Screening For Carotid Stenosis Research Articles

Benefits of prophylactic carotid revascularization in patients with asymptomatic carotid artery stenosis undergoing coronary artery bypass surgery: A narrative review.

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Selective screening for carotid stenosis may be justified in patients undergoing coronary artery bypass grafting

Selective screening for carotid stenosis may be justified in patients undergoing coronary artery bypass grafting

IS SCREENING FOR EXTRACRANIAL CAROTID STENOSIS EFFECTIVE IN PREVENTING ISCHEMIC STROKE? LITERATURE REVIEW

This literature review shows the essence of the problem of extracranial carotid artery stenosis, since this disease is a treatable cause of ischemic stroke and can be reliably detected and assessed by using vascular ultrasound. In Kazakhstan, due to acute disorders of cerebral circulation, 11.1 thousand patients die every year. The reliability of the information in the article was obtained by using the literature data of the last 10 years. The reflection of the criteria for diagnosing stenosis of the extracranial carotid artery, the use of which, in conjunction with standard tests and other sensitive methods, makes it possible to determine the lesion of the extracranial carotid artery at an early stage, as well as a detailed description of diagnostic methods of this complication and evaluation of their effectiveness. Screening for carotid stenosis is important, and whether routine carotid ultrasound is recommended in general population for the prevention of ischemic stroke remains controversial. Screening for carotid stenosis by ultrasound is crucial not only for the daily clinical setting, but also for the management of patients with acute ischemic stroke.

Task Force Recommendation on Asymptomatic Carotid Stenosis Screening Points to the Need for Data, Experts Say

Task Force Recommendation on Asymptomatic Carotid Stenosis Screening Points to the Need for Data, Experts Say

Epidemiology of atherosclerotic carotid artery disease

Atherosclerotic carotid artery disease is a significant cause of stroke in the United States and globally. Its prevalence increases with age and it is more prevalent in men and White and Native-American populations. However, the outcomes related to carotid disease are worse in women and Black patients. Research suggests the disparities exist due to a multitude of factors, including disease pathophysiology, access to care, provider bias, and socioeconomic status. The prevalence of carotid stenosis in the general population is low (3%), and routine screening for carotid stenosis is not recommended in adults. Randomized clinical trials have shown benefits of stroke risk reduction with surgery (carotid endarterectomy or stenting) for symptomatic patients. Management is controversial in asymptomatic patients, as modern medical management has results equivalent to those of surgery and ongoing randomized clinical trials will address this important question. Carotid surgery is not appropriate in asymptomatic patients with limited life expectancy. Future work should explore comprehensive care models for care of patients with carotid disease and assessment of patient-reported outcomes to measure quality of care.

USPSTF Recommendations for Screening for Carotid Stenosis to Prevent Stroke—The Need for More Data

USPSTF Recommendations for Screening for Carotid Stenosis to Prevent Stroke—The Need for More Data

Echographic features of the structure of atherosclerotic plaques in carotid ischemic stroke

An assessment of not only the degree of stenosis, but also the structure of atherosclerotic plaques (ASPs) in the carotid arteries can reveal atheromas that are dangerous for the development of cerebrovascular events in asymptomatic individuals. Objective: to study the echostructure of ASPs in patients in the acutest period of carotid ischemic stroke (IS) and to analyze predictors for its development according to ultrasonic duplex scanning (DS). Patients and methods. A study group included the results of DS in 668 patients (370 men and 298 women aged 63±11 and 69±9 years, respectively) with IS in the middle cerebral artery bed. Out of 222 patients, 160 (72.1%), 56 (25.2%), 4 (1.8%), and 2 (0.9%) people had atherothrombotic, cardioembolic, hemodynamic, and lacunar subtypes of IS, respectively. A control group consisted of 903 asymptomatic individuals matched to the patients for gender and age. Results and discussion . In patients with IS, carotid stenoses were characterized by the higher degree of a reduction in the lumen of both the internal carotid arteries (ICA): on the right (r) (53±23%) and left (l) (54±24%) sides, and the common carotid arteries (CCA): on both sides (40±12%) compared to asymptomatic individuals: rICA (40±14%), lICA (39±15%); and both CCAs (32±9%). At the same time, ASPs in the carotid arteries in the acutest period of IS were significantly more frequently homogeneous hypoechoic (21.2%) or heterogeneous with a hypoechoic component (25.6%), and also more frequently had an uneven contour in the rICA (41.3%) and lICA (33.6%), compared to those in asymptomatic individuals (hypoechoicity (7.0 and 5.6%, respectively); the uneven contour was in the rICA (3.2%) and lICA (4.0%). The study indicated that a set of echo signs (the degree of stenosis in the ICA and CCA; the homogeneity and hypoechoicity of ASP in the ICA; the uneven contour of ASP in the carotid arteries) was formed for primary ultrasound carotid stenosis screening carried out using a routine DS technique. Additional studies that can more accurately identify ASPs that are dangerous for the development of cerebral vascular events are recommended for asymptomatic individuals with ASP and the above signs, which will determine their treatment policy. Conclusion. Atheromas in the carotid arteries in the acutest period of IS are different from those in asymptomatic individuals by a number of features identified during routine ultrasonic DS. The most valuable individual prognostic sign of the development of carotid IS was the uneven contour of ASP in the carotid arteries.

