title: Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
abstract: BACKGROUND
  Stroke occurs more commonly after carotid artery stenting than after carotid endarterectomy. Details regarding stroke type, severity, and characteristics have not been reported previously. We describe the strokes that have occurred in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
  
  
  RESULTS
  CREST is a randomized, open-allocation, controlled trial with blinded end-point adjudication. Stroke was a component of the primary composite outcome. Patients who received their assigned treatment within 30 days of randomization were included. Stroke was adjudicated by a panel of board-certified vascular neurologists with secondary central review of clinically obtained brain images. Stroke type, laterality, timing, and outcome were reported. A periprocedural stroke occurred among 81 of the 2502 patients randomized and among 69 of the 2272 in the present analysis. Strokes were predominantly minor (81%, n=56), ischemic (90%, n=62), in the anterior circulation (94%, n=65), and ipsilateral to the treated artery (88%, n=61). There were 7 hemorrhages, which occurred 3 to 21 days after the procedure, and 5 were fatal. Major stroke occurred in 13 (0.6%) of the 2272 patients. The estimated 4-year mortality after stroke was 21.1% compared with 11.6% for those without stroke. The adjusted risk of death at 4 years was higher after periprocedural stroke (hazard ratio, 2.78; 95% confidence interval, 1.63-4.76).
  
  
  CONCLUSIONS
  Stroke, particularly severe stroke, was uncommon after carotid intervention in CREST, but stroke was associated with significant morbidity and was independently associated with a nearly 3-fold increased future mortality. The delayed timing of major and hemorrhagic stroke after revascularization suggests that these strokes may be preventable.
authors.affiliation: Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.forename: William
authors.initials: W
authors.lastname: Brooks
authors.forename: Ariane
authors.initials: A
authors.lastname: Mackey
authors.forename: Wayne M
authors.initials: WM
authors.lastname: Clark
authors.forename: James F
authors.initials: JF
authors.lastname: Meschia
authors.forename: William F
authors.initials: WF
authors.lastname: Morrish
authors.forename: J P
authors.initials: JP
authors.lastname: Mohr
authors.forename: J David
authors.initials: JD
authors.lastname: Rhodes
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Popma
authors.forename: Brajesh K
authors.initials: BK
authors.lastname: Lal
authors.forename: Mary E
authors.initials: ME
authors.lastname: Longbottom
authors.forename: Jenifer H
authors.initials: JH
authors.lastname: Voeks
authors.forename: George
authors.initials: G
authors.lastname: Howard
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Brott
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000628:therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D015607:Stents / Q000009:adverse effects*; D020521:Stroke / Q000209:etiology* / Q000401:mortality