The Carotid Surgery for Ischemic Stroke trial: A prospective observational study on carotid endarterectomy in the early period after ischemic stroke

Eckstein, H.‐H.; Ringleb, P; Dörfler, Arnd; Klemm, Klaus; Müller, Bárbara; Zegelman, M.; Bardenheuer, Hubert J.; Hacke, Werner; Bruckner, Tom; Sandmann, W.; Allenberg, Jens-Rainer

doi:10.1067/mva.2002.128303

Cited by 81 publications

(63 citation statements)

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“…Moreover, ADC lesions were shown to normalize more often within three hours after stroke onset as compared to the three-to six-hour time window, particularly when they were accompanied by a smaller perfusion lesion (15,21). However, there are acute patients with a persisting perfusion-diffusion mismatch who benefit from immediate carotid artery surgery both clinically and in terms of cerebral perfusion (46,47). Similarly, Desmoteplase was shown to be an effective thrombolytic treatment during the three-to six-hour window in patients with acute stroke and a perfusion-diffusion mismatch (48).…”

Section: Discussionmentioning

confidence: 99%

Significance of the perfusion‐diffusion mismatch in chronic cerebral ischemia

Surikova

Meisel

Siebler

et al. 2006

Magnetic Resonance Imaging

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Purpose: To determine whether the perfusion deficit could predict brain infarction in patients with chronic cerebral ischemia who experienced recurring episodes of neurological symptoms and showed a perfusion-diffusion mismatch on magnetic resonance (MR) images. Materials and Methods:In 53 consecutive patients (38 males and 15 females, 62 Ϯ 13 years old) with ischemia in the middle cerebral artery (MCA) territory, lesion volumetry was performed on parametric maps of the time-to-peak, the cerebral blood volume, and diffusion-weighted (DW) images. The infarct lesions were assessed on follow-up T2-weighted (T2W) MR images after eight days. Cerebrovascular changes were determined by time-of-flight (TOF) MR angiography (MRA). Inferential and correlation statistics were used. Results:Patients with chronic ischemic brain disease (N ϭ 39) who presented with a severe perfusion-diffusion mismatch in the presence of a normal cerebral blood volume had no or small brain infarctions as found on follow-up T2W images. MRA revealed widespread abnormalities of the basal cerebral arteries compatible with brain perfusion abnormalities. In contrast, in acute stroke patients (N ϭ 14) the deficit of cerebral perfusion predicted the infarct lesion in the T2W images. Conclusion:Our results suggest that in chronic cerebral ischemia the normal blood volume was maintained despite the depression of cerebral perfusion and recurring minor insults.

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Section: Discussionmentioning

confidence: 99%

Significance of the perfusion‐diffusion mismatch in chronic cerebral ischemia

Surikova

Meisel

Siebler

et al. 2006

Magnetic Resonance Imaging

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“…Of these, 7 papers reported risks in older patients but did not compare their results to younger patients in the same centre(s) and were therefore excluded. Among the 62 remaining eligible papers [35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97], there were no differences in the associations between either age or sex and overall 30-day stroke rate, death rate or combined stroke and death rate between studies reporting the associations as their primary aim and those which reported them as a subanalysis along with other risk factors (fig. 1, 2) and so data from both types of study are combined in the analyses below.…”

