ISCHEMIC STROKE / PREVENTION

Created 31/01/2023, last revision 21/04/2023

• CEA is the gold standard for the management of significant carotid stenosis (both symptomatic and asymptomatic)
  • randomized trials have confirmed the effect of CEA compared to conservative treatment:
    • symptomatic stenosis (NASCET , ECST , joint data analysis of ACTS, NASCET and VA trials)
    • asymptomatic stenosis (ACAS , ACST, ACST-2, CREST)
      
• an alternative to CEA represents carotid angioplasty and stenting (CAS)
  • long-term effect is the same for CEA and CAS (annual risk of ipsilateral stroke approx. 0.6 and 0.64% respectively), periprocedural complications are higher with CAS [Brott, 2019]
  • CEA appears to be preferable to CAS in patients ≥ 70 years of age, and both procedures are comparable in younger patients  [Müller, 2020]   (AHA/ASA 2021 2a/B-R)
• the benefit of transcarotid revascularization (TCAR) is unclear  (AHA/ASA 2021 2b/B-NR)
• the decision to revascularize should be made by a team that includes a neurologist, neurosurgeon/vascular surgeon, and/or interventional radiologist

Indications

Timing

Arrangements before surgery

• assess carotid stenosis – usually, neurosonology in combination with CTA (or MRA) is used; DSA is less common
  • severity of stenosis and its etiology
  • high-risk plaque characteristics?
  • collateral circulation and contralateral ICA status?

→ measurement of stenosis on CTA (according to NASCET)
→ quantification of stenosis by ultrasound
→ assessment of intracranial flow including vasomotor reactivity

• consider the infarct characteristics on imaging  (CT/MR) and neurological deficit (incl. NIHSS)
  • stenosis symptomatic or asymptomatic?
  • recent or older infarct? 
  • what is its extent?
  • is it relevant to carotid stenosis?
    
  • is there a hemorrhagic component?
• a history and preoperative physical examination (myocardial infarction is the most common cause of death after CEA and the most common non-neurological complication)
  • physical examination
  • ECG
  • TTE
  • coronarography or TEE in selected cases
    
• proper correction of hypertension in the perioperative period is critical (to reduce the risk of hyperperfusion syndrome)
• do not interrupt antiplatelet and statin therapy ( (the effect is mainly seen in symptomatic stenoses)  (AHA/ASA I/A)

Procedure and post-procedural care

• surgery can be performed under local (LA) or general anesthesia (GA)
  • the choice of anesthesia does not affect the outcome (GALA trial)
  • neuromonitoring (SSEP, TCD) is beneficial during GA
  • the choice is based on the patient, surgeon, or anesthesiologist’s preference
• the incision and arteriotomy are longitudinal or transverse (eversion CEA)
• heparinisation is used before clamping the artery
• use a temporary shunt to maintain adequate blood flow to the brain in the following situations:
  • impaired consciousness after carotid clamping / impaired neuromonitoring parameters during GA
  • known contralateral ICA occlusion, poor collateral circulation
• patch x direct suture
  • patches are reported to have a lower risk of restenosis  [Malas, 2015]
  • patches are less likely to be detectable by ultrasound postoperatively
    
• heparin is neutralized after surgery is completed
• the patient is transferred to the ICU for monitoring of vital signs
  • ensure strict BP correction (<150/100mm Hg) to prevent hyperperfusion syndrome
  • regularly monitor neurostatus and surgical wound  (bleeding, infection, etc.)

Complications

•  the risk of perioperative complications depends on the following:
  • correct indication and timing of the procedure
  • quality of preprocedural care (statins, antiplatelet therapy, optimal BP, etc.)
  • the experience and skill of the surgical team and the level of postoperative care
• increased perioperative risk is associated with the following conditions:
  • unstable neurological status (evolving or fluctuating lesions)
  • manifestation of multiple vascular lesions
  • occlusion of the contralateral ICA or CCA (RR 1.91)
  • tandem intracranial stenosis (RR 1.56)
  • intraluminal thrombus
  • female sex, advanced age (RR 1.36 in patients over 75 years)
  • coronary heart disease
  • history of heart failure
  • chronic pulmonary disease (most commonly obstructive disease)
  • arterial hypertension (RR 1.82)
  • atherosclerotic peripheral artery disease (PAD); RR 2.19

Restenosis

Follow-up

• it is recommended to perform an ultrasound examination at 1, (3) and 6 months after surgery to detect early restenosis
  • according to AHA/ASA 2014, routine follow-up is not necessary (cost-benefit)
  • however, in clinical practice, annual ultrasound follow-up is quite common
• follow up in the vascular clinic with comprehensive secondary prevention (including risk factor management) is advisable