Results of Carotid Endarterectomies for Transient Ischemic Attacks-Five Years Later

SUMMARY Seventy-three patients with an angiographically identified asymptomatic stenosis (>50%) and/or ulceration of the common carotid bifurcation have been followed from 6 months to 10 years (average 4 years). All patients had previously undergone contralateral carotid endarterectomy for a transient ischemic attack (TIA) or minor stroke in that carotid territory. During follow-up, 22 patients (30%) developed new symptoms of cerebral ischemia. Twelve developed ischemia referable to the previously asymptomatic side (10 TIA's, 2 strokes). Six developed recurrent ischemic symptoms in the territory of the previously symptomatic and operated carotid artery (2 TIA's, 4 strokes). Five developed ischemia in the vertebro-basilar territory (2 TIA's, 3 strokes). Thirteen patients (17%) died during follow-up, including 6 from cardiovascular disease and 3 from stroke.In our series the incidence of stroke in the territory of a significant asymptomatic carotid plaque was low (3%). Patients were as likely to develop stroke in the territory of a previously operated carotid artery (5%) or in the vertebro-basilar territory (4 %). It seems that a reasonable approach to the management of patients with asymptomatic carotid lesions is to keep them under review and to consider endarterectomy only if appropriate ischemic symptoms (which are most likely to be TIA's) develop.Stroke, Vol 13, No 4, 1982 PATIENTS WITH SIGNIFICANT but asymptomatic atheromatous plaques at the origin of the internal carotid artery are commonly identified in the investigation of symptomatic cerebrovascular disease by arterial angiography. Such patients are likely to be identified with increasing frequency as the non-invasive Doppler techniques become more reliable and as digital-subtraction angiography becomes more widely available. The proper management of such patients is uncertain as little is known of the natural history of asymptomatic carotid plaques. Some authors 1,2 advocate an aggressive approach, recommending prophylactic carotid endarterectomy in the belief that such lesions carry a greater risk of subsequent stroke without surgery. Others 3, 4 ' 5 have found little evidence that these lesions are particularly ominous and recommend a conservative approach, reserving the option of surgical treatment until such time as appropriate symptoms arise. We have carried out a retrospective survey of our patients with such lesions for the purpose of providing additional information regarding their natural history.Clinical Material Seventy-three patients with an asymptomatic atheromatous plaque at the common carotid bifurcation producing a significant lesion were available for study. For the purposes of this study, a significant lesion is defined as either a stenosis of the origin of the internal carotid artery of greater than 50%, an obvious ulceration, or both as determined angiographically. The 73 asymptomatic lesions were identified among a group of 324 patients who were investigated and treated by carotid endarterectomy for a symptomatic plaque

Section: Discussionmentioning

confidence: 67%

The natural history of asymptomatic carotid bifurcation plaques.

Durward¹,

Ferguson²,

Barr³

1982

“…Hertzer et al 12 Duke et al 13 Moore et al 14 Thompson and Talkington 13 White et al 16 Lees and Hertzer 17 Burke et al' 8 Bunt and Haynes 19 Fode et al 20 This study Community hospitals Nunn 3 Easton and Sherman 21 Cornell 22 Kremer and Ahlquist 23 Carmichael 24 Modi et al 23 Tables 4-6 list those reports from which data on complications could be extracted by subgroups of asymptomatic stenosis, TLA, orestab- DeBakey et al 5 Yashon et al 28 Heyman et al 6 Bloodwell et al 29 Young et al 7 Erikson et al 30 Fields et al 31 DeWeese et al 8 Smith et al 32 DeWeese et al 33 Hooshmand et al 34 Ford et al 35 Ojemann et al 10 Kanaly et al" Mungas and Baker 3 * Stanford et al 37 Hertzer et al 12 Toole et al 1 Duke et al 13 Thompson and Talkington 13 Riles et al 38 Owens et al 39 White ct al 16 Carson et al 40 Lees and Hertzer 17 Whisnant et al 41 Bunt Yashon et al 28 Heyman et al 6 Erikson ct al 30 Thompson et al 43 DeWeese e...…”

Section: Resultsmentioning

confidence: 99%

Declining morbidity and mortality of carotid endarterectomy. The Wake Forest University Medical Center experience.

Till¹,

Toole²,

Howard³

et al. 1987

The 30-day mortality as well as morbidity for stroke and myocardial infarction were determined by review of the charts for every carotid endarterectomy (iV = 389 operations on 356 patients) performed at Wake Forest University Medical Center from 1979 through 1983 to ascertain whether the 16% morbidity and 6% mortality documented in our previous report of 1978 had changed over time. For endarterectomies performed on asymptomatic patients (n = 155), major morbidity included 2 myocardial infarctions and 1 stroke (1.9%). There were 3 fatalities -2 myocardial infarctions and 1 stroke (1.9%). For the symptomatic group (n = 234), major morbidity was 2.1%, mortality 2.6%. The combined morbidity for asymptomatic and symptomatic carotid stenosis was 2%, mortality 2.3%. Perioperative stroke rate (morbidity plus mortality) was 2.6%, 9 ipsilateral to the carotid endarterectomy, suggesting distal embolism as its probable cause. We contend that quality control measures implemented to correct the unacceptable rates reported in 1978 have contributed to dramatic and sustained reductions in complication rates. (Stroke 1987;18:823-829)

“…There was a combined stroke morbidity and mortality rate of 21.1%. Among the 57 patients with 57 Fields, et al 55 Wylie and Ehrenfeld 68 DeWeese, et al 69 OeWeese, et al 60 Nunn 61 Toole, et al 37 Kaston TIAs the stroke morbidity and mortality rate was 21%. Eleven patients operated on for asymptomatic carotid bruit had a stroke morbidity rate of 18.2%.…”

Section: Atherosclerosis -Surgery -Endarterectomymentioning

confidence: 99%

Treatment of transient ischemic attacks.

Millikan¹,

McDowell²

1978

SUMMARY Transient ischemic attacks are the most important warning symptoms of impending stroke. They occur in up to one-half of all patients who develop stroke but, unfortunately, less than half of the patients who have them seek help from their physicians before stroke occurs. Physicians should regularly question patients about the possibility of such symptoms and patients with them should seek prompt help. When transient ischemic attack is diagnosed, patients should be evaluated for elevated blood pressure, hyperlipidemia, cardiac dysrhythmia, cardiac disease, anemia, polycythemia and thrombocytosis. When these conditions are found they should be treated. Patients with carotid system TIAs should be evaluated clinically and radiologically for evidence of vascular disease. The neck should be auscultated for bruit and absent pulses and the peripheral vessels palpated. Patients with carotid system TIAs should have angiography of all 4 cerebral vessels and the angiogram should be evaluated for the presence and number of arterial stenoses and the presence of ulcerated plaques. When patients with carotid system TIAs are found to have localized extracranial atherosclerotic obstruction or ulcerated plaques in a vessel appropriate to the side of their symptoms of cerebral ischemia, they should be considered for prompt surgical correction of the lesion. For patients with carotid system TIAs, who have multiple sites of extracranial vascular disease, medical treatment is advisable with either anticoagulants or platelet antiaggregating agents. In view of the recently reported favorable results using aspirin in the prevention of TIA and stroke, this agent may be preferable to anticoagulants in instances where hypertension, patient compliance and laboratory facilities are a problem.