke was recorded. Incidence rates and odds ratios (logistic regression models) were estimated at the respective 125 cm/s and 180 cm/s cut points. Results: Mean age was 72.8 years with 57.6% women. A total of 11 425 bifurcations had PSV measurements. Of the 514 carotid bifurcations with PSV above 125 cm/s, 20 ipsilateral incident strokes were seen, whereas 6 strokes occurred among the 126 bifurcations with PSV above 180 cm/s. Shifting the cut point decreased categorizing ischemic stroke as due to LAA by 70% (14/20). The odds ratio (1.75; 95% confidence interval, 1.01-3.02) of incident stroke for a PSV between 125 cm/s and 180 cm/s was significant ( P < .05) when compared with a PSV <125 cm/s. Conclusion: Shifting the PSV cut point for a 50% carotid stenosis from 125 cm/s to 180 cm/s would have significant implications when categorizing ischemic stroke as being associated with LAA.

Ipsilateral and contralateral carotid stenosis contribute to the outcome of reperfusion treatment for ischemic stroke.

Ipsilateral and contralateral carotid stenosis (ICS, CCS) influence acute ischemic stroke (AIS) severity and prognosis. Few data are available about their impact on reperfusion therapies efficacy. Aim of this study was to evaluate the impact of ICS and CCS on the effect of intravenous thrombolysis (IT), mechanical thrombectomy (MT) or both and of antiplatelet therapy (AT). We enrolled all the consecutive patients admitted for AIS to our stroke unit and submitted to IT, MT, IT+MT, or AT. We established the presence of a significant ICS or CCS (≥70%) by ultrasound examination or brain angio-CT, or MRI. Clinical and instrumental information were collected; delta National Institutes of Health Stroke Scale (NIHSS) from pre-treatment to patients' discharge was employed as the main outcome measure. In total, 460 subjects were enrolled, 86 with ICS and 38 with CCS. We observed a significant linear trend of delta (NIHSS) between carotid stenosis categories for patients undergoing IT (p = 0.011), MT (p = 0.046), and MT+IT (p = 0.040), but no significant trend among subjects receiving no reperfusion treatments was observed (p = 0.174). According to our findings, ICS and CCS negatively influence AIS patients' outcome treated by interventional therapies. ICS might exert an unfavorable effect both by cerebral hypoperfusion and by continuous microembolization toward ischemic area, while CCS is probable involved in reducing the collateral circles effectiveness. The importance of early carotid stenosis detection and treatment should then be reevaluated not only to manage the prevention approaches but also to obtain insights about post-stroke treatment strategies efficacy.

A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system

ObjectiveThe results of current prospective trials comparing the effectiveness of carotid endarterectomy (CEA) vs standard medical therapy for long-term stroke prevention in patients with asymptomatic carotid stenosis (ACS) will not be available for several years. In this study, we compared the observed effectiveness of CEA and standard medical therapy vs standard medical therapy alone to prevent ipsilateral stroke in a contemporary cohort of patients with ACS. MethodsThis cohort study was conducted in a large integrated health system in adult subjects with 70% to 99% ACS (no neurologic symptom within 6 months) with no prior ipsilateral carotid artery intervention. Causal inference methods were used to emulate a conceptual randomized trial using data from January 1, 2008, through December 31, 2017, for comparing the event-free survival over 96 months between two treatment strategies: (1) CEA within 12 months from cohort entry vs (2) no CEA (standard medical therapy alone). To account for both baseline and time-dependent confounding, inverse probability weighting estimation was used to derive adjusted hazard ratios, and cumulative risk differences were assessed based on two logistic marginal structural models for counterfactual hazards. Propensity scores were data-adaptively estimated using super learning. The primary outcome was ipsilateral anterior ischemic stroke. ResultsThe cohort included 3824 eligible patients with ACS (mean age: 73.7 years, 57.9% male, 12.3% active smokers), of whom 1467 underwent CEA in the first year, whereas 2297 never underwent CEA. The median follow-up was 68 months. A total of 1760 participants (46%) died, 445 (12%) were lost to follow-up, and 158 (4%) experienced ipsilateral stroke. The cumulative risk differences for each year of follow-up showed a protective effect of CEA starting in year 2 (risk difference = 1.1%, 95% confidence interval: 0.5%-1.6%) and persisting to year 8 (2.6%, 95% confidence interval: 0.3%-4.8%) compared with patients not receiving CEA. ConclusionsIn this contemporary cohort study of patients with ACS using rigorous analytic methodology, CEA appears to have a small but statistically significant effect on stroke prevention out to 8 years. Further study is needed to appropriately select the subset of patients most likely to benefit from intervention.

