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16/06/2016 - Press release

When is the best time to have carotid stenosis surgery after a stroke?

? A multicentre study provides data from one of the largest cohorts of patients with this type of stroke

An international study led by the Neurology Service at Hospital del Mar and the Neurovascular research group at the Hospital del Mar Medical Research Institute (IMIM) has quantified the risk and developed predictors for ischemic stroke in patients with carotid artery stenosis. The results of the study, published in the journal Neurology, have confirmed that there is a high risk of recurrence in the first 14 days after the stroke, which is the recommended time for carotid revascularisation surgery. But since very urgent surgery entails a considerable surgical risk, it is necessary to determine the most appropriate time for undertaking this operation in the fourteen days following the stroke. The study provides a starting point and randomised trials are recommended to determine the benefits and safety of emergency revascularisation as opposed to subacute carotid revascularisation within 14 days after the onset of symptoms.

The study was aimed at quantifying the risk and defining predictors for ipsilateral carotid stenosis in patients with symptomatic ischemic stroke waiting for revascularisation (carotid endarterectomy [CEA] or carotid artery stenting) by grouping the data from individual patients included in recent prospective studies with high rates of drug treatment for preventing strokes. This study gathered together information from the databases of three groups (Hospital del Mar, Umea Hospital in Sweden, and Dublin in Ireland) to improve the statistical power of the data.

Because of the high risk of recurrent ischemic events in the same carotid territory up to 14 days after a stroke due to carotid stenosis, it is currently recommended that a CEA be conducted. But this technique is not without risk. Despite the improvement in secondary prevention treatment and improvement in early operating times, randomised trials are needed to determine the benefits and safety of emergency revascularisation (within the first 72 hours) versus subacute carotid revascularisation within 14 days of the onset of symptoms. These trials should be used to determine the optimal time for carrying out this operation, in order to balance the risk of recurrence and the surgical risk, and establish precisely whether to operate on a patient or not, and whether it is necessary to reduce the time for doing so.

The data for the study comes from two prospective records from hospitals (Umea and Barcelona) and a prospective population-based study (Dublin) that together comprise a database of cases from 2005 up to the present day. Included in the study were patients with symptomatic carotid stenosis of 50% -99% who were candidates for carotid revascularisation and who received follow-up for the beginnings of recurrent ipsilateral stroke or retinal artery occlusion (RAO). "Of the 607 patients with symptomatic stenosis, 377 met the previously specified inclusion criteria . The risk of having another ischemic stroke was 2.7% (in the first day), 5.3% (for the first 3 days), 11.5% (in the first 14 days), and 18.8% (by 90 days)", explains Dr. Elisa Cuadrado, neurologist at Hospital del Mar and a researcher in the IMIM's neurovascular group. She goes on to say that: "We found a high risk of a recurrent ipsilateral ischemic event within a period of 14 days, the time within which it is currently recommended a CEA be performed. We need randomised trials to be able to determine the benefits and safety of more urgent revascularisation (in first 72 hours), before subacute carotid revascularisation within 14 days after the onset of symptoms."

The sample size used is important, because the bigger it is, the higher the statistical power and, therefore, the more accurate the risk estimate. One concern related to the study is the fact that it includes patients treated since 2005, when treatment with high doses of statins and dual antiplatelet therapy was not yet being used systematically. It is possible that current secondary prevention treatment for the risk of recurrence is lower, something which should be considered in future studies. More studies are therefore needed to unify surgical intervention criteria. What is clear is that these recently incorporated treatments decrease the recurrence rate, so we need to establish the time when medical treatment and surgical risk offer the greatest benefits and pose the least risk.

Reference article:

Johansson E1, Cuadrado-Godia E2, Hayden D1, Bjellerup J1, Ois A1, Roquer J1, Wester P1, Kelly PJ1. Recurrent stroke in symptomatic carotid stenosis awaiting revascularisation: a pooled analysis. Neurology 2016 http://www.ncbi.nlm.nih.gov/pubmed/26747885

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