Identifying which patients with asymptomatic carotid stenosis could benefit from intervention (original) (raw)

Abstract

C arotid guidelines recommend carotid endarterectomy (CEA) for patients with 60% to 99% asymptomatic carotid stenosis (ACS) provided the perioperative stroke/death rates are <3%. 1,2 Several reports have noted that the average annual risk of ipsilateral/any territory stroke among patients with asymptomatic moderate to severe internal carotid artery stenosis receiving medical therapy (MT) alone has now fallen to ≈1%. 3-5 The decreased incidence of stroke has been attributed to modern MT and has made opinion leaders demand a revision of management strategies 4 by either refraining from CEA 6 or by identifying high-risk patients. 7 Such high-risk patients should be offered prophylactic CEA in addition to MT to reduce the risk of a future stroke. It is therefore essential to develop methods to identify these ACS patients at high enough risk to warrant prophylactic intervention.

Loading...

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

References (83)

  1. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Stroke Assocation; American Association of Neuroscience Nurses; American Association of Neurological Surgeons; American College of Radiology; American Society of Neuroradiology; Congress of Neurolgocial Surgeons; Society of Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of NeuroInterventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery; American Academy of Neurology and Society of Cardiovascular Computed Tomography. 2011 ASA/ACCF/ AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/ SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42:e464-e540.
  2. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1-e31.
  3. Abbott AL. Medical (nonsurgical) intervention alone is now best for pre- vention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009;40:e573-e583.
  4. Naylor AR. Time to rethink management strategies in asymptomatic carotid artery disease. Nat Rev Cardiol. 2012;9:116-124.
  5. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treat- ment: a prospective, population-based study. Stroke. 2010;41:e11-e17.
  6. Spence JD, Coates V, Li H, Tamayo A, Muñoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67:180-186.
  7. Chaturvedi S. Aggressive medical therapy alone is adequate in certain patients with severe symptomatic carotid stenosis. Stroke. 2013;44:2957-2958.
  8. Spence JD, Tamayo A, Lownie SP, Ng WP, Ferguson GG. Absence of microemboli on transcranial Doppler identifies low-risk patients with asymptomatic carotid stenosis. Stroke. 2005;36:2373-2378.
  9. Topakian R, King A, Kwon SU, Schaafsma A, Shipley M, Markus HS; ACES Investigators. Ultrasonic plaque echolucency and emboli signals pre- dict stroke in asymptomatic carotid stenosis. Neurology. 2011;77:751-758.
  10. Markus HS, King A, Shipley M, Topakian R, Cullinane M, Reihill S, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observa- tional study. Lancet Neurol. 2010;9:663-671.
  11. Kakkos SK, Griffin MB, Nicolaides AN, Kyriacou E, Sabetai MM, Tegos T, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke. J Vasc Surg. 2013;57:609-618.e1, discussion 617.
  12. Gupta A, Chazen JL, Hartman M, Delgado D, Anumula N, Shao H, et al. Cerebrovascular reserve and stroke risk in patients with carotid stenosis or occlusion: a systematic review and meta-analysis. Stroke. 2012;43:2884-2891.
  13. Singh N, Moody AR, Gladstone DJ, Leung G, Ravikumar R, Zhan J, et al. Moderate carotid artery stenosis: MR imaging-depicted intraplaque hemorrhage predicts risk of cerebrovascular ischemic events in asymp- tomatic men. Radiology. 2009;252:502-508.
  14. Hellings WE, Peeters W, Moll FL, Piers SR, van Setten J, Van der Spek PJ, et al. Composition of carotid atherosclerotic plaque is asso- ciated with cardiovascular outcome: a prognostic study. Circulation. 2010;121:1941-1950.
  15. van Lammeren GW, den Hartog AG, Pasterkamp G, Vink A, de Vries JP, Moll FL, et al. Asymptomatic carotid artery stenosis: identification of subgroups with different underlying plaque characteristics. Eur J Vasc Endovasc Surg. 2012;43:632-636.
  16. Qiao Y, Etesami M, Astor BC, Zeiler SR, Trout HH III, Wasserman BA. Carotid plaque neovascularization and hemorrhage detected by MR imaging are associated with recent cerebrovascular ischemic events. AJNR Am J Neuroradiol. 2012;33:755-760.
  17. Kakkos SK, Sabetai M, Tegos T, Stevens J, Thomas D, Griffin M, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg. 2009;49:902-909.
  18. Miwa K, Hoshi T, Hougaku H, Tanaka M, Furukado S, Abe Y, et al. Silent cerebral infarction is associated with incident stroke and TIA indepen- dent of carotid intima-media thickness. Intern Med. 2010;49:817-822.
