What's New in Stroke? The Top 10 for 2004/05
Carotid Artery Stenosis
It is generally accepted that carotid endarterectomy offers benefits for patients with high-grade (≥70%) cervical carotid stenosis who also have ipsilateral focal ischemic events (symptomatic stenosis), because the rate of stroke without surgery is high (~15% per year).[9] Symptomatic patients with mild stenosis (<50%) usually do not benefit from surgery;[10] for moderate stenosis (50–69%), modest benefit has been showed, and surgery is recommended for selected patients. Although carotid endarterectomy has been shown to reduce the risk of ipsilateral ischemic stroke for patients with asymptomatic carotid stenosis, the magnitude of this reduction is much smaller than for patients with symptomatic stenosis.[11] The Asymptomatic Carotid Surgery Trial (ACST) assigned 3,120 patients with asymptomatic cervical carotid artery stenosis of 60% or greater according ultrasound to best medical therapy versus best medical therapy plus endarterectomy.[12] During a mean follow-up of 3.4 years, endarterectomy reduced stroke (P < .001), with an absolute reduction of about 1% per year for those assigned to surgery. Although highly statistically significant, the number needed to treat was large; one stroke would be prevented for every 20 patients undergoing surgery and followed for 5 years. Paradoxically, although the ACST clearly demonstrated that surgery reduces stroke in patients with asymptomatic carotid stenosis, the absolute stroke risk in the medically treated arm was sufficiently low to question the routine use of endarterectomy in this setting. For those aged 75 and older, no benefit of surgery was evident. These results seem to reaffirm an initial conservative medical approach to most patients with asymptomatic carotid artery stenosis (and especially the very vigorous elderly) to include risk-factor management, antiplatelet prophylaxis, and periodic re-education about symptoms of TIA.
J Am Geriatr Soc. 2006;54(4):674-679. ©2006 Blackwell Publishing
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