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Eusi Stroke

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RECOMMENDATIONS FOR STROKE MANAGEMENT

RECOMMENDATIONS FOR STROKE MANAGEMENT

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  • 1. - SYMPOSIUM RECOMMENDATIONS FOR STROKE MANAGEMENT European Federation of Neurological Societies EFNS Copenhagn 2000
  • 2. RECOMMENDATIONS FOR STROKE MANAGEMENT
    • Part 1: Organizing Modern Stroke Care Tom Skyhoj Olsen, Copenhagn (DEN)
    • Part 2: Risk Factors and Primary Prevention Julien Bogousslavsky, Lausanne (SUI)
    • Part 3: Acute Stroke Care - General Therapy Markku Kaste, Helsinki (FIN)
    • Part 4: Acute Stroke Care - Specific Therapy Werner Hacke, Heidelberg (GER)
    • Part 5: Rehabilitation and Secondary Prevention Jean-Marc Orgogozo, Bordeaux (FRA)
  • 3. RECOMMENDATIONS FOR STROKE MANAGEMENT
    • Part 1: Organizing Modern Stroke Care Tom Skyhoj Olsen, Copenhagn (DEN)
  • 4. RECOMMENDATIONS FOR STROKE MANAGEMENT
    • Part 2: Risk Factors and Primary Prevention Julien Bogousslavsky, Lausanne (SUI)
  • 5. RECOMMENDATIONS FOR STROKE MANAGEMENT
    • Part 3: Acute Stroke Care - General Therapy Markku Kaste, Helsinki (FIN)
  • 6. RECOMMENDATIONS FOR STROKE MANAGEMENT
    • Part 4: Acute Stroke Care - Specific Therapy Werner Hacke, Heidelberg (GER)
  • 7. RECOMMENDATIONS FOR STROKE MANAGEMENT
    • Part 5: Rehabilitation and Secondary Prevention Jean-Marc Orgogozo, Bordeaux (FRA)
  • 8. Definitions of Levels of Evidence modified from Adams et al. 1994
    • Level I: Highest Level of Evidence
      • Sources: a) Primary endpoint of double blind RCT with adequate sample size
      • b) Meta-analysis of qualitatively outstanding RCTs
    • Level II: Intermediate Level of Evidence
      • Sources: a) Randomised not blinded trials
      • b) Small randomised trials
      • c) Predefined secondary endpoints of large RCTs
    • Level III: Lower Level of Evidence
      • Sources: a) Prospective case series with concurrent or historical control
      • b) Post hoc analyses of large RCTs
    • Level IV: Undetermined Level of Evidence
      • Sources: a) Small uncontrolled case series
      • b) General agreement despite lack of evidence
  • 9. Acute Stroke Care- Emergency Diagnostic Tests
    • Differentiation between different types of stroke
    • Ruling out other brain diseases
    • Assessing the underlying cause of brain ischemia
    • Providing a basis for physiological monitoring of the stroke patient
    • Identifying concurrent diseases or complications associated with stroke
  • 10. Emergency Diagnostic Tests
    • Cranial computed tomography (CCT)
      • distinguishes reliably between hemorrhagic and ischemic stroke
      • early signs of ischemia detected as early as 2 h after stroke onset
      • identifies hemorrhages almost immediately
      • detects SAH in the majority of cases
      • helps to identify other neurological diseases (e.g. neoplasms)
  • 11. Emergency Diagnostic Tests
    • Magnetic resonance imaging (MRI)
      • only helpful in centres using modern MRI techniques
      • diffusion- and perfusion-weighted MRI may help to differentiate between infarcted tissue and tissue at risk
  • 12. Emergency Diagnostic Tests
    • Electrocardiogram
      • high incidence of heart involvement in stroke patients
      • coincidence of stroke and myocardial infarction
      • ischemic stroke may cause arrhythmias
      • detection of atrial fibrillation as a possible cause of embolic stroke
  • 13. Emergency Diagnostic Tests
    • Ultrasound studies
      • cw/pw- Doppler and/or duplex sonography of the extracranial cervical and the basal intracranial arteries
        • identification of vessel stenosis, occlusion, state of collaterals, or recanalisation
      • transesophageal echocardiography to screen for cardiogenic emboli (not in the ER but recommended within the first 24 h after stroke onset)
  • 14. Emergency Diagnostic Tests
    • Laboratory tests
      • hematology
      • clotting parameters
      • electrolytes
      • renal and hepatic chemistry