  19. Balestrini S, Lupidi F, Balucani C, Altamura C, Vernieri F, Provinciali L, et al. One-year progression of moderate asymptomatic carotid stenosis predicts the risk of vascular events. Stroke. 2013;44:792-794.
  20. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Predictors and clinical significance of pro- gression or regression of asymptomatic carotid stenosis. J Vasc Surg. 2014;59:956-967.e1.
  21. Conrad MF, Boulom V, Baloum V, Mukhopadhyay S, Garg A, Patel VI, et al. Progression of asymptomatic carotid stenosis despite optimal medi- cal therapy. J Vasc Surg. 2013;58:128-35.e1.
  22. Madani A, Beletsky V, Tamayo A, Munoz C, Spence JD. High-risk asymptomatic carotid stenosis: ulceration on 3D ultrasound vs TCD microemboli. Neurology. 2011;77:744-750.
  23. King A, Markus HS. Doppler embolic signals in cerebrovascular dis- ease and prediction of stroke risk: a systematic review and meta-analysis. Stroke. 2009;40:3711-3717.
  24. Abbott AL, Chambers BR, Stork JL, Levi CR, Bladin CF, Donnan GA. Embolic signals and prediction of ipsilateral stroke or transient ischemic attack in asymptomatic carotid stenosis: a multicenter prospective cohort study. Stroke. 2005;36:1128-1133.
  25. King A, Shipley M, Markus H; ACES Investigators. Optimizing proto- cols for risk prediction in asymptomatic carotid stenosis using embolic signal detection: the Asymptomatic Carotid Emboli Study. Stroke. 2011;42:2819-2824.
  26. Bogiatzi C, Cocker MS, Beanlands R, Spence JD. Identifying high-risk asymptomatic carotid stenosis. Expert Opin Med Diagn. 2012;6:139-151.
  27. Panerai BB. Transcranial Doppler for evaluation of cerebral autoregula- tion. Clin Auton Res. 2009;19:197-211.
  28. Rosengarten B, Deppe M, Kaps M, Klingelhöfer J. Methodological aspects of functional transcranial Doppler sonography and recommendations for simultaneous EEG recording. Ultrasound Med Biol. 2012;38:989-996.
  29. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Asymptomatic internal carotid artery stenosis and cerebro- vascular risk stratification. J Vasc Surg. 2010;52:1486-1496.e1.
  30. Gur AY, Bova I, Bornstein NM. Is impaired cerebral vasomotor reac- tivity a predictive factor of stroke in asymptomatic patients? Stroke. 1996;27:2188-2190.
  31. Silvestrini M, Vernieri F, Pasqualetti P, Matteis M, Passarelli F, Troisi E, et al. Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA. 2000;283:2122-2127.
  32. Yamamoto KK, Miyata T, Momose T, Nagayoshi M, Akagi D, Hosaka A, et al. Reduced vascular reserve measured by stressed single photon emission computed tomography carries a high risk for stroke in patients with carotid stenosis. Int Angiol. 2006;25:385-388.
  33. Markus H, Cullinane M. Severely impaired cerebrovascular reactivity predicts stroke and TIA risk in patients with carotid artery stenosis and occlusion. Brain. 2001;124(pt 3):457-467.
  34. Bernick C, Kuller L, Dulberg C, Longstreth WT Jr, Manolio T, Beauchamp N, et al; Cardiovascular Health Study Collaborative Reseach Group. Silent MRI infarcts and the risk of future stroke: the cardiovascu- lar health study. Neurology. 2001;57:1222-1229.
  35. Vermeer SE, Hollander M, van Dijk EJ, Hofman A, Koudstaal PJ, Breteler MM; Rotterdam Scan Study. Silent brain infarcts and white mat- ter lesions increase stroke risk in the general population: the Rotterdam Scan Study. Stroke. 2003;34:1126-1129.
  36. Martin JD, Valentine RJ, Myers SI, Rossi MB, Patterson CB, Clagett GP. Is routine CT scanning necessary in the preoperative evaluation of patients undergoing carotid endarterectomy? J Vasc Surg. 1991;14:267-270.
  37. Cao P, Zannetti S, Giordano G, De Rango P, Parlani G, Caputo N. Cerebral tomographic findings in patients undergoing carotid endarter- ectomy for asymptomatic carotid stenosis: short-term and long-term implications. J Vasc Surg. 1999;29:995-1005.
  38. Sabeti S, Schlager O, Exner M, Mlekusch W, Amighi J, Dick P, et al. Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients. Stroke. 2007;38:2887-2894.
