Management Of Severe Carotid Stenosis Research Articles

Functional MRI evaluation of cognitive effects of carotid stenosis revascularization.

IntroductionSevere internal carotid stenosis, if left untreated, can pose serious risks for ischemic stroke and cognitive impairments. The effects of revascularization on any aspects of cognition, however, are not well understood, as conflicting results are reported, which have mainly been centered on paper‐based cognitive analyses. Here, we summarized and evaluated the publications to date of functional MRI (fMRI) studies that examined the mechanisms of functional brain activation and connectivity as a way to reflect cognitive effects of revascularization on patients with carotid stenosis.MethodsA PubMed and Google Scholar (covering the relevant literature until November 1, 2021) search yielded eight original studies of the research line, including seven resting‐state and one task‐based fMRI reports.ResultsFindings demonstrated treatment‐related alterations in fMRI signal intensity and symmetry level, regional fMRI activation pattern, and functional brain network connectivity. The functional brain changes were associated largely with improvement in cognitive function assessed using standard cognitive test scores.ConclusionsThese findings support the contribution of fMRI to the understanding of brain functional activation and connectivity changes revealing cognitive effects of revascularization in the management of severe carotid stenosis. The review also highlighted the importance of reproducibility through enhancing experimental designs and cognitive task applications with future research for potential clinical translation.

Role of carotid artery stenting in the management of severe carotid stenosis

Cardiologia CROATICA Carotid artery stenosis is the cause of 20% to 25% of strokes. The risk of stroke depends upon the severity of the carotid stenosis. According to the NASCET trial, 75% to 94% stenosis is associated with a stroke risk of 27% in symptomatic and 18.5% in asymptomatic patients. Many RCTs have compared the safety and efficacy of CEA with that of CAS in treating carotid artery stenosis, producing conflicting results. The most recent and largest National Institutes of Health-sponsored trial (the Carotid Revascularization Endarterectomy vs. Stenting Trial [CREST]) enrolled both symptomatic and asymptomatic patients and excluded patients with previous disabling stroke or with atrial fibrillation. In contrast to other trials, only one kind of stent and embolic protection filter was allowed and rigorous training criteria were used to standardize operator skill. The rates of stroke, death, and myocardial infarction (MI) were lower than or equal to rates in previous trials for both CAS and CEA. CREST results showed that CAS and CEA were associated with similar rates of death and disabling stroke. In January 2011, the FDA’s Circulatory System Device Panel expanded the indications for CAS in standard-risk patients to include stenosis of ≥70% by ultrasound or ≥50% by angiogram combined with neurologic symptoms, and stenosis of ≥70% by ultrasound or ≥60% by angiogram in the absence of symptoms. In our institution, we performed CAS in 78 patients with stenosis of ≥70% by ultrasound or ≥60% by angiogram. 49 patients were asymptomatic (63%). In all procedures we used a filter wire for embolic protection. Within the 30-day periprocedural period we did not detect any major complication such as death, stroke or MI. In two patients we observed transient ischaemic attack.

Surgery for Acute Stroke: Current Status

Although investigations regarding surgery for acute ischemic stroke span 4 decades, the topic remains controversial. This review considers emergency carotid surgery for acute stroke from four perspectives: an operation attempting to reverse an acute neurological deficit, an operation soon after acute stroke to prevent further neurologic deficit, reoperative surgery for acute neurological deficit early after carotid endarterectomy (CEA), and management of severe carotid stenosis after successful thrombolytic therapy for acute ischemic stroke. The available clinical data are absent or incomplete for each of these unusual aspects of carotid surgery. In the absence of a badly needed ran domized trial, case selection is important and should be accompanied by a proven record of successful, low-morbidity, elective carotid surgery before undertaking more controversial indications. Delaying CEA for 4 to 6 weeks after stroke has repeatedly been shown to be unnecessary and to increase risk of interval new stroke. Fi...

Elective stenting of the extracranial carotid arteries.

Surgical endarterectomy has been shown to be superior to medical management in the management of severe carotid stenosis in both symptomatic and asymptomatic patients. Endarterectomy, although effective, does have limitations, and percutaneous techniques may offer an alternative method of treatment. The feasibility and safety of percutaneous carotid angioplasty and elective (primary) stenting was evaluated prospectively in a consecutive series of 107 patients. One hundred twenty-six carotid arteries with significant stenosis were treated. This series represented a high-risk subset that included patients with previous ipsilateral endarterectomy and severe medical comorbidity. Forty-five percent of the patients were referred by surgeons. Patients had independent neurological examinations before and after the procedure and follow-up cerebral angiography at 6 months. The mean (+/- SD) stenosis was reduced from 78 +/- 14% to 2 +/- 5%. There were 7 minor strokes, 2 major strokes, and 1 death during the initial hospitalization and first 30 days after the procedure. For the combined end point of all strokes and death, the incidence was 7.9%. For ipsilateral major stroke and death, the incidence was 1.6%. There were no strokes during the follow-up period. Mean angiographic stenosis at 6 months in 81 patients was 18 +/- 16% (range, -21% to 57%). Four (4.9%) of these 81 patients had asymptomatic restenosis. Five asymptomatic patients had repeat intervention: 2 had angioplasty for restenosis, 2 had angioplasty for stent deformation, and 1 had endarterectomy for restenosis. In a high-risk group of patients, percutaneous carotid angioplasty and stenting are feasible and can be performed with low restenosis and repeat intervention rates.