Section: Resultsmentioning

confidence: 99%

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

et al. 2005

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Background: Randomized trials of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis have demonstrated that benefit is decreased in women, due partly to a high operative risk, which is independent of age. However, it is uncertain whether these trial-based observations are generalisable to routine clinical practice. Methods: We performed a systematic review of all publications reporting data on the association between age and/or sex and procedural risk of stroke and/or death following CEA from 1980 to 2004. Results: 62 eligible papers reported relevant data. Females had a higher rate of operative stroke and death (25 studies, OR = 1.31, 95% CI = 1.17–1.47, p < 0.001) than males, but no increase in operative mortality (15 studies, OR = 1.05, 95% CI = 0.81–0.86, p = 0.78). Compared with younger patients, operative mortality was increased at ≧75 years (20 studies, OR = 1.36, 95% CI = 1.07–1.68, p = 0.02), at age ≧80 years (15 studies, OR = 1.80, 95% CI = 1.26–2.45, p < 0.001) and in older patients overall (35 studies, OR = 1.50, 95% CI = 1.26–1.78, p < 0.001). In contrast, risk of non-fatal stroke did not increase with age and so the combined perioperative risk was only slightly increased at age ≧75 years (21 studies, OR = 1.18, 95% CI = 0.94–1.44, p = 0.06), at age ≧80 years (10 studies, OR = 1.14, 95% CI = 0.92–1.36, p = 0.34) and in older patients overall (36 studies, OR = 1.17, 95% CI = 1.04–1.31, p = 0.01). Conclusions: The effects of age and sex on the operative risk of CEA in published case series are consistent with those observed in the trials. Operative risk of stroke is increased in women and operative mortality is increased in patients aged ≧75 years.

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“…The actual timing of CEA does not seem to influence the complication rate [1,14,15,16]. Following the recommendations from a meta-analysis, the procedure should ideally take place within 2 weeks after onset of symptoms [6].…”

Section: Discussionmentioning

confidence: 99%

Primary Stroke Unit Treatment Followed by Very Early Carotid Endarterectomy for Carotid Artery Stenosis after Acute Stroke

Aleksic

Rueger

Lehnhardt³

et al. 2006

Cerebrovasc Dis

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Background: Although it is recognized that carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery (ICA) stenosis, in the past, very early CEA has been shown to carry substantial risks. We assessed an interdisciplinary concept of very early CEA in patients with high-grade (>70%) symptomatic ICA stenosis at a single center. Patients and Methods: The course of treatment and outcomes of patients who underwent CEA as early as possible after being referred to the stroke unit for symptoms of transient ischemic attack and stroke were prospectively evaluated, including the following parameters: age, severity of ischemia-related symptoms according to the modified Rankin scale, duration of symptoms until admission, multimodal imaging findings (color-coded duplex, cranial computed tomography, magnetic resonance imaging, positron emission tomography), duration until CEA, perioperative course and complications, as well as duration of in-hospital care. Results: Fifty consecutive patients (median age 68 years, range 44–90) with clinical and imaging signs of transient ischemic attack (n = 19) or stroke (n = 31) were included from January 2000 until December 2004. All except 1 patient showed a preoperative Rankin <4. There was a median time period of 6 h between the onset of symptoms and admission (range 1 h to 15 days) and a median duration of 4 days after admission until operation (range 1–21 days). Seven patients underwent CEA of the contralateral, severely stenosed ICA after symptomatic ipsilateral ICA occlusion. Four out of 5 patients who primarily underwent systemic thrombolysis recovered almost completely. Three patients (6%) experienced a clinical deterioration before surgery. In the majority of patients (43/50), CEA was performed under local anesthesia with selective shunt use which became necessary in 26%. Three patients (6%) had postoperative worsening due to new infarcts. In 2 cases, an intracerebral hemorrhage occurred, of which 1 remained asymptomatic. In 1 case, surgical revision was necessary because of an ICA thrombosis without permanent neurological decline. Patients were discharged after a median time of 14.5 days (range 4–44). Conclusions: After careful selection and preparation in a stroke unit, patients with acute stroke due to carotid stenosis can undergo very early CEA under local anesthesia with a perioperative risk comparable with the risk of later endarterectomy, therefore preventing very early stroke recurrences.

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The Carotid Surgery for Ischemic Stroke trial: A prospective observational study on carotid endarterectomy in the early period after ischemic stroke

Cited by 81 publications

References 0 publications

Significance of the perfusion‐diffusion mismatch in chronic cerebral ischemia

Significance of the perfusion‐diffusion mismatch in chronic cerebral ischemia

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

Primary Stroke Unit Treatment Followed by Very Early Carotid Endarterectomy for Carotid Artery Stenosis after Acute Stroke

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