  39. Bertges DJ, Muluk V, Whittle J, Kelley M, MacPherson DS, Muluk SC. Relevance of carotid stenosis progression as a predictor of ischemic neu- rological outcomes. Arch Intern Med. 2003;163:2285-2289.
  40. Muluk SC, Muluk VS, Sugimoto H, Rhee RY, Trachtenberg J, Steed DL, et al. Progression of asymptomatic carotid stenosis: a natural his- tory study in 1004 patients. J Vasc Surg. 1999;29:208-214, discussion 214.
  41. Biasi GM, Froio A, Diethrich EB, Deleo G, Galimberti S, Mingazzini P, et al. Carotid plaque echolucency increases the risk of stroke in carotid stenting: the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation. 2004;110:756-762.
  42. KEY WORD: endarterectomy, carotid References
  43. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Stroke Assocation; American Association of Neuroscience Nurses; American Association of Neurological Surgeons; American College of Radiology; American Society of Neuroradiology; Congress of Neurolgocial Surgeons; Society of Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of NeuroInterventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery; American Academy of Neurology and Society of Cardiovascular Computed Tomography. 2011 ASA/ACCF/ AHA/ AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42:e464-e540.
  44. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1-e31.
  45. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis:results of a systematic review and analysis. Stroke. 2009; 40:e573-e583.
  46. Naylor AR. Time to rethink management strategies in asymptomatic carotid artery disease. Nat Rev Cardiol. 2012;9:116-124.
  47. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke. 2010;41:e11-e17.
  48. Spence JD, Coates V, Li H, Tamayo A, Munoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67:180-186.
  49. Chaturvedi S. Aggressive medical therapy alone is adequate in certain patients with severe symptomatic carotid stenosis. Stroke. 2013;44:2957-2958.
  50. Spence JD, Tamayo A, Lownie SP, Ng WP, Ferguson GG. Absence of microemboli on transcranial Doppler identifies low-risk patients with asymptomatic carotid stenosis. Stroke. 2005;36:2373-2378.
  51. Topakian R, King A, Kwon SU, Schaafsma A, Shipley M, Markus HS; ACES Investigators. Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis. Neurology. 2011;77:751-758.
  52. Markus HS, King A, Shipley M, Topakian R, Cullinane M, Reihill S, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol. 2010;9:663-671.
  53. Kakkos SK, Griffin MB, Nicolaides AN, Kyriacou E, Sabetai MM, Tegos T, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke. J Vasc Surg. 2013;57:609-618.e1, discussion 617.
  54. Gupta A, Chazen JL, Hartman M, Delgado D, Anumula N, Shao H, et al. Cerebrovascular reserve and stroke risk in patients with carotid stenosis or occlusion: a systematic review and meta-analysis. Stroke. 2012;43:2884-2891.
  55. Singh N, Moody AR, Gladstone DJ, Leung G, Ravikumar R, Zhan J, et al. Moderate carotid artery stenosis: MR imaging-depicted intraplaque hemorrhage predicts risk of cerebrovascular ischemic events in asymptomatic men. Radiology. 2009;252:502-508.
  56. Hellings WE, Peeters W, Moll FL, Piers SR, van Setten J, Van der Spek PJ, et al. Composition of carotid atherosclerotic plaque is associated with cardiovascular outcome: a prognostic study. Circulation. 2010;121:1941-1950.
  57. van Lammeren GW, den Hartog AG, Pasterkamp G, Vink A, de Vries JP, Moll FL, et al. Asymptomatic carotid artery stenosis: identification of subgroups with different underlying plaque characteristics. Eur J Vasc Endovasc Surg. 2012;43:632-636.
  58. Qiao Y, Etesami M, Astor BC, Zeiler SR, Trout HH III, Wasserman BA. Carotid plaque neovascularization and hemorrhage detected by MR imaging are associated with recent cerebrovascular ischemic events. AJNR Am J Neuroradiol. 2012;33:755-760.
  59. Kakkos SK, Sabetai M, Tegos T, Stevens J, Thomas D, Griffin M, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg. 2009;49:902-909.
  60. Miwa K, Hoshi T, Hougaku H, Tanaka M, Furukado S, Abe Y, et al. Silent cerebral infarction is associated with incident stroke and TIA independent of carotid intima-media thickness. Intern Med. 2010;49:817-822.
  61. Balestrini S, Lupidi F, Balucani C, Altamura C, Vernieri F, Provinciali L, et al. One-year progression of moderate asymptomatic carotid stenosis predicts the risk of vascular events. Stroke. 2013; 44:792- 794.
  62. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis. J Vasc Surg. 2014;59:956-967.e1.
