Carotid Endarterectomy

Specific Treatments for Patients with Tia or Minor Stroke
Depending on the mechanism of the cerebral ischemic event, there are now options from which to chose for the prevention of first or recurrent stroke. Newer treatments such as thrombolysis and neuroprotection may prove beneficial in the acute setting, while other therapies are aimed at reducing the stroke recurrence risk. One early decision which must be addressed among patients presenting with TIAs or minor strokes is whether to chose surgery versus medical therapies for stroke prevention.

Carotid Endarterectomy

Surgical clinical trials have documented the benefit of carotid endarterectomy to reduce the risk of ischemic stroke in some symptomatic persons. In the North American Symptomatic Carotid Endarterectomy Trial (NASCET) among persons with TIA or minor stroke and an ipsilateral carotid stenosis of 70% or more, the 2-year risk of ipsilateral stroke was 9% in the surgical group and 26% in the medical group (ASA 1300 mg/day). The VA Cooperative Study showed that among those with greater than 50% carotid stenosis, the risks of stroke after a mean follow-up of 11.9 months were 7.7% in the surgical group and 19.4% in the non-surgical group. The European Carotid Surgery Trial (ECST) demonstrated similar findings as in the latter two studies for high-grade symptomatic carotid stenosis, but there was no significant benefit of surgery for those with 0-29% stenosis. Recent NASCET data has extended the benefits of carotid endarterectomy to persons with symptomatic carotid stenosis of greater than 50%. This degree of stenosis is based on the NASCET angiographically-based measurement and is equivalent to approximately 75% stenosis by ECST criteria and greater than 60-80% stenosis by carotid Duplex Doppler criteria.
The consensus is clear that for patients with a TIA or minor stroke and ipsilateral carotid stenosis more than 50-60%, then carotid endarterectomy is the best option for prevention of a recurrent event. For those with <50-60% stenosis, endarterectomy offers little benefit compared to medical therapy.

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