Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks

Abstract

IMPORTANCEThromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack.OBJECTIVE To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack.EVIDENCE REVIEW This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine.OBSERVATIONS Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy. CONCLUSIONS AND RELEVANCECrescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.

Assessment of carotid atherosclerotic disease using three-dimensional cardiovascular magnetic resonance vessel wall imaging: comparison with digital subtraction angiography

“…One possible reason for the excellent performance of the 3D CMR VWI technique is that a non-selective excitation radio-frequency pulse has been used to shorten the echo time, which helps improve the SNR of images [23,24,27]. Additionally, 3D CMR VWI provided a high isotropic resolution of 0.63 × 0.63 × 0.63 mm 3 , and achieves good flexibility with regard to image visualization, which thereby enables the visualization of plaques located in the tortuous and deep-seated intracranial carotid. Furthermore, dedicated CSF signal suppression is implemented in this technique, which can help to visualize the outer boundaries of the vessel wall [23,27].…”

“…Patients were scanned in a supine, head-first position. After localization, 3D CMR VWI images were obtained using the following imaging parameters: sagittal orientation, echo time (TE)/ repetition time (TR) = 14/900 ms, field of view (FOV) = 180 × 200 × 120 mm 3 , spatial resolution = 0.63 × 0.63 × 0.63 mm 3 , matrix size = 284 × 320 × (208-240) with 7.7-25% partition oversampling, number of slices = 192, number of averages = 1, bandwidth = 488 Hz/pixel, parallel imaging (GRAPPA) factor = 2, and scan time = 7 min and 3 s. A trailing magnetization flip-down module was used to improve CSF signal attenuation [23]. The scan coverage included the C1-C7 segments of the bilateral internal carotid artery (ICA) and a distal portion of the common carotid artery (CCA).…”

“…Carotid atherosclerosis is increasingly recognized as the leading cause of ischemic stroke [1][2][3]. Previous studies have shown that accurate evaluation of the degree of carotid stenosis would be beneficial for predicting the risk of stroke [4][5][6].…”

Assessment of carotid atherosclerotic plaque using 3D motion- sensitized driven-equilibrium prepared rapid gradient echo: a comparative study

“…Carotid atherosclerosis is increasingly considered the leading cause of ischemic stroke (1,2). Some specific morphological features of symptomatic carotid plaque, such as plaque burden, plaque size, surface status, and components, are risk factors for stroke (3)(4)(5)(6).…”

Concurrent intracranial and extracranial artery stenosis and the prognosis of transient ischaemic symptoms or imaging-negative ischaemic stroke

“…It has been recommended in selecting candidates for mechanical thrombectomy. 12 Compared with patients with persistent ischaemic symptom(s) and positive DWI findings, TSI and DWI-negative AIS are considered to have milder clinical manifestations and are prone to be excluded from clinical trials. 13 14 Identification of higher risk patients is crucial for customised monitoring and treatment schedule.…”