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.

中文翻译：

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未曾预料的中风后通常不可能进行颈动脉内膜切除术：未预料的中风在颈动脉狭窄中

目标

正在进行的文献建议主要针对具有神经系统症状的患者进行颈动脉内膜切除术（CEA），但是严重卒中或完全颈动脉闭塞可阻止CEA的发生。本研究旨在评估未发作的中风对先前可能考虑用于CEA的无症状性颈动脉狭窄（ACS）患者的影响。

材料和方法

从2009年至2019年，我们考虑了ACS患者中风未发作的患者。通过神经系统检查，将患者分为不适合CEA（uCEA）–根据中风的严重程度（根据改良的Rankin量表– mRS）或总颈动脉闭塞的发作–将患者接受CEA。评估uCEA和中风严重程度的预测指标。

结果

在总共532例有症状的颈动脉狭窄患者中，有277例（52％）未发作的中风被纳入研究。一百零一（36％）被认为是uCEA：由于其神经系统疾病（mRS：5）而被认为是uCEA：64（23％），由于颈动脉闭塞的发生被认为是uCEA：37（13％）。一百七十六（64％）名患者接受了CEA。uCEA患者与CEA患者的术前药物治疗相似。年龄≥80岁和女性与uCEA独立相关（OR：5.9，95％CI：3.1-11.4，P <.01； OR：3.9，95％CI：2.0-7.6，P <.01）。接受CEA治疗的患者在102（37％）例中的mRS：0–2，在74（27％）中的mRS：3-4。对侧颈动脉闭塞（CCO）与mRS：3–4（OR：8.4，95％CI 1.8–79，P= .01）。CEA术后的卒中率为2.9％（4/167）；术前mRS：3-4的患者比mRS：0-2的患者发生中风的风险更高（5.9％vs. 0％，P = .02）。

结论

ACS患者中无先兆的中风会导致一半以上的病例严重神经系统受损，这可能会阻止CEA（36％）或增加术后并发症的风险（27％）。女性，年龄≥80和CCO是这些事件的独立预测因素，ACS患者应考虑这些因素。