carotid endarterectomy in stroke prevention update

Carotid Endarterectomy in Stroke Prevention

Denise Crute, MD, FACSMount Sinai School of Medicine

© Dr. Denise Crute 2013

Stroke Prevention Recognition and

diagnosis Awareness of new

techniques Familiarity with

appropriate treatments

Paralysis – Manrov Vornam


Stroke “A Neurological deficit of cerebrovascular

cause that persists beyond 24 hours or is interrupted by death within 24 hours.”

“Death of brain cells due to inadequate blood flow.” Ischemia versus infarction Dysfunction versus death


Stroke Diagnosis: Ischemic Infarction 70% to 80% of all

strokes Delayed

appearance on CT Emergency care Critical care


Stroke Diagnosis: Ischemia TIA (Transient

Ischemic Attack) Stroke-in-

evolution


Stroke Diagnosis: Hemorrhage Subdural Hematoma (SDH) Epidural Hematoma (EDH) Intraventricular Hemorrhage (IVH)


Stroke Diagnosis: Hemorrhage Subarachnoid Hemorrhage Intracerebral Hemorrhage


Stroke Treatment and Prevention Carotid Endarterectomy Stenting TPA Craniotomy Craniectomy

© Dr. Denise Crute 2013 Operating Hands, Bipolar, Denise Crute , MD

Carotid Stenosis Common carotid

artery Anterior circulation Internal Carotid

Artery External Carotid

Artery Plaque formation


Carotid Stenosis Extra cranial

carotid occlusive disease

Flow reduction through reduced lumen

Embolic source


Carotid Endarterectomy Surgical correction of extra-cranial internal

carotid occlusive disease

© Dr. Denise Crute 2013Operative approach for CEA Denise Crute , MD

Carotid Endarterectomy 1954: Described for

treatment of stroke. 1985: Questioned 1995: Guidelines

published 2010: Guidelines

refined

© Dr. Denise Crute 2013 Operative approach for CEA Denise Crute , MD

Carotid Endarterectomy Intraoperative

monitoring EEG Local anesthesia Cerebral oximetry

© Dr. Denise Crute 2013 Operative technique for CEA, Denise Crute , MD

Carotid Endarterectomy

ACAS Trial NASCET Study ECST Collaborative

Group CREST results

© Dr. Denise Crute 2013 Operative closure for CEA, Denise Crute , MD

Carotid Endarterectomy: ACAS Asymptomatic Carotid Atherosclerosis

Study 1987-1993 1662 patients 40-79 years old Surgical: Stroke risk 5.1% at 5 years Medical: Stroke risk 11% at 5 years


Carotid Endarterectomy: ACAS Surgery beneficial Clear benefit when:

>60% asymptomatic stenosis Surgical risk <3% Life expectancy at least 5 years


Carotid Endarterectomy: ECST European Carotid Surgery Trialists 455 surgical, 323 medical patients No surgical quality control or uniform

medical therapy requirement CEA beneficial for 70-99% stenosis


Carotid Endarterectomy: NASCET North American Symptomatic Carotid

Endarterectomy Trial 659 patients, 328 surgical Medical: stroke risk at 2 years 13.1% Surgical: risk at 2 years 2.5% <50% stenosis risks > benefits Benefit for >69% stenosis


Carotid Endarterectomy: CREST Carotid Revascularization Endarterectomy

versus Stenting Trial February 2010 2500 patients Strokes in stent group: 4.1%, CEA group

2.3%, no difference in major disabling stroke

Patient age >69 surgery Patient age <70 stenting


Case Study 60 year-old lady Restrained driver in MVA: Ran a stoplight

and collided with an oncoming car +LOC, emesis in ambulance, GCS=15,

amnestic for event and drowsy Complains of severe headache BP 210/110, PMH HTN, DM and 30 pack-

years tobacco


Carotid Endarterectomy

70% stenosis 70 years Time is brain Prevention Treatment


Stroke Prevention Patient lifestyle Recognize

ischemia Awareness of new

techniques Familiarity with

appropriate treatments

Paralysis – Manrov Vornam© Dr. Denise Crute 2013

carotid endarterectomy in stroke prevention update

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