Risk of very early recurrent cerebrovascular events in symptomatic carotid artery stenosis

Abstract

Object The risk of recurrence of cerebrovascular events within the first 72 hours of admission in patients hospitalized with symptomatic carotid artery (CA) stenoses and the risks and benefits of emergency CA intervention within the first hours after the onset of symptoms are not well known. Therefore, the authors aimed to assess 1) the ipsilateral recurrence rate within 72 hours of admission, in the period from 72 hours to 7 days, and after 7 days in patients presenting with nondisabling stroke, transient ischemic attack (TIA), or amaurosis fugax (AF), and with an ipsilateral symptomatic CA stenosis of 50% or more, and 2) the risk of stroke in CA interventions within 48 hours of admission versus the risk in interventions performed after 48 hours. Methods Ninety-four patients were included in this study. These patients were admitted to hospital within 48 hours of a nondisabling stroke, TIA, or AF resulting from a symptomatic CA stenosis of 50% or more. The patients underwent carotid endarterectomy (85 patients) or CA stenting (9 patients). At baseline, the cardiovascular risk factors of the patients, the degree of symptomatic CA stenosis, and the type of secondary preventive treatment were assessed. The in-hospital recurrence rate of stroke, TIA, or AF ipsilateral to the symptomatic CA stenosis was determined for the first 72 hours after admission, from 72 hours to 7 days, and after 7 days. Procedure-related cerebrovascular events were also recorded. Results The median time from symptom onset to CA intervention was 5 days (interquartile range 3.00–9.25 days). Twenty-one patients (22.3%) underwent CA intervention within 48 hours after being admitted. Overall, 15 recurrent cerebrovascular events were observed in 12 patients (12.8%) in the period between admission and CA intervention: 3 strokes (2 strokes in progress and 1 stroke) (3.2%), 5 TIAs (5.3%), and 1 AF (1.1%) occurred within the first 72 hours (total 9.6%) of admission; 1 TIA (1.1%) occurred between 72 hours and 7 days, and 5 TIAs (5.3%) occurred after more than 7 days. The corresponding actuarial cerebrovascular recurrence rates were 11.4% (within 72 hours of admission), 2.4% (between 72 hours and 7 days), and 7.9% (after 7 days). Among baseline characteristics, no predictive factors for cerebrovascular recurrence were identified. Procedure-related cerebrovascular events occurred at a rate of 4.3% (3 strokes and 1 TIA), and procedures performed within the first 48 hours and procedures performed after 48 hours had a similar frequency of these events (4.5% vs 4.1%, respectively; p = 0.896). Conclusions The in-hospital recurrence of cerebrovascular events was quite low, but all recurrent strokes occurred within 72 hours. The risk of stroke associated with a CA intervention performed within the first 48 hours was not increased compared with that for later interventions. This raises the question of the optimal timing of CA intervention in symptomatic CA stenosis. To answer this question, more data are needed, preferably from large randomized trials.

Thirty-day Outcome of Delayed Versus Early Management of Symptomatic Carotid Stenosis

“…Few authors describing early CEA have provided information allowing comparative analysis with their own previous delayed CEA experience (table VI). However, some authors [35][36][37]40,42 have recently reported that early CEA within 2 weeks in comparison with a delayed surgery was not associated with higher perioperative stroke and death risk, thus supporting our findings. In her study describing very early CEA, i.e., within 2 days, Stromberg et al 34 showed an impressive 30-day stroke and death rate of 11.5% but this observation was not confirmed by the most recent publications [35][36][37][38] in which 30-day stroke and death rate range from 2.4% to 4.5%.…”

Time is brain: an update

“…In a similar series, where patients were seen about 14 days after symptom onset, Kastrup observed that over the next 7 days, 3% suffered a recurrent TIA, while 12% developed new DWI lesions on MRI [79]. In Mono's series, where 94 patients were admitted within 48 h of onset of symptoms and where CEA was performed a median of 5 days after onset of symptoms, 13% suffered in patient recurrent neurological events before undergoing CEA [15]. The highest rates of recurrent stroke (prior to expedited CEA) were reported by Johansson, who found that the rate of recurrent ipsilateral stroke was 5% at 48 h after onset of symptoms, increasing to 8% at 7 days and 11% at 14 days [12].…”

“…Johansson (2013) 5% 8% 11% [12] Mono (2013) 4% [15] Merwick (2013) 8% [17] Marnane ( Salem et al have also reported that ultrasound markers of carotid plaque instability (in this case a large lipid core and a Gray Scale Median <25) were highly predictive of a significantly increased risk of recurrent neurological events in the 48-72-h period prior to expedited CEA [22]. In a subsequent study, two ultrasound-based plaque features were associated with a high probability of there being a histologically unstable carotid plaque: i) plaque area >95 mm 2 and ii) a juxta-luminal black area >6 mm 2 .…”

Stroke unit treatment: long-term effects

“…However, t he q uestion o f the optimal t iming of intervention in the individual case of symptomatic carotid artery remains to be answered [70].…”