Temporal Trends and Determinants of Stroke Risk in Patients With Medically Treated Asymptomatic Carotid Stenosis.

Effectiveness of carotid procedures (surgery and stenting) in patients with asymptomatic carotid artery stenosis (ACAS) depends on the absolute risk reduction that patients might receive from these procedures. We aimed to quantify the risk of ipsilateral ischemic stroke and examined temporal trends and determinants of these risks in patients with ACAS treated conservatively. We conducted a systematic review from inception to March 9, 2023, of peer-reviewed trials and cohort studies describing ipsilateral ischemic stroke risk in medically treated patients with ACAS of ≥50%. Risk of bias was assessed with an adapted version of the Quality in Prognosis Studies tool. We calculated the annual incidence rates of ipsilateral ischemic stroke. We explored temporal trends and associations of sex and degree of stenosis with ipsilateral ischemic stroke using Poisson metaregression analysis and incidence rate ratios, respectively. After screening 5915 reports, 73 studies describing ipsilateral ischemic stroke rates of 28 625 patients with midyear of recruitment ranging from 1976 to 2014 were included. The incidence of ipsilateral ischemic stroke was 0.98 (95% CI, 0.93-1.04) per 100 patient-years (median duration of follow-up, 3.3 years). The incidence decreased 24% with every 5 years more recent midyear of recruitment (rate ratio, 0.76 [95% CI, 0.73-0.78]). Incidence rates of ipsilateral ischemic stroke were lower in female patients (rate ratio, 0.74 [95% CI, 0.63-0.87]) and in patients with moderate versus severe stenosis when assessed in cohort studies, with incidence rate ratios of 0.41 ([95% CI, 0.35-0.49] cutoff, 70%) and 0.42 ([95% CI, 0.30-0.59] cutoff, 80%). Reported risks of ipsilateral ischemic stroke in patients with ACAS have declined 24% every 5 years from mid-1970s onward, further challenging the routine use of carotid procedures. Risks were lower in female patients and more than twice as high with severe compared with moderate ACAS. Inclusion of these findings in individualized risk assessment can help to determine the benefit of carotid procedures in selected individual patients with ACAS. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021222940.

Rates of Stroke in Patients With Different Presentations of Carotid Artery Stenosis

Carotid artery stenosis may present without the classical symptoms of transient ischaemic attack or stroke but the rates of stroke for these presentations is unknown. The aim of this study was to examine the rates of stroke in patients with different presentations of carotid artery stenosis. A multicentre prospective cohort study was conducted across three Australian vascular centres with low rates of surgical treatment of patients without transient ischaemic attack or stroke. Patients with a 50 - 99% carotid artery stenosis presenting with non-focal symptoms (e.g., dizziness or syncope; n= 47), prior contralateral carotid endarterectomy (n= 71), prior ipsilateral symptoms more than six months earlier (n= 82), and no symptoms (n = 304) were recruited. The primary outcome was ipsilateral ischaemic stroke. Secondary outcomes were any ischaemic stroke and cardiovascular death. Data were analysed using Cox proportional hazard and Kaplan-Meier analyses. Between 2002 and 2020, 504 patients were enrolled (mean age 71 years, 30% women) and followed for a median of 5.1 years (interquartile range 2.5, 8.8; 2 981 person years). Approximately 82% were prescribed antiplatelet therapy, 84% were receiving at least one antihypertensive drug, and 76% were prescribed a statin at entry. After five years the incidence of ipsilateral stroke was 6.5% (95% confidence interval [CI] 4.3 - 9.5). There were no statistically significant differences in the annual rate of ipsilateral stroke among people with non-focal symptoms (2.1%; 95% CI 0.8 - 5.7), prior contralateral carotid endarterectomy (0.2%; 0.03 - 1.6) or ipsilateral symptoms > 6 months prior (1.0%; 0.4 - 2.5) compared with those with no symptoms (1.2%; 0.7 - 1.8; p= .19). There were no statistically significant differences in secondary outcomes across groups. This cohort study showed no large differences in stroke rates among people with different presentations of carotid artery stenosis.

Association Between Spotty Calcification in Nonstenosing Extracranial Carotid Artery Plaque and Ipsilateral Ischemic Stroke.

