Risk of Stroke at the Time of Carotid Occlusion

Yang, Chiou-Ying; Bogiatzi, Chrysi; Spence, J. David

doi:10.1001/jamaneurol.2015.1843

Cited by 50 publications

(21 citation statements)

References 31 publications

(21 reference statements)

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“…This may be due to a mistaken perception that a carotid occlusion would be analogous to occlusion of a left main coronary artery—often called a ‘ticking time bomb’. However, since the circle of Willis is so effective in maintaining perfusion beyond a carotid stenosis or occlusion, the risk of stroke at the time of carotid occlusion is actually very low: 0.3%,46 well below the risk of either endarterectomy or stenting. Prevention of occlusion is not a valid reason for carotid intervention in ACS.…”

Section: Risk Of Stenting and Endarterectomy In Acsmentioning

confidence: 99%

Appropriate management of asymptomatic carotid stenosis

2016

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With modern intensive medical therapy, the annual risk of ipsilateral stroke in patients with asymptomatic carotid stenosis (ACS) is now down to ∼0.5%. Despite this, there is a widespread practice of routine intervention in ACS with carotid endarterectomy (CEA) and stenting (CAS). This is being justified on the basis of much higher risks with medical therapy in trials conducted decades ago, compared with lower risks of intervention in recent trials with no medical arm. Such extrapolations are invalid. Although recent trials have shown that after subtracting periprocedural risks the outcomes with CEA and CAS are now comparable to medical therapy, the periprocedural risks still far outweigh the risks with medical therapy. In the asymptomatic carotid trial (ACT) 1 trial, the 30-day risk of stroke or death was 2.9% with CAS and 1.7% with CEA. In the CREST trial, the 30-day risk of stroke or death among asymptomatic patients was 2.5% for stenting and 1.4% for endarterectomy. Thus, intensive medical therapy is much safer than either CAS or CEA. The only patients with ACS who should receive intervention are those who can be identified as being at high risk. The best validated method is transcranial Doppler embolus detection. Other approaches in development for identifying vulnerable plaques include intraplaque haemorrhage on MRI, ulceration and plaque lucency on ultrasound, and plaque inflammation on positron emission tomography/CT. Intensive medical therapy for ACS includes smoking cessation, a Mediterranean diet, effective blood pressure control, antiplatelet therapy, intensive lipid-lowering therapy and treatment with B vitamins (with methylcobalamin instead of cyanocobalamin), particularly in patients with metabolic B12 deficiency. A new strategy called ‘treating arteries instead of risk factors’, based on measurement of carotid plaque volume, is promising but requires validation in randomised trials.

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Section: Risk Of Stenting and Endarterectomy In Acsmentioning

confidence: 99%

Appropriate management of asymptomatic carotid stenosis

2016

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“…8,9 In another study with follow-up of about 3700 patients in a atherosclerotic clinic during a 20-year period with regular Doppler examinations, <10% were identified as having progression to occlusion. 10 Interestingly, 80% of occlusion occurred before 2002 corresponding to the era of widespread use of statins. 10 In addition, lifestyle modification, such as smoking cessation and reduction of body weight, may also have an impact on the event rate in patients with asymptomatic carotid disease.…”

Section: What Do We Know About the Need For Revascularization In Patimentioning

confidence: 99%

“…10 Interestingly, 80% of occlusion occurred before 2002 corresponding to the era of widespread use of statins. 10 In addition, lifestyle modification, such as smoking cessation and reduction of body weight, may also have an impact on the event rate in patients with asymptomatic carotid disease.…”

Section: What Do We Know About the Need For Revascularization In Patimentioning

confidence: 99%

Case of Asymptomatic Carotid Artery Stenosis in a Hypertensive Patient

Calvet

Amar²,

Rossi³

et al. 2017

Hypertension

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“…A diagnostic test obviously preceded the detection of the stenosis, although the subsequent occlusionpreventive intervention is seldom a valid indication in asymptomatic patients. 29 Because of the above cited considerations, payers are often cautious about utilization of certain tests and their consequent expensive treatments. Thus, circumspection on part of the payers, especially for tests based on novel technologies, would not be an unreasonable expectation.…”

Section: Appropriate Usementioning

confidence: 99%

Clinical exome sequencing in neurologic disease

Fogel

Satya‐Murti²,

Cohen

2016

Neur Clin Pract

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Purpose of review: The landscape of genetic diagnostic testing has changed dramatically with the introduction of next-generation clinical exome sequencing (CES), which provides an unbiased analysis of all protein-coding sequences in the roughly 21,000 genes in the human genome. Use of this testing, however, is currently limited in clinical neurologic practice by the lack of a framework for appropriate use and payer coverage. Recent findings: CES can be cost-effective due to its high diagnostic yield in comparison to other genetic tests in current use and should be utilized as a routine diagnostic test in patients with heterogeneous neurologic phenotypes facing a broad genetic differential diagnosis. CES can eliminate the need for escalating sequences of conventional neurodiagnostic tests. Summary: This review discusses the role of clinical exome sequencing in neurologic disease, including its benefits to patients, limitations, appropriate use, and billing. We also provide a reference template policy for payer use when considering testing requests. Neurol Clin Pract 2016;6:164-176

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Risk of Stroke at the Time of Carotid Occlusion

Cited by 50 publications

References 31 publications

Appropriate management of asymptomatic carotid stenosis

Appropriate management of asymptomatic carotid stenosis

Case of Asymptomatic Carotid Artery Stenosis in a Hypertensive Patient

Clinical exome sequencing in neurologic disease

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