title: Risk of stroke, transient ischemic attack, and vessel occlusion before endarterectomy in patients with symptomatic severe carotid stenosis.
abstract: OBJECTIVE
  We aimed to identify and determine the clinical relevance of parameters predictive of stroke recurrence and vessel occlusion before carotid endarterectomy.
  
  
  METHODS
  One hundred forty-three consecutive patients (105 men; mean age, 66.1+/-8 years) with symptomatic severe carotid artery stenosis were prospectively followed up until carotid endarterectomy. Patients had suffered an ischemic vascular event in the ipsilateral anterior circulation 9.6 days (median; range, 0 to 92 days) before presentation and assessment of stenosis. Admission examination included medical history, neurological status, extracranial and transcranial Doppler/duplex sonography, CT/MRI, ECG, and routine laboratory examination. All patients were reevaluated in the same way the day before surgery (without CT/MRI) and at recurrence of an ischemic event (including CT/MRI).
  
  
  RESULTS
  The end point of follow-up after 19.0 days (median; range, 0 to 118) was carotid endarterectomy in 120 patients, ipsilateral recurrent ischemia in 15 patients (7 transient events and 8 disabling strokes, with carotid occlusion in 4), and (asymptomatic) carotid occlusion in 8 patients. An exhausted cerebrovascular reactivity as determined by a Doppler CO2 test in the middle cerebral artery ipsilateral to the stenosis was the only independent predictive parameter for disabling stroke (odds ratio [OR], 9.7; 95% confidence interval [CI], 2.1 to 44.1; P=0.003). Stroke rate in patients with exhausted reactivity was 27% per month compared with 5.2% in those with normal reactivity. Progression of stenosis toward occlusion was observed in 12 patients and correlated with decreased poststenotic peak systolic velocity (OR, 0.75; 95% CI, 0.62 to 0.90; P=0.002), poststenotic arterial narrowing (OR, 22.7; 95% CI, 3.6 to 141.6; P=0.001), and very severe stenosis (OR, 13.6; 95% CI, 2.2 to 83.7; P=0.005). In patients without hemodynamic compromise, occlusion was not associated with increased stroke risk.
  
  
  CONCLUSIONS
  Patients with recently symptomatic high-grade carotid artery stenosis and ipsilateral hemodynamic compromise are at high risk for early disabling stroke. Assessment of the hemodynamic status is recommended after diagnosis of severe carotid stenosis in symptomatic patients to further investigate and evaluate whether these patients may benefit from early endarterectomy.
authors.affiliation: Department of Neurology, University of Magdeburg, Magdeburg, Germany.
authors.forename: Till
authors.initials: T
authors.lastname: Blaser
authors.forename: Katrin
authors.initials: K
authors.lastname: Hofmann
authors.forename: Thomas
authors.initials: T
authors.lastname: Buerger
authors.forename: Olaf
authors.initials: O
authors.lastname: Effenberger
authors.forename: Claus-Werner
authors.initials: CW
authors.lastname: Wallesch
authors.forename: Michael
authors.initials: M
authors.lastname: Goertler
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D002339:Carotid Arteries / Q000000981:diagnostic imaging / Q000601:surgery; D016893:Carotid Stenosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery*; D002561:Cerebrovascular Disorders / Q000453:epidemiology / Q000209:etiology*; D018450:Disease Progression; D015716:Electrocardiography, Ambulatory; D016894:Endarterectomy, Carotid; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D002546:Ischemic Attack, Transient / Q000453:epidemiology / Q000209:etiology*; D008297:Male; D011237:Predictive Value of Tests; D011300:Preoperative Care; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D020521:Stroke / Q000453:epidemiology / Q000209:etiology*; D016019:Survival Analysis; D013599:Systole; D014463:Ultrasonography