Prevalence and the Risk Factors for Asymptomatic Carotid Artery Stenosis Among Type II Diabetes Mellitus Patients

Prevalence and the Risk Factors for Asymptomatic Carotid Artery Stenosis Among Type II Diabetes Mellitus Patients

Screening with doppler ultrasound for carotid artery stenosis in patients with stroke or transient ischaemic attack.

Carotid endarterectomy of symptomatic internal carotid artery stenosis in patients with stroke or transient ischaemic attack reduces the risk of recurrent stroke, particularly if performed within 2weeks from the first event. We evaluated the efficiency of a screening programme based on Doppler ultrasound in patients hospitalized with stroke or transient ischaemic attack in the stroke centre at Rigshospitalet, Glostrup, Denmark, concerning timeliness of referral to the vascular surgeon and performance of carotid endarterectomy according to national recommendations. Prospective study of a consecutive cohort of patients with transient ischaemic attack or stroke, referred for carotid Doppler ultrasound over a one-year period. We examined 1390 patients (1048 with stroke, 342 with transient ischaemic attack), 71% within 24h and 93% within 4days after admission. Carotid stenosis or occlusion was found in 171 patients (12·3%) and was hemisphere related in 78 patients (5·6%). Among these, 68 (87%) were referred to the vascular department, 94% within 4days of admission. Carotid endarterectomy was performed in 16 patients, all within 14days from admission, and was not declined in any patient due to procedural delay. In a major Danish stroke centre, the national recommended time limit of 4days in patients with stroke or transient ischaemic attack for screening for carotid stenosis was met in almost all patients. No patients were excluded from surgery as a result of a time limit of 14days from admission to surgery being exceeded. Of all patients screened, 1·2% underwent carotid endarterectomy.

CREST-2: Identifying the Best Method of Stroke Prevention for Carotid Artery Stenosis: National Institute of Neurological Disorders and Stroke Organizational Update.

One of the great achievements of modern medicine is the successful prevention of stroke and other cardiovascular diseases. Although the incidence of stroke has substantially declined over the last 30 years, ≈200 000 preventable stroke deaths still occur annually in the United States. According to a recent study based on the Greater Cincinnati/Northern Kentucky Stroke Study, annually ≈41 000 strokes in the United States are attributed to extracranial internal carotid artery stenosis. Early revascularization for symptomatic carotid stenosis—that is, in patients with recent ipsilateral stroke or TIA—is well established as effective at preventing ipsilateral stroke. Carotid stenosis in the absence of symptoms is extremely common, but the best treatment is unclear. While 2 randomized trials showed a benefit of carotid endarterectomy (CEA) over antiplatelet therapy with aspirin, the number needed to treat approaches 200. Does aggressive risk factor control change that balance? Population screening for carotid stenosis followed by revascularization is considered to cause net harm. Are complication rates from endarterectomy and stenting now low enough to justify expanding their indications in asymptomatic patients? The National Institute of Neurological Disorders and Stroke (NINDS)–funded CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) is an ambitious attempt to further refine the treatment of asymptomatic carotid stenosis. As one of the largest randomized stroke prevention trials, the first CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) was designed to compare the safety and efficacy of 2 stroke prevention procedures for carotid artery narrowing—CEA and carotid artery stenting (CAS)—in symptomatic and asymptomatic individuals. Starting in December 2000, this NINDS-funded trial enrolled >2500 patients at 117 sites in the United States and Canada. Because of slow enrollment, the trial took 9 years to complete. In 2010, the results of CREST indicated that the 2 revascularization procedures were equivalent for …

Asymptomatic carotid artery stenosis--is screening useful?

Stenoses of the carotid artery are associated with an increased stroke risk. Duplex ultrasound is the method of choice for screening for carotid artery stenosis. Unselected screening for carotid stenosis in unselected persons is not efficient and cannot be recommended. Screening by vascular ultrasound, however, is indicated in patients with neurologic symptoms from cerebral territories supplied by the anterior or mid cerebral artery, and in asymptomatic patients with carotid bruits, atherosclerotic disease in other vascular territories, after contralateral carotid artery revascularization, and after radiation therapy of the neck.