Background Small spotty calcifications in the coronary arteries are associated with an increased risk of myocardial infarction. We examined the association between spotty calcifications near the carotid bifurcations and ipsilateral ischemic stroke in patients with <50% luminal stenosis of the extracranial carotid arteries. Methods and Results We used data from the CAESAR (Cornell Acute Stroke Academic Registry), a prospective registry of all patients with acute ischemic stroke admitted to our institution. We included patients who met criteria for cryptogenic stroke and underwent computed tomography angiography and brain magnetic resonance imaging. Patients with extracranial carotid artery stenosis ≥50% and patients with posterior or bilateral anterior circulation infarcts were excluded. We examined the carotid bifurcations for spotty calcifications, defined as ≥1 contiguous regions of luminal calcification ≤3 mm along the long axis of the vessel. We also measured low-density plaque and maximum plaque thickness. The eligible cohort consisted of 117 patients with a mean age of 66.7±1.65 years with a median National Institute of Health Stroke Scale stroke at the time of arrival of 6 (range, 3-13). The number of spotty calcifications present within a low-density plaque was significantly associated with ipsilateral infarction (0.3±0.8 versus 0.1±0.4, P=0.02). Maximum plaque thickness was also significantly associated with ipsilateral infarction (1.4 mm ±1.5 versus 1.0 mm ±1.1, P=0.004). Conclusions Spotty calcifications associated with low-density plaque and maximum plaque thickness were associated with ipsilateral ischemic stroke in patients with nonstenotic carotid atherosclerosis, suggesting a role as imaging markers of high-risk plaque.

Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting

Background/aimsData are limited on the frequency of ‘consensus decisions’ between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM ‘adherence’ to such advice.MethodsThis prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom ‘consensus management decisions’ were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), ‘indeterminate symptomatic status stenosis’ (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / − intervention.ResultsOne hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50–99% SCS patients was 12.5 days (IQR: 9–18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1–7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up.ConclusionsThe high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.

399 Role of Plaque Inflammation in Symptomatic Carotid Stenosis

INTRODUCTION: Prior studies have shown that plaque inflammation on FDG-PET and the SCAIL score were associated with recurrent ischemic events. However, the findings have thus far not been widely validated. METHODS: This was a single-center prospective cohort study that included patients with (1) recent TIA or ischemic stroke within the past 30 days, (2) ipsilateral carotid artery stenosis of ≥50%, and (3) not considered for early carotid revascularization. The (1) maximum standardized uptake value (SUVmax) of the symptomatic carotid plaque, (2) stenosis severity of the symptomatic carotid artery, and (3) the SCAIL score (a composite score consisting of the degree of plaque inflammation and stenosis severity) were measured for all patients. The outcomes were (1) a 90-day ipsilateral ischemic stroke and (2) a 90-day ipsilateral symptomatic TIA or major adverse cardiovascular event (MACE). RESULTS: Of 131 included patients, 21 (16.0%) patients had a 90-day ischemic stroke, and 41 (31.3%) patients had a 90-day TIA or MACE. Symptomatic plaque SUVmax (AUC = 0.92; 95% CI = 0.82–1.00) was superior to the SCAIL score (AUC = 0.79; 95% CI = 0.65, 0.92) in predicting 90-day ischemic stroke. Symptomatic plaque SUVmax (AUC = 0.84; 95% CI = 0.76, 0.92) was also superior to the SCAIL score (AUC = 0.76; 95% CI = 0.66, 0.85) in predicting 90-day TIA or MACE. CONCLUSIONS: Plaque inflammation may serve as a reliable biomarker for risk stratification and selection of patients for carotid revascularization and/or anti-inflammatory therapy.

Carotid Artery Coiling Associated with Ipsilateral Ischemic Stroke Treated by Mechanical Thrombectomy

Carotid Artery Coiling Associated with Ipsilateral Ischemic Stroke Treated by Mechanical Thrombectomy

Staged endovascular recanalization for symptomatic atherosclerotic non-acutely occluded internal carotid artery