      • cardiac enzymes
      • basic parameters of infection
  • 15. Emergency Diagnostic Tests
    • EUSI Recommendations
      • 1. CCT is the most important diagnostic tool in patients with suspected stroke (Level IV)
      • 2.Early evaluation of physiological parameters, blood chemistry and hematology, and cardiac function (ECG, pulsoximetry, chest x-ray) is recommended in the management of acute stroke patients
  • 16. Emergency Diagnostic Tests
    • EUSI Recommendations
      • 3. Cardiac and Neurological ultrasound should be readily available (Level IV)
  • 17. Acute Stroke Care- General Management
    • EUSI-recommendations include
      • Pulmonary and airway care
      • Blood pressure
      • Body temperature
      • Glucose metabolism
      • Fluid and electrolyte management
  • 18. General Management
    • Monitoring of vital and neurological functions
      • continuous monitoring:
        • heart rate
        • O 2 saturation
      • discontinuous monitoring
        • Blood pressure (e.g. automatic inflatable sphygmomanometry)
        • Clinical: Vigilance / GCS, pupils
        • Neurological (e.g. NIH and Scandinavian stroke scale)
  • 19. General treatment
    • Pulmonary function and airway protection
      • Adequate oxygenation important for preservation of the penumbra
      • Improved blood oxygenation by administration of > 2 l O 2 (S O 2 -guided)
      • Risk for aspiration in patients with pseudobulbar/bulbar paralysis and reduced vigilance: side positioning, consider tracheotomia
      • Consider hypoventilation by pathological respiration pattern
      • Risk of airway obstruction (vomiting, oropharyngeal muscular hypotonia): mechanical airway protection
  • 20. General treatment
    • Blood pressure (BP)
      • elevated in most of the patients with acute stroke
      • Flow in the critical penumbra passively dependent on the mean arterial pressure
      • Sufficient post-stenotic flow requires high blood pressure
  • 21. General treatment
    • Blood pressure
      • There are no controlled, randomised studies guiding BP management
        • Recommended target BP in patients with prior hypertension: 180 / 100-105 mmHg
        • Recommended target BP in previously normotonic patients: 160-180 / 90-100 mmHg
        • Avoid and treat hypotension or drastic reductions in BP
  • 22. General treatment
    • Blood pressure
      • Indications for immediate antihypertensive therapy in acute stroke:
        • Non-ischemic cause for stroke
        • Cardiac insufficiency
        • Aortic dissection
        • Acute renal failure
        • Hypertensive encephalopathy
  • 23. General treatment
    • Body temperature
      • Facts
        • Fever negatively influences neurological outcome after stroke
        • Experimentally, fever increases infarct size
        • Many patients with acute stroke develop a febrile infection after stroke
      • Although no controlled trial supporting treatment of an elevated temperature, consider to treat fever when the body temperature reaches 37.5°C rectally
  • 24. General treatment
    • Glucose metabolism
      • Facts
        • Pre-existent diabetic metabolic derangement can be worsened
        • High glucose levels in the acute phase of stroke may increase the size of the infarction and reduce functional outcome
        • Hypoglycemia worsens outcome as well
        • Hypoglycemia can mimic an acute ischemic infarction
  • 25. General treatment
    • Fluid and electrolyte management
      • Serious electrolyte abnormalities are rare after ischemic stroke but frequent after ICH and SAH
      • Balanced electrolyte and fluid status are important to avoid:
        • plasma volume contraction
        • raised hematocrit
        • impaired rheologic properties
  • 26. General treatment
    • EUSI Recommendations
      • 1. Neurological status and vital functions should be monitored
      • 2. Glucose and body temperature should be monitored and corrected, if elevated (Level III)
      • 3. Do not treat hypertension in patients with ischemic stroke, if they do not have critically elevated BP levels (Level III)