Improving imaging to optimize screening strategies for carotid artery stenosis

Carotid stenosis is a major risk factor for ischemic stroke. Recently, the United States Preventive Services Task Force issued a recommendation against screening for carotid stenosis in the general population. There is the potential for efficient risk-stratifying or staged screening approaches that identify individuals at highest risk for carotid stenosis and stroke, but these tools have yet to be proven effective in external validation studies. In this paper, we review how medical imaging can be used to detect carotid stenosis and highlight several areas that could be improved to identify potentially efficient screening strategies for carotid stenosis.

Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting?

A number of institutions routinely perform carotid artery ultrasound screening before coronary artery bypass grafting (CABG) to identify carotid artery disease requiring revascularization before or during CABG, with the expectation of reducing perioperative neurologic events. The assumptions are that carotid disease is causally related to perioperative stroke and that prophylactic carotid revascularization decreases the risk of post-CABG neurologic events. Although carotid artery stenosis is a known risk factor for perioperative stroke in patients undergoing CABG, it might be a surrogate marker for diffuse atherosclerotic disease rather than a direct etiologic factor. Moreover, the benefit of prophylactic carotid revascularization in patients with asymptomatic unilateral carotid disease is uncertain. Therefore, we have reviewed the literature for evidence that preoperative carotid artery screening, by identifying patients with significant carotid artery stenosis and altering their management, reduces perioperative neurologic events in those undergoing CABG.

Co-prevalence of carotid stenosis and coronary artery disease in Chinese patients with paroxysmal atrial fibrillation.

To investigate the co-prevalence of coronary artery disease (CAD) and carotid stenosis and to determine predictors related to CAD in Chinese patients with paroxysmal atrial fibrillation (PAF), presenting without previously diagnosed or excluded CAD. Consecutive patients with PAF were recruited. CAD was evaluated using multislice computed tomography. Intima-media thickness (IMT) of the carotid artery was evaluated via ultrasonography. A total of 62/192 (32.3%) patients had CAD. Carotid stenosis was observed in 26/192 (13.5%) patients. The co-prevalence of carotid stenosis and CAD was 7.8% (15/192). The prevalence of carotid stenosis was 8.5%, 16.7%, 25.0%, and 41.7% in patients with zero-, one-, two-, and three-vessel CAD, respectively. Diabetes mellitus, maximal IMT and hyperhomocysteinaemia were independently related to the presence of CAD. The prevalence of CAD was 32.3% in Chinese patients with PAF. Carotid stenosis and CAD co-occurred in 7.8% of patients, and the prevalence of carotid stenosis correlated with the severity of CAD. Screening of carotid stenosis is recommended, especially in patients with PAF and multivessel CAD.

Carotid stenosis: what is the high-risk population?

OBJECTIVE:Prevention is the best treatment for cerebrovascular disease, which is why early diagnosis and the immediate treatment of carotid stenosis contribute significantly to reducing the incidence of stroke. Given its silent nature, 80% of stroke cases occur in asymptomatic individuals, emphasizing the importance of screening individuals with carotid stenosis and identifying high-risk groups for the disease. The aim of this study was to determine the prevalence and the most frequent risk factors for carotid stenosis.METHODS:A transversal study was conducted in the form of a stroke prevention campaign held on three non-consecutive Saturdays. During the sessions, carotid stenosis diagnostic procedures were performed for 500 individuals aged 60 years or older who had systemic arterial hypertension and/or diabetes mellitus and/or coronary heart disease and/or a family history of stroke.RESULTS:The prevalence of carotid stenosis in the population studied was 7.4%, and the most frequent risk factors identified were mean age of 70 years, carotid bruit, peripheral obstructive arterial disease, coronary insufficiency and smoking. Independent predictive factors of carotid stenosis include the presence of carotid bruit or peripheral obstructive arterial disease and/or coronary insufficiency.CONCLUSIONS:The population with peripheral obstructive arterial disease and/or coronary insufficiency and carotid bruit should undergo routine screening for carotid stenosis.

Estimation of coefficients of individual agreement (CIAs) for quantitative and binary data using SAS and R

The coefficients of individual agreement (CIAs), which are based on the ratio of the intra- and inter-observer disagreement, provide a general approach for evaluating agreement between two fixed methods of measurements or human observers. In this paper, programs in both SAS and R are presented for estimation of the CIAs between two observers with quantitative or binary measurements. A detailed illustration of the computations, macro variable definitions, input and output for the SAS and R programs are also included in the text. The programs provide estimations of CIAs, their standard errors as well as confidence intervals, for the cases with or without a reference method. Data from a carotid stenosis screening study is used as an example of quantitative measurements. Data from a study involving the evaluation of mammograms by ten radiologists is used to illustrate a binary data example.