Symptomatic "non-acutely" occluded internal carotid artery (NAOICA) results in stroke, cognitive impairment, and hemicerebral atrophy through cerebral hypoperfusion and artery-to-artery embolism. Atherosclerosis is the main cause of NAOICA. Conventional one-stage endovascular recanalization showed effectiveness but was plagued by many challenges. This retrospective analysis reports the technical feasibility and outcomes of the staged endovascular recanalization in patients with NAOICA. Eight consecutive patients with atherosclerotic NAOICA and ipsilateral ischemic stroke within 3 months between January 2019 and March 2022 were retrospectively reviewed. The patients (all males, with a mean age of 64.6 years) underwent staged endovascular recanalization 13 to 56 days after documented occlusion by imaging techniques (mean 28.8 days); the mean follow-up period was 20 months (range: 6-28). The approach of the staged intervention was as follows. In the first stage, the occluded ICA was successfully recanalized using the simple small balloon dilation technique. In the second stage, angioplasty with a stent implant was performed with >50% residual stenosis in the initial segment or ≥70% residual stenosis in the C2-C5 segment. The technical success rate, the incidence of clinical adverse events (any stroke, death, cerebral hyperperfusion), and long-term in-stent stenosis (ISR) and reocclusion rates were evaluated. Technical success was achieved in seven patients, with early reocclusion occurring in one patient after the first-stage intervention. There were no adverse events observed within 30 days (0%), and long-term reocclusion and long-term ISR rates were both 14% (1/7). However, all patients developed iatrogenic arterial dissections during the first stage, indicating the challenge of reaching the true lumen through the occlusion site without damaging the intima. Based on the National Heart, Lung and Blood Institute (NHLBI) classification, there were two type A, four type B, three type C, and two type D dissections. The mean time interval between the two stages was 46.1 days (21-152 days). All type A and B dissections resolved spontaneously after ≥3 weeks of dual antiplatelet therapy, whereas most type C and all type D dissections did not heal spontaneously before the second stage. Also, one type C dissection led to reocclusion. This observation suggested that occlusions without flow limit and persistent vessel staining or extravasation could be clinically observed, while severe dissections (characterized as type C or greater) required prompt stenting rather than conservative treatment. Performing high-resolution MRI preoperatively to exclude fresh thrombus in the occluded vessel segment is indispensable in selecting appropriate candidates for endovascular recanalization. This could avoid downstream embolism during the interventional procedure. This retrospective study found that staged endovascular recanalization for symptomatic atherosclerotic NAOICA may be feasible with an acceptable technical success rate and a low complication rate in the selected candidates.

Role of plaque inflammation in symptomatic carotid stenosis.

Prior studies have shown that plaque inflammation on FDG-PET and the symptomatic carotid atheroma inflammation lumen-stenosis (SCAIL) score were associated with recurrent ischemic events, but the findings have thus far not been widely validated. Therefore, we aimed to validate the findings of prior studies. A single-center prospective cohort study that recruited patients with (1) recent TIA or ischemic stroke within the past 30 days, (2) ipsilateral carotid artery stenosis of ≥50%, and (3) were not considered for early carotid revascularization. The (1) maximum standardized uptake value (SUVmax) of the symptomatic carotid plaque, (2) the SCAIL score, and (3) stenosis severity of the symptomatic carotid artery were measured for all patients. The outcomes were (1) a 90-day ipsilateral ischemic stroke and (2) a 90-day ipsilateral symptomatic TIA or major adverse cardiovascular event (MACE). Among the 131 patients included in the study, the commonest cardiovascular risk factor was hypertension (95 patients, 72.5%), followed by diabetes mellitus (77 patients, 58.8%) and being a current smoker (64 patients, 48.9%). The median (IQR) duration between the index cerebral ischemic event and recruitment to the study was 1 (0, 2.5) days. The median (IQR) duration between the index cerebral ischemic event and FDG-PET was 5 (4, 7) days. A total of 14 (10.7%) patients had a 90-day stroke, and 41 (31.3%) patients had a 90-day TIA or MACE. On comparison of the predictive performances of the SCAIL score and SUVmax, SUVmax was found to be superior to the SCAIL score for predicting both 90-day ipsilateral ischemic stroke (AUC: SCAIL = 0.79, SUVmax = 0.92; p < 0.001; 95% CI = 0.072, 0.229) and 90-day TIA or MACE (AUC: SCAIL = 0.76, SUVmax = 0.84; p = 0.009; 95% CI = 0.020, 0.143). Plaque inflammation as quantified on FDG-PET may serve as a reliable biomarker for risk stratification among patients with ECAD and recent TIA or ischemic stroke. Future studies should evaluate whether patients with significant plaque inflammation as quantified on FDG-PET benefit from carotid revascularization and/or anti-inflammatory therapy.

