Symptomatic Carotid Stenosis and Short-Term Recurrent Stroke Risk
A prospective, community-based study indicates that even short delays in surgery may expose patients to unnecessary risk.
Guidelines recommend carotid revascularization within 2 weeks after a stroke or transient ischemic attack (TIA) in most patients with ¥50% carotid stenosis, because data from randomized trials suggest less benefit if surgery is delayed. However, studies have suggested that the risk for recurrent stroke is high within days of the initial symptoms, raising concern that even 2 weeks’ delay until surgery may be too long. Therefore, researchers prospectively studied a community-based cohort with symptomatic carotid stenosis to determine the risk for recurrent stroke within the 2-week window after presentation.
Of 314 patients with ischemic stroke, 36 had carotid stenosis. Only eight of the 36 underwent carotid revascularization, seven of them after 2 weeks, allowing observation of the short-term natural history of this disease. Among the 36 patients, rates of antiplatelet (97%) and statin (91%) therapy in the 72 hours after the index stroke were excellent. In the first 72 hours, the risk for recurrent stroke was 5.6% in those with carotid stenosis vs. 0.4% in those without carotid stenosis. All three patients with carotid stenosis and recurrent stroke became severely disabled.
Comment: This well-designed study confirms earlier research suggesting that patients with symptomatic carotid stenosis face a high early risk for recurrent stroke. These results support urgent surgery for stable patients with stroke or TIA caused by carotid stenosis; research has demonstrated the safety of early carotid endarterectomy in these patients. For unstable patients with very large or fluctuating strokes, the risks and benefits of acute intervention are less clear. However, these patients also have a high risk for early stroke recurrence with medical therapy alone, a point that should factor into the decision about timing of surgery.
Hooman Kamel, MD
Dr. Kamel is Assistant Professor, Department of Neurology and Neuroscience, Weill Cornell Medical College, New York City.
Published in Journal Watch Neurology October 4, 2011
Marnane M et al. Stroke recurrence within the time window recommended for carotid endarterectomy. Neurology 2011 Aug 23; 77:738.