The Efficacy of Carotid Surgery by Subgroups: The Concept of Stroke Prevention Potential

Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.

Carotid endarterectomy and the risk of perioperative stroke: The importance of chronic ischaemic lesions and small vessel disease

BACKGROUND AND PURPOSE

Perioperative stroke is a well-recognized complication of carotid endarterectomy (CEA), but well-performing prediction models do not exist for it. Our aim was to identify novel predictors for perioperative ischaemic cerebrovascular events (iCVEs), emphasizing cerebrovascular imaging and potential biomarkers for stroke in carotid stenosis (CS) patients in a well-characterized prospective CS cohort.

METHODS

Helsinki Carotid Endarterectomy Study 2 is an observational prospective and consecutive cohort study of CS patients subjected to CEA during 2012-2015. The associations between perioperative stroke and transient ischaemic attack (iCVEs) and potential predictive factors were evaluated by univariate and Cox regression analyses.

RESULTS

Of 488 operated CS patients, 33 (7%) sustained an iCVE including 21 (4%) ischaemic strokes. In univariate analysis, moderate ipsilateral CS (hazard ratio [HR] 2.14, 95% confidence interval [CI] 1.08-4.23), covert or chronic ipsilateral brain infarct in imaging (HR 2.27, 95% CI 1.09-4.76) and severe cerebral small vessel disease (HR 3.36, 95% CI 1.04-10.88) appeared as novel risk factors for perioperative iCVE. In Cox proportional hazards regression modelling, female gender (HR 3.03, 95% CI 1.30-7.04), a history of coronary heart disease (HR 3.59, 95% CI 1.52-8.47), covert or chronic ipsilateral infarct (HR 2.32, 95% CI 1.01-5.34) and severe small vessel disease (HR 2.63, 95% CI 1.07-6.47) were the strongest independent predictors of perioperative iCVE.

CONCLUSIONS

In addition to the previously reported clinical risk factors, it was found that imaging markers of past cerebrovascular disease, covert or chronic ipsilateral infarct and severe small vessel disease, and moderate ipsilateral stenosis are associated with perioperative iCVEs.

Long-term cognitive and neurovascular changes after carotid endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) has been associated with both cognitive decline and improvement, but the underlying neurovascular mechanisms are unclear. The aim of this study was to investigate the relationship between neurovascular indices and cognitive changes after CEA.

METHODS

We studied 55 patients with severe (≥70%) symptomatic or asymptomatic carotid stenosis before and six months after CEA. A wide array of neuropsychological tests was arranged in eight cognitive domains and cognitive functions specific to hemisphere ipsilateral to operation. Differences in cognitive performance between patients and 38 matching healthy controls were studied with linear mixed models. Neurovascular functioning and microembolic signals were assessed with transcranial Doppler ultrasound of the middle cerebral artery. Associations between neurovascular indices and cognitive change were assessed with linear regression analyses.

RESULTS

On group level, the CEA patients improved more than controls in working memory, whereas no cognitive deterioration was detected. Also on individual level, improvement was most frequently observed in working memory. Worse preoperative cerebrovascular reactivity was related with improvement in cognitive functions of the ipsilateral hemisphere. Low preoperative pulsatility index was associated with improvement in executive functioning and ipsilateral cognitive functions. Poorer preoperative blood flow velocity associated with improvement in complex attention. Microembolic signals were rare.

CONCLUSION

The present findings suggest that CEA may have beneficial long-term effects on cognition. These effects may specifically involve patients with impaired preoperative circulatory adaptive mechanisms.

Hypothesis of "stroke-stop" formula: a tool for risk index determination in development of acute cerebrovascular disease in asymptomatic individuals with carotid stenosis

Background

Extracranial carotid artery disease is considered a risk factor for developing acute cerebrovascular diseases. The paper suggests the “Stroke-Stop” formula as hypothesis for the determination of the risk of developing stroke in asymptomatic individuals with carotid stenosis. The formula is based on a mathematical calculation of the major risk factors for stroke: the degree of ICA (internal carotid artery) stenosis, the morphological structure of the atherosclerotic plaque and the level of lipoprotein-associated phospholipase A2 (Lp-PLA2) concentration.

Methods

The cross sectional study included 70 patients with atherosclerotic ICA stenosis. Among vascular inflammatory markers, Lp-PLA2 was determined with concentration 252.7–328.6 mg/l. The obtained results were evaluated using descriptive statistics (the frequency, percentage ratio) as well as the one-way analysis of variance (ANOVA) and chi-square test.

Results

The risk of stroke development is eminently increasing with the progression of ICA stenosis and elevation of Lp-PLA2 levels. In patients with echolucent plaque, the risk of stroke development was significantly higher in correlation with patients with echogenic plaque. Based on calculations using “Stroke-Stop” formula, three main groups were generated: low (< 70 points), medium (70–100 points) and high (> 100 points) risk of stroke development.

Conclusions

Hypothesis of “Stroke-Stop” formula is proposed for better selection of patients who should be indicated for surgical treatment and will be evaluated in prospective study. In order to verify this hypothesis, we plan to do prospective study using “Stroke-Stop” formula for ipsilateral annual stroke rate in asymptomatic individuals with carotid stenosis who receive conservative therapy.

Stenosis, ulceration of the atherosclerotic plaque and Lp-PLA2 concentration are calculated

3 groups of stroke risk development were set (low, medium and high)

Proposed formula form personalized approach to the diagnosis and prevention of stroke