Extrakranielle Karotisstenose

BackgroundIn Germany, approximately 20,000-30,000 patients per year suffer a first-time carotid-associated stroke. The prevalence of extracranial carotid narrowing >50% is about 7% in patients older than 65 years and 15-25% in patients with an additional arteriosclerotic manifestation [peripheral artery disease (PAD), coronary heart disease]. A combination of colour-coded duplex ultrasound imaging and magnetic resonance angiography can detect carotid stenosis of >50% with a sensitivity and a specificity of >90%.Patients and methodsA mathematical model of a screening programme has been proposed to answer the following questions: 1) Is screening for carotid stenosis in patients older than 65 years reasonable? 2) What is the numbers-needed-to-screen (NNS) to prevent one stroke in 5 years in patients older than 65 years and in patients also suffering from PAD?ResultsIn patients older than 65 years, the NNS was calculated to be between 540 and 1,478, and in patients with PAD, between 82 and 540.ConclusionsScreening of patients older than 65 years seems to be worthwhile; however, approximately 1,000 patients would have to be screened to avoid one stroke in 5 years. By focusing the screening programme on patients who also have PAD, the NNS could be decreased to about 300. The economic feasibility and organisational aspects need to be considered.

Prevalence of Carotid Stenosis in a High-Risk Caribbean Population

The purpose of this study was to determine the prevalence of carotid stenosis among patients presenting to the University Hospital of West Indies (UHWI) Accident and Emergency Department (A&E) with an ischemic stroke or transient ischemic attack (TIA). Beginning in August 2006, all patients presenting to the UHWI A&E with an acute stroke or TIA were screened for enrollment. Patients were excluded if they had a hemorrhagic stroke or if informed consent could not be obtained. Demographic and clinical information were collected by chart review and interviewer-administered questionnaires. All participants had noncontrast head computed tomography (CT) and bilateral carotid duplex ultrasounds. 133 patients were enrolled in the study. 90% presented with a stroke and 10% with a TIA. Mean age was 64 years, 52% were male, 96% self-identified as black. 78% had diabetes mellitus or hypertension or both, 27% were current or past smokers. 65.1% had a normal carotid ultrasound, 28.5% had <50% stenosis, 1.6% had 50% to 69% stenosis, 0.8% had >or=70% stenosis to near occlusion, 1.6% had near occlusion and 1.6% total occlusion. The prevalence of moderate or high-grade carotid stenosis in this high-risk black Caribbean population presenting with an ischemic stroke or a TIA is 5.6%. This is lower than that described in other populations. Further studies are needed to determine the cost-effectiveness of routine screening for carotid stenosis in this population.

CT and duplex scanning: A comparison of imaging techniques for evaluation of the carotid tree in head and neck cancer patients

Carotid artery disease is a common condition which, like head and neck cancer, is primarily smoking related. Internal carotid stenosis may result in cerebro-vascular complications, while severe stenosis of the external carotid can potentially compromise microvascular free tissue transfer reconstruction. We were interested to see whether any co-existing carotid artery disease could be assessed on the neck CT scan by comparing it to definitive duplex scanning in head and neck cancer patients. CT and duplex scanning of the common, internal and external carotid arteries was compared in 30 patients (180 vessels). The arterial phase of the neck CT scans were reviewed by two radiologists and all duplex scans were performed by one vascular technician to minimise inter-operator variability. The respective findings were blinded. Significant correlations were found between CT and duplex in confirming stenosis of the common and internal carotid arteries (P<0.001). There was a weak correlation between CT and duplex in the assessment of the external carotid system (P=0.02 and P=0.08), with CT under-estimating the true extent of stenosis in this vessel. The sensitivity and specificity of CT compared to duplex was 77% and 94% respectively. CT is useful not only for imaging the neck of head and neck cancer patients, but also in screening for carotid stenosis. Duplex scanning is more accurate than CT in assessing the external artery, and is useful for evaluating patients with significant stenosis of the carotid tree.

Resampling Dependent Concordance Correlation Coefficients

The concordance correlation coefficient (CCC) is a popular index for measuring the reproducibility of continuous variables. We examine two resampling approaches, permutation testing and the bootstrap, for conducting hypothesis tests on dependent CCCs obtained from the same sample. Resampling methods are flexible, require minimal marginal and joint distributional assumptions, and do not rely on large sample theory. However, the permutation test requires a restrictive assumption (exchangeability) which limits its applicability in this situation. Simulation results indicate that inference based on the bootstrap is valid, although type-I error rates are inflated for small sample sizes (≈30). For illustration we analyze data from a carotid stenosis screening study.