  63. Conrad MF, Boulom V, Baloum V, Mukhopadhyay S, Garg A, Patel VI, et al. Progression of asymptomatic carotid stenosis despite optimal medical therapy. J Vasc Surg. 2013;58:128-35.e1.
  64. Madani A, Beletsky V, Tamayo A, Munoz C, Spence JD. High-risk asymptomatic carotid stenosis: ulceration on 3D ultrasound vs TCD microemboli. Neurology. 2011;77:744-750.
  65. King A, Markus HS. Doppler embolic signals in cerebrovascular disease and prediction of stroke risk: a systematic review and meta- analysis. Stroke. 2009;40:3711-3717.
  66. Abbott AL, Chambers BR, Stork JL, Levi CR, Bladin CF, Donnan GA. Embolic signals and prediction of ipsilateral stroke or transient ischemic attack in asymptomatic carotid stenosis: a multicenter prospective cohort study. Stroke. 2005;36:1128-1133.
  67. King A, Shipley M, Markus H; ACES Investigators. Optimizing protocols for risk prediction in asymptomatic carotid stenosis using embolic signal detection: the Asymptomatic Carotid Emboli Study. Stroke. 2011;42:2819-2824.
  68. Bogiatzi C, Cocker MS, Beanlands R, Spence JD. Identifying high- risk asymptomatic carotid stenosis. Expert Opin Med Diagn. 2012;6:139-151.
  69. Panerai BB. Transcranial Doppler for evaluation of cerebral autoregulation. Clin Auton Res. 2009;19:197-211.
  70. Rosengarten B, Deppe M, Kaps M, Klingelhofer J. Methodological aspects of functional transcranial Doppler sonography and recommendations for simultaneous EEG recording. Ultrasound Med Biol. 2012;38:989-996.
  71. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, et al; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification. J Vasc Surg. 2010;52:1486-1496.e1.
  72. Gur AY, Bova I, Bornstein NM. Is impaired cerebral vasomotor reactivity a predictive factor of stroke in asymptomatic patients? Stroke. 1996;27:2188-2190.
  73. Silvestrini M, Vernieri F, Pasqualetti P, Matteis M, Passarelli F, Troisi E, et al. Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA. 2000; 283:2122-2127.
  74. Yamamoto KK, Miyata T, Momose T, Nagayoshi M, Akagi D, Hosaka A, et al. Reduced vascular reserve measured by stressed single photon emission computed tomography carries a high risk for stroke in patients with carotid stenosis. Int Angiol. 2006;25:385- 388.
  75. Markus H, Cullinane M. Severely impaired cerebrovascular reactivity predicts stroke and TIA risk in patients with carotid artery stenosis and occlusion. Brain. 2001;124(pt 3):457-467.
  76. Bernick C, Kuller L, Dulberg C, Longstreth WT Jr, Manolio T, Beauchamp N, et al; Cardiovascular Health Study Collaborative Reseach Group. Silent MRI infarcts and the risk of future stroke: the cardiovascular health study. Neurology. 2001;57:1222-1229.
  77. Vermeer SE, Hollander M, van Dijk EJ, Hofman A, Koudstaal PJ, Breteler MM; Rotterdam Scan Study. Silent brain infarcts and white matter lesions increase stroke risk in the general population: the Rotterdam Scan Study. Stroke. 2003;34:1126-1129.
  78. Martin JD, Valentine RJ, Myers SI, Rossi MB, Patterson CB, Clagett GP. Is routine CT scanning necessary in the preoperative evaluation of patients undergoing carotid endarterectomy? J Vasc Surg. 1991;14:267-270.
  79. Cao P, Zannetti S, Giordano G, De Rango P, Parlani G, Caputo N. Cerebral tomographic findings in patients undergoing carotid endarterectomy for asymptomatic carotid stenosis: short-term and long-term implications. J Vasc Surg. 1999;29:995-1005.
  80. Sabeti S, Schlager O, Exner M, Mlekusch W, Amighi J, Dick P, et al. Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients. Stroke. 2007;38:2887-2894.
  81. Bertges DJ, Muluk V, Whittle J, Kelley M, MacPherson DS, Muluk SC. Relevance of carotid stenosis progression as a predictor of ischemic neurological outcomes. Arch Intern Med. 2003;163:2285- 2289.
  82. Muluk SC, Muluk VS, Sugimoto H, Rhee RY, Trachtenberg J, Steed DL, et al. Progression of asymptomatic carotid stenosis: a natural history study in 1004 patients. J Vasc Surg. 1999;29:208-214, discussion 214.
  83. Biasi GM, Froio A, Diethrich EB, Deleo G, Galimberti S, Mingazzini P, et al. Carotid plaque echolucency increases the risk of stroke in carotid stenting: the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation. 2004;110:756-762.