Elias Johansson1, Elisa Cuadrado-Godia2, Derek Hayden1, Jakob Bjellerup1, Angel Ois1, Jaume Roquer1, Per Wester1, Peter J Kelly1. 1. From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland. 2. From the Department of Public Health and Clinical Medicine, Umeå Stroke Centre (E.J., J.B., P.W.), and Department of Pharmacology and Clinical Neuroscience (E.J.), Umeå University, Sweden; Department of Neurology (E.C.-G., A.O., J.R.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Spain; and Neurovascular Unit for Translational and Therapeutics Research (D.H., P.J.K.), Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland. ecuadrado@hospitaldelmar.cat.
Abstract
OBJECTIVE: We aimed to quantify the risk and predictors of ipsilateral ischemic stroke in patients with symptomatic carotid stenosis awaiting revascularization (carotid endarterectomy [CEA] or carotid artery stenting) by pooling individual patient data from recent prospective studies with high rates of treatment with modern stroke prevention medications. METHODS: Data were included from 2 prospective hospital-based registries (Umeå, Barcelona) and one prospective population-based study (Dublin). Patients with symptomatic 50%-99% carotid stenosis eligible for carotid revascularization were included and followed for early recurrent ipsilateral stroke or retinal artery occlusion (RAO). RESULTS: Of 607 patients with symptomatic 50%-99% carotid stenosis, 377 met prespecified inclusion criteria. Ipsilateral recurrent ischemic stroke/RAO risk pre-revascularization was 2.7% (1 day), 5.3% (3 days), 11.5% (14 days), and 18.8% (90 days). On bivariate analysis, presentation with a cerebral vs ocular event was associated with higher recurrent stroke risk (log-rank p = 0.04). On multivariable Cox regression, recurrence was associated with older age (adjusted hazard ratio [HR] per 10-year increase 1.5, p = 0.02) with a strong trend for association with cerebral (stroke/TIA) vs ocular symptoms (adjusted HR 2.7, p = 0.06), but not degree of stenosis, smoking, vascular risk factors, or medications. CONCLUSIONS: We found high risk of recurrent ipsilateral ischemic events within the 14-day time period currently recommended for CEA. Randomized trials are needed to determine the benefits and safety of urgent vs subacute carotid revascularization within 14 days after symptom onset.
OBJECTIVE: We aimed to quantify the risk and predictors of ipsilateral ischemic stroke in patients with symptomatic carotid stenosis awaiting revascularization (carotid endarterectomy [CEA] or carotid artery stenting) by pooling individual patient data from recent prospective studies with high rates of treatment with modern stroke prevention medications. METHODS: Data were included from 2 prospective hospital-based registries (Umeå, Barcelona) and one prospective population-based study (Dublin). Patients with symptomatic 50%-99% carotid stenosis eligible for carotid revascularization were included and followed for early recurrent ipsilateral stroke or retinal artery occlusion (RAO). RESULTS: Of 607 patients with symptomatic 50%-99% carotid stenosis, 377 met prespecified inclusion criteria. Ipsilateral recurrent ischemic stroke/RAO risk pre-revascularization was 2.7% (1 day), 5.3% (3 days), 11.5% (14 days), and 18.8% (90 days). On bivariate analysis, presentation with a cerebral vs ocular event was associated with higher recurrent stroke risk (log-rank p = 0.04). On multivariable Cox regression, recurrence was associated with older age (adjusted hazard ratio [HR] per 10-year increase 1.5, p = 0.02) with a strong trend for association with cerebral (stroke/TIA) vs ocular symptoms (adjusted HR 2.7, p = 0.06), but not degree of stenosis, smoking, vascular risk factors, or medications. CONCLUSIONS: We found high risk of recurrent ipsilateral ischemic events within the 14-day time period currently recommended for CEA. Randomized trials are needed to determine the benefits and safety of urgent vs subacute carotid revascularization within 14 days after symptom onset.
Authors: Christina L Cui; Hanaa Dakour-Aridi; Jens Eldrup-Jorgensen; Marc L Schermerhorn; Jeffrey J Siracuse; Mahmoud B Malas Journal: J Vasc Surg Date: 2020-10-08 Impact factor: 4.268
Authors: Aravind Ganesh; Luca Bartolini; Ravinder-Jeet Singh; Abdulaziz S Al-Sultan; David J T Campbell; John H Wong; Bijoy K Menon Journal: Neurol Clin Pract Date: 2021-02