Complication Rate After Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure: Long-Term Outcome

Objective: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest European Society of Vascular Surgery (ESVS) guidelines on the management of atherosclerotic carotid disease, routine patching is preferred to routine primary closure. However, there are no RCT’s evaluating selective patching strategies. This follow-up study aimed to assess long term complication rate and restenosis after carotid endarterectomy with selective patching. Methods: Two hundred thirteen consecutive carotid endarterectomies over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Patient population consisted of 141 procedures on males and 72 on females with mean age 73 years at the time of surgery (standard deviation (SD) 8.57, range 53-95). There was a follow-up of 89%. Postoperative risk factors were assessed such as hypertension, diabetes mellitus, coronary artery disease and smoking. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after carotid endarterectomy. Results: Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups' baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05). In four cases patients experienced symptoms of cranial nerve damage postoperatively, two in each group. In one of the two cases in each group, the patient fully recovered and the other had persistent complaints (P-value= 1). None of the patients experienced amaurosis fugax during the 5-year follow up period. In five cases a patient had an ipsilateral cerebrovascular thrombosis in the group after patch angioplasty compared to zero in the primary closure group (P-value= .02). In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P-value = .70). One was caused by cerebral hyperperfusion syndrome within one month postoperative after patch angioplasty and none were caused by an ipsilateral ischemic stroke. Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P-value= .43). In twelve cases patients showed a restenosis between 50-70% (6 primary closure and 6 patch angioplasty), none of the patients had high grade restenosis of more than 70%. Patient characteristics did not show a significant effect on long term outcomes. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P-value= .006), restenosis (P-value= .01) and mortality (P-value= .003). Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected cases. Best medical treatment and especially the use of antihypertensive medication should be emphasized.

Regional Anesthesia for Carotid Endarterectomy in Patients with Acute Ischemic Stroke (Pilot Study)

Objective. The aim of this study is to assess the safety of the use of regional anesthesia for performing carotid endarterectomy (CEA) in patients in the acute phase of ischemic stroke.Material and methods. The study included 66 patients in the acute phase of ischemic stroke (atherothrom-botic subtype according to the TOAST classification) who underwent carotid endarterectomy. The inclusion criteria for the study were as follows: acute phase of atherothrombotic ischemic stroke (first 28 days), ipsilateral symptomatic ≥ 50% stenosis of the internal carotid artery, 1-4 points neurological deficit according to the modified Rankin Scale (mRS), 1-13 points neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), size of the cerebral ischemic lesion ≤ 4 cm. This single-center prospective cohort study compared two anesthetic approaches, regional anesthesia (RA, 46 patients) and general anesthesia (GA, 20 patients). The RA techniques included ultrasound-guided superficial and deep cervical plexus blocks on the side of the surgery.Results. The study found no significant differences in the baseline patient characteristics, surgery techniques and clinical outcomes between the groups. There were no neurological or cardiovascular toxic reactions to the local anesthetics. Conversions from RA to GA were not performed. In the RA group, recurrent ipsilateral ischemic strokes, myocardial infarctions, wound hemorrhagic complications and lethal outcomes did not occur.Conclusion. This pilot study has demonstrated the safety of RA for performing CEA in patients in the acute phase of ischemic stroke. RA provides adequate neuromonitoring and timely intraoperative recognition of «new» ischemic complications. To compare the efficacy of RA and GA for performing CEA in patients with acute ischemic stroke, large randomized controlled trials are needed.

Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms – SCENT: 3-year outcomes

BackgroundTo report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck...

Modifiable risk factors for occurrence of ipsilateral ischemic events after carotid endarterectomy beyond perioperative period