  • 27. General treatment
    • EUSI Recommendations
      • 4. Secure airways and supply oxygen to patients with severe acute stroke (Level IV)
      • 5. Monitoring and correction of electrolyte and fluid disturbances are advised (Level IV)
  • 28. Acute Stroke Care- Specific Treatment
    • EUSI-recommendations include
      • Acute anti-thrombotic therapy
        • Thrombolytic therapy
        • Defibrinogenating enzymes
        • ASA
      • Neuroprotection
      • Treatment of elevated ICP and brain edema
        • Medical treatment
        • Surgical treatment
  • 29. Thrombolytic Therapy
    • IV-Thrombolysis (rtPA)
      • Facts (NINDS Pt. 1 + 2, ECASS I + II, ATLANTIS)
        • 3h time window approved in USA, CDN, MEX, I.V. 0.9mg/kg, max 90mg
        • Not yet approved in Europe
        • Efficacy signal beyond 3h (meta-analysis)
    • IV-Thrombolysis (SK)
      • Facts (MAST-I, MAST-E, AST)
        • Although some efficacy signal in early time windwow, SK currently abandoned
  • 30. Thrombolytic Therapy
    • IA-Thrombolysis (rtPA, UK)
      • Facts
        • Only cases and some prospective uncontrolled case series
    • IA-Thrombolysis (rPUK)
      • Facts (PROACT I and II)
        • Efficacy proven in small RCT, 6h window,
        • Not approved, PROACT III?
  • 31. Thrombolytic Therapy
    • EUSI Recommendations (for centers offering thrombolysis)
      • 1. I.V. rtPA (0.9mg/kg; max 90mg, 10% bolus, followed by 60 min infusion) is recommended within 3 hours after stroke onset (Level I)
      • 2. The benefit from the use of I.V. rtPA beyond 3 hours is smaller, but present in selected patients (Level I)
      • 3. I.V. rtPA is not recommended when time of onset is uncertain
  • 32. Thrombolytic Therapy
    • EUSI Recommendations (for centers offering thrombolysis)
      • 4. I.V. SK outside of the setting of acontrolled clinical trial is dangerous and not indicated for the management of persons with ischemic stroke (Level I)
      • 5. Intra-arterial treatment of acute M1 occlusion in a 6 h time window using rPUK results in a significantly improved outcome (Level II)
      • 3. Acute BA-occlusion may be treted with I.A, therapy in selected centers (Level IV)
  • 33. Defibrinogenating Therapy
    • ANCROD
      • Treatment of acute ischemic stroke with I.V. Ancrod in a 3 h time window results in significantly improved outcome (primary endpoint only (STAT)
      • Futility analysis of 6 h trial (ESTAT) led to premature termination of the trial
  • 34. Defibrinogenating Therapy
    • EUSI Recommendation
    • 1. Ancrod given in a 3 h time window significantly improves outcome after acute ischemic stroke (Level II)
  • 35. Platelet Inhibitors
    • ASA
      • only substance tested in acute (<48 h) stroke (IST, CAST)
      • CT not required for randomisation
      • small but significant reduction of mortality and recurrence of stroke in combined analysis of both trials
  • 36. Platelet Inhibitors
    • EUSI-recommendation
      • 1. Aspirin 100-300 mg/day may be given to an unselected stroke population (Level II)
  • 37. Therapeutic Anticoagulation
    • Unfractionated heparin
      • no formal trial available testing standard I.V. heparin
      • IST showed no benefit for sc heparin treated patients, increased risk of ICH
    • Low molecular weight heparins
      • Postive effect seen in small pilot trial (Kay 1995) was not found in subsequent trial (fisBIS)
    • Heparinoid (Orgaran)
      • TOAST trial negative
  • 38. Therapeutic Antioagulation
    • EUSI-recommendation
      • 1. There is no recommendation for the general use of heparin, low molecular weight heparines or heparinoids after ischemic stroke (Level I)
      • 2. Full dose heparin may be used in selected indications such as AF, other cardiac sources with high risk of re-embolism, arterial dissection, or high grade arterial stenosis (Level IV)
      • 3. Administration for DVT-prophylaxis see general treatment
  • 39. Neuroprotection
    • Up to now, not a single neuroprotective substance has been shown to influence outcome after stroke.
