Carotid Endarterectomy is often not Possible after an Unheralded Stroke: Unheralded Stroke in Carotid Artery Stenosis

Rodolfo Pini; Gianluca Faggioli; Antonio Muscari; Cristina Rocchi; Sergio Palermo; Andrea Vacirca; Enrico Gallitto; Mauro Gargiulo

doi:10.1016/j.jstrokecerebrovasdis.2020.105594

Carotid Endarterectomy is often not Possible after an Unheralded Stroke: Unheralded Stroke in Carotid Artery Stenosis

J Stroke Cerebrovasc Dis. 2021 Mar;30(3):105594. doi: 10.1016/j.jstrokecerebrovasdis.2020.105594. Epub 2021 Jan 8.

Authors

Rodolfo Pini¹, Gianluca Faggioli², Antonio Muscari³, Cristina Rocchi², Sergio Palermo², Andrea Vacirca², Enrico Gallitto², Mauro Gargiulo²

Affiliations

¹ Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy. Electronic address: rodolfo.pini@studio.unibo.it.
² Division of Vascular Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy.
³ Department of Medical and Surgical Science, University of Bologna, Italy.

PMID: 33429239
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105594

Abstract

Objectives: The ongoing literature recommends carotid endarterectomy (CEA) primarily for patients with neurological symptoms, however CEA can be precluded by the onset of a severe stroke or a total carotid occlusion. The present study aims to evaluate the effect of unheralded strokes in patients with a previously asymptomatic carotid stenosis (ACS) possibly considered for CEA.

Materials and methods: From 2009 to 2019, patients with an unheralded stroke from an ACS were considered. By neurological examination, patients were divided in unfit-for-CEA (uCEA) - either for the severity of the stroke (according to modified Rankin-Scale - mRS) or the onset of a total carotid occlusion - and patients submitted to CEA. Predictors for uCEA and stroke severity were evaluated.

Results: Over a total of 532 patients with symptomatic carotid stenosis, 277 (52%) with unheralded stroke were included in the study. One hundred and one (36%) were considered uCEA: 64(23%) due to their neurological conditions (mRS:5) and 37 (13%) because of the onset of carotid occlusion. One hundred seventy-six (64%) patients underwent CEA. The preoperative medical therapy was similar in uCEA vs CEA patients. Age≥80 years and female sex were independently associated with uCEA (OR:5.9, 95%CI:3.1-11.4, P<.01; OR:3.9, 95%CI:2.0-7.6, P<.01. respectively). Patients submitted to CEA had mRS: 0-2 in 102(37%) cases and mRS:3-4 in 74 (27%). The contralateral carotid occlusion (CCO) was independently associated with mRS:3-4 (OR:8.4, 95%CI 1.8-79, P=.01). Postoperative stroke rate after CEA was 2.9% (4/167); patients with preoperative mRS:3-4 had a higher risk for postoperative stroke compared to those with mRS:0-2 (5.9% vs. 0%. P=.02).

Conclusions: An unheralded stroke in patients with ACS leads to a severe neurological damage in more than half of cases, either precluding CEA (36%) or increasing the risk of postoperative complications (27%). Female sex, age≥80 and CCO are independent predictors of these occurrences and should be considered in ACS patients.

Keywords: Asymptomatic; Carotid artery stenosis; Endoarterectomy; Stroke.

MeSH terms

Age Factors
Aged
Aged, 80 and over
Carotid Stenosis / complications
Carotid Stenosis / diagnostic imaging
Carotid Stenosis / surgery*
Clinical Decision-Making
Databases, Factual
Endarterectomy, Carotid / adverse effects*
Female
Humans
Male
Postoperative Complications / etiology*
Retrospective Studies
Risk Assessment
Risk Factors
Severity of Illness Index
Sex Factors
Stroke / diagnosis
Stroke / etiology*
Treatment Outcome