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[Argirios Argiriou]

October 8, 2015

What's the Prognosis When Asymptomatic Carotid Stenosis Progresses to Occlusion?

Allan S. Brett, MD reviewing Yang C et al. JAMA Neurol 2015 Sep 21.

In one retrospective study, the stroke rate was remarkably low.

We tend to assume that patients with asymptomatic carotid stenosis are at high risk for stroke if stenosis progresses to total occlusion. To explore this assumption, Canadian researchers analyzed data, collected from stroke prevention clinics between 1990 and 2014, on 3681 patients with asymptomatic carotid disease who underwent annual carotid ultrasonography.

A total of 316 patients (9%) developed carotid occlusion; of these, only 1 patient had an ipsilateral stroke at the time of the occlusion, and only 3 patients suffered strokes during average follow-up of 3 years (maximum follow-up, 20 years) after occlusion was documented. Most occlusions developed before 2002, the year when more-intensive medical therapy began to be implemented in this cohort.

COMMENT

In this study, stroke occurred very rarely in patients with asymptomatic carotid stenosis who progressed to total carotid occlusion. As emphasized by the authors, the circle of Willis usually maintains cerebral blood flow despite unilateral — or even bilateral — carotid occlusion.

This study reminds us that carotid revascularization in patients with asymptomatic stenosis has become controversial. Although randomized trials published in 1995 (NEJM JW Gen Med Jun 1 1995 and JAMA 1995; 273:1421) and 2004 (NEJM JW Gen Med Jun 15 2004 and Lancet 2004; 363:1491) suggested that endarterectomy conferred a small net benefit in patients with asymptomatic carotid stenosis, we now have indirect evidence that contemporary medical therapy might be preferable to invasive intervention. In an ongoing randomized trial (CREST-2), researchers are comparing revascularization plus intensive medical management with intensive medical management alone.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Allan S. Brett, MD at time of publication
Nothing to disclose

CITATION(S):

Yang C et al. Risk of stroke at the time of carotid occlusion. JAMA Neurol 2015 Sep 21; [e-pub]. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

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