ObjectiveThe purpose of this study was to quantify the effects of several modifiable variables on the occurrence of stroke after the initial perioperative period for patients who had undergone carotid endarterectomy (CEA). MethodsThe primary outcome for the present study was the development of an ischemic stroke or transient ischemic attack (TIA) in the cerebral hemisphere ipsilateral to CEA after the initial hospitalization. All CEAs in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. The exclusion criteria for the study were the lack of follow-up data for >30 days, concomitant coronary artery bypass surgery, concomitant proximal or distal carotid intervention at CEA, other arterial interventions at CEA, and stroke or TIA during the initial hospital admission, leaving 126,290 patients for analysis. We used the χ2 test for statistical analysis of the outcome of ipsilateral ischemic stroke or TIA after the initial CEA hospital admission to determine the relevant variables. Age was evaluated as an ordinal variable using the Student t test. Variables with P ≤ .05 on univariable analysis were included in the multivariable Cox regression time-to-event analysis for the primary outcome. Kaplan-Meier curves were constructed of the most significant variables on Cox regression as a visual aid. ResultsThe following variables achieved significance on Cox regression for an association with development of ipsilateral hemispheric ischemic events after the index CEA hospital admission: lack of patch placement at CEA site (hazard ratio [HR], 18.24; P < .0001), lack of antiplatelet therapy at long-term follow-up (LTFU; HR, 9.75; P < .0001), lack of statin therapy at LTFU (HR, 3.18; P < .001), lack of statin therapy at hospital discharge (HR, 1.25; P = .015), anticoagulation at LTFU (HR, 1.53; P < .001), development of >70% recurrent stenosis (HR, 2.15; P < .001), and shunt use at surgery (HR, 1.20; P = .007). Patients with patch placement at surgery and patients with confirmed antiplatelet therapy at LTFU had had 99.8% and 99.6% freedom from an ischemic event ipsilateral to the side of the CEA at LTFU, respectively. This finding is in contrast to the 5.7% and 4.7% positivity for ischemic events for those without patch placement at surgery and those not receiving antiplatelet therapy at LTFU, respectively (P < .0001 for both). ConclusionsPerformance of patch angioplasty arterial closure was remarkably protective against ipsilateral cerebral ischemic events at LTFU after CEA. Discharging and maintaining patients with antiplatelet and statin medication after CEA significantly reduces the incidence of future ipsilateral ischemic events. Thus, a significant opportunity exists for enhanced outcomes with improved implementation of these measures.

Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trial

The optimal treatment for patients with asymptomatic carotid artery stenosis is under debate. Since best medical treatment (BMT) has improved over time, the benefit of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. Randomised data comparing the effect of CEA and CAS versus BMT alone are absent. We aimed to directly compare CEA plus BMT with CAS plus BMT and both with BMT only. SPACE-2 was a multicentre, randomised, controlled trial at 36 study centres in Austria, Germany, and Switzerland. We enrolled participants aged 50-85 years with asymptomatic carotid artery stenosis at the distal common carotid artery or the extracranial internal carotid artery of at least 70%, according to European Carotid Surgery Trial criteria. Initially designed as a three-arm trial including one group for BMT alone (with a randomised allocation ratio of 2·9:2·9:1), the SPACE-2 study design was amended (due to slow recruitment) to become two substudies with two arms each comparing CEA plus BMT with BMT alone (SPACE-2a) and CAS plus BMT with BMT alone (SPACE-2b); in each case in a 1:1 randomisation. Participants and clinicians were not masked to allocation. The primary efficacy endpoint was the cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years. The primary safety endpoint was any stroke or death from any cause within 30 days after CEA or CAS. The primary analysis was by intention-to treat, which included all randomly assigned patients in SPACE-2, SPACE-2a, and SPACE-2b, analysed using meta-analysis of individual patient data. We did two-step hierarchical testing to first show superiority of CEA and CAS to BMT alone then to assess non-inferiority of CAS to CEA. Originally, we planned to recruit 3640 patients; however, the study had to be stopped prematurely due to insufficient recruitment. This report presents the primary analysis at 5-year follow-up. This trial is registered with ISRCTN, number ISRCTN78592017. 513 patients across SPACE-2, SPACE-2a, and SPACE-2b were recruited and surveyed between July 9, 2009, and Dec 12, 2019, of whom 203 (40%) were allocated to CEA plus BMT, 197 (38%) to CAS plus BMT, and 113 (22%) to BMT alone. Median follow-up was 59·9 months (IQR 46·6-60·0). The cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years (primary efficacy endpoint) was 2·5% (95% CI 1·0-5·8) with CEA plus BMT, 4·4% (2·2-8·6) with CAS plus BMT, and 3·1% (1·0-9·4) with BMT alone. Cox proportional-hazard testing showed no difference in risk for the primary efficacy endpoint for CEA plus BMT versus BMT alone (hazard ratio [HR] 0·93, 95% CI 0·22-3·91; p=0·93) or for CAS plus BMT versus BMT alone (1·55, 0·41-5·85; p=0·52). Superiority of CEA or CAS to BMT was not shown, therefore non-inferiority testing was not done. In both the CEA group and the CAS group, five strokes and no deaths occurred in the 30-day period after the procedure. During the 5-year follow-up period, three ipsilateral strokes occurred in both the CAS plus BMT and BMT alone group, with none in the CEA plus BMT group. CEA plus BMT or CAS plus BMT were not found to be superior to BMT alone regarding risk of any stroke or death within 30 days or ipsilateral stroke during the 5-year observation period. Because of the small sample size, results should be interpreted with caution. German Federal Ministry of Education and Research (BMBF) and German Research Foundation (DFG).