    • Currently there is no recommendation to treat patients with neuroprotective drugs after ischaemic stroke (Level I)
  • 40. Elevated Intracranial Pressure and Brain Edema Treatment
    • Medical therapy
      • Basic management
        • Head positioning <30°
        • Pain relief and sedation
        • Normothermia
        • Osmotic agents
          • Glycerol
          • Mannitol
          • Hypertonic saline
        • Barbiturates, hyperventilation and THAM-buffer
  • 41. Elevated Intracranial Pressure and Brain Edema Treatment
    • Surgical Therapy
      • Ventricular drainage
        • Posterior fossa space occupying infarction
        • Thalamic infarction (rare)
      • Decompressive surgery
        • Posterior fossa space occupying infarctian
        • Malignant MCA/hemispheric infarction
          • Encouraging reduction of mortality with decent outcome i prospective case series
          • RCT (HEADFIRST) starts recruiting
  • 42. Elevated Intracranial Pressure and Brain Edema Treatment
    • EUSI-recommendations
      • 1. Osmotherapy is recommended for patients whose condition is deteriorating secondary to increased ICP, including those with herniation syndromes (Level III)
      • 2. Surgical decompression of large cerebellar infarctions that compress the brainstem is justified (Level III)
      • 3.Surgical decompression of large hemispheric infarction can be life-saving (Level III)
  • 43. Stroke Units
    • Definition:
      • Hospital or part of a hospital that (nearly) exclusively takes care of stroke patients
      • Specialised staff with multidisciplinary approach to treatment and care
      • Core disciplines: medical treatment, nursing, physiotherapy, occupational therapy, speech and language therapy, social work
  • 44. Stroke Units
    • Facts (Stroke Unit Trialist´s Collaboration)
      • Acute treatment in a stroke unit results in significant reduction in mortality, death, dependence, or need of institutional care in comparison to a general medical ward
  • 45. Stroke Units
    • Types of stroke units:
      • 1. Acute stroke unit
        • acute treatment < 1 week (2-3 days)
      • 2. Combined acute and rehabilitation stroke unit
        • acute phase + reha for several weeks / months
      • 3. Rehabilitation stroke unit
        • admission after 1to 2 weeks after stroke onset
      • 4. Mobile stroke team
        • offers stroke care and treatment on a variety of wards
  • 46. Stroke Units
    • EUSI Recommendations
      • 1. Stroke patients should be treated in specialised stroke units (Level I)
  • 47. Rehabilitation
    • Early rehabilitation
      • 40% of stroke patients need active reha services
      • active rehabilitation should start as soon as possible
      • if the patient is unconscious, rehabilitation is passive to prevent contractions and other immobilisation-associated complications
  • 48. Rehabilitation
    • Rehabilitation programs
      • - Assessment for the degree of disability (motor, cognitive, sensory, visual)
      • - Assessment of the ability to respond to rehabilitation (financial burden, chances to return to social activities and work and to live alone, need of help)
      • - adaptation of the intensity of the rehabilitation to status and the degree of disability
  • 49. Rehabilitation
    • Rehabilitation programs
      • - daily documentation of the patients progress
      • - teaching and involvement of the patient and his family members
      • - home visitation as early as possible (smoothing the transit, increasing motivation)
      • - planning the transfer to a specialised rehabilitation hospital if a longer reha period is expected
  • 50. Rehabilitation
    • ideal multidisciplinary stroke team for adequate rehabilitation
      • - stroke physician and nurses experienced in stroke management
      • - physiotherapist, speech therapist and occupational therapist trained in stroke rehabilitation
      • - neuropsychologist and social worker accustomed to stroke rehabilitation
  • 51. Rehabilitation
    • EUSI Recommendations
      • 1. Rehabilitation should be initiated early after stroke (Level I)
      • 2. Every patient should have access to evaluation for rehabilitation (Level III)
      • 3. Rehabilitation services should be provided by a multidisciplinary team (Level III)
