title: Symptomatic Carotid Occlusion Is Frequently Associated With Microembolization.
abstract: Symptomatic carotid artery disease is associated with significant morbidity and mortality. The pathophysiologic mechanisms of cerebral ischemia among patients with carotid occlusion remain underexplored.
  
  
  
  We conducted a prospective observational cohort study of patients hospitalized within 7 days of ischemic stroke or transient ischemic attack because of ≥50% carotid artery stenosis or occlusion. Transcranial Doppler emboli detection was performed in the middle cerebral artery ipsilateral to the symptomatic carotid. We describe the prevalence of microembolic signals (MES), characterize infarct topography, and report clinical outcomes at 90 days.
  
  
  
  Forty-seven patients, 19 with carotid occlusion and 28 with carotid stenosis, had complete transcranial Doppler recordings and were included in the final analysis. MES were present in 38%. There was no difference in MES between those with carotid occlusion (7/19, 37%) compared with stenosis (11/28, 39%; P=0.87). In patients with radiographic evidence of infarction (n=39), 38% had a watershed pattern of infarction, 41% had a nonwatershed pattern, and 21% had a combination. MES were present in 40% of patients with a watershed pattern of infarction. Recurrent cerebral ischemia occurred in 9 patients (19%; 6 with transient ischemic attack, 3 with ischemic stroke). There was no difference in the rate of recurrence in those with compared to those without MES.
  
  
  
  Cerebral embolization plays an important role in the pathophysiology of ischemia in both carotid occlusion and stenosis, even among patients with watershed infarcts. The role of aggressive antithrombotic and antiplatelet therapy for symptomatic carotid occlusions may warrant further investigation given our findings.
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.). avliberm@montefiore.org.
authors.forename: Ava L
authors.initials: AL
authors.lastname: Liberman
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Ali
authors.initials: A
authors.lastname: Zandieh
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Caitlin
authors.initials: C
authors.lastname: Loomis
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Raser-Schramm
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Christina A
authors.initials: CA
authors.lastname: Wilson
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Jose
authors.initials: J
authors.lastname: Torres
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Koto
authors.initials: K
authors.lastname: Ishida
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Swaroop
authors.initials: S
authors.lastname: Pawar
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Rebecca
authors.initials: R
authors.lastname: Davis
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Michael T
authors.initials: MT
authors.lastname: Mullen
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Steven R
authors.initials: SR
authors.lastname: Messé
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Scott E
authors.initials: SE
authors.lastname: Kasner
authors.affiliation: From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
authors.forename: Brett L
authors.initials: BL
authors.lastname: Cucchiara
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000628:therapy; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000628:therapy; D015331:Cohort Studies; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016037:Single-Blind Method
keywords: carotid artery diseases; carotid stenosis; cerebral ischemia; embolism; ultrasonography, doppler, transcranial