  • 52. Primary Prevention
    • Conditions and lifestyle factors identified as a risk for stroke:
      • arterial hypertension
      • myocardial infarction
      • atrial fibrillation
      • diabetes mellitus
      • elevated cholesterol levels
      • carotid artery disease
      • smoking
      • alcohol use
      • physical activity
  • 53. Primary Prevention
    • Hypertension
      • Facts
        • most prevalent and modifiable risk factor for stroke
        • significant reduction of stroke incidence with a decrease of 5 mmHg in diastolic BP or teatment of isolated systolic BP elevation
  • 54. Primary Prevention
    • Diabetes mellitus
      • Facts
        • independent risk factor for ischemic stroke
        • strict control of blood glucose not established for stroke prevention
        • elevated blood glucose at stroke onset worsens mortality and functional outcome
  • 55. Primary Prevention
    • Hypercholesterolemia
      • Facts
        • no strong association between serum cholesterol levels and stroke
        • reduction in the relative risk of stroke with pravastatin therapy
        • reduction of stroke mortality by statin therapy: controversial
  • 56. Primary Prevention
    • Cigarette smoking
      • Facts (Cohort studies)
        • independent risk factor for ischemic stroke in men and women
        • 6-fold risk compared to non-smokers
        • 50% risk reduction by stop of smoking
  • 57. Primary Prevention
    • Alcohol consumption
      • decreased risk by moderate consumption (men: 20-30 mg/die)
      • increased risk for both ischemic and hemorrhagic stroke by heavy alcohol consumption
  • 58. Primary Prevention
    • Physical activity
      • Facts
        • vigorous exercise is associated with a decreased risk of stroke
      • this effect may be mediated by reduction in body weight, BP, cholesterol and increased glucose tolerance
  • 59. Primary Prevention
    • Antithrombotic drugs
      • Facts
        • trend to higher incidence of disabling strokes (hemorrhagic) by aspirin ingestion (325-500 mg/die) in males
        • no risk alteration in women
        • risk reduction in MI for both men and women
  • 60. Primary Prevention
    • EUSI-recommendations
      • 1. BP measurement should be an essential component of regular health care visits; BP should be lowered to normal (140/85 mmHg) values by means of life-style and/or pharmacological treatment (Level I)
      • 2. Although strict control of glucose or high cholesterol levels has not been proven to be associated with a decreased risk of stroke, it should be encouraged because of benefits in terms of other diseases (Level III)
  • 61. Primary Prevention
    • EUSI-recommendations
      • 3. In coronary patients, treatment with simvastatin or pravastatin clearly reduces the risk of stroke (Level II). Statins should be prescribed in patients with CHD and high or moderate cholesterol levels; the benefits of statins probably extend to patients with stroke and high cholesterol levels.
      • 4. Cigarette smoking should be discouraged (Level II)
  • 62. Primary Prevention
    • EUSI-recommendations
    • 5. Heavy use of alcohol should be avoided, while moderate consumption may be permitted (Level II)
      • 6. Regular physical activity is recommended (Level II)
      • 7. There is no scientific support for prescribing aspirin to reduce the risk of stroke in asymptomatic patients (Level I); however, aspirin may reduce the risk of MI (Level I)
  • 63. Primary Prevention
    • Atrial fibrillation (AF)
      • Facts
        • average stroke rate of 5% per year
        • warfarin reduces the rate of ischemic strokes by 25 %
        • anticoagulation with an INR of 2.0 to 3.0 reduces the rate of ischemic and hemorrhagic events by 80% when compared to below 2.0, where non-significant reduction in thromboembolic events is seen
        • unacceptable risk for bleeding complications with an INR > 5.0
  • 64. Primary Prevention
    • Atrial fibrillation
      • Facts
        • aspirin (300 mg) achieves a pooled risk reduction of 21 %
        • aspirin is less efficacious than warfarin
        • patients less than 65 years of age with “lone AF” are at low risk, whereas patients older than 65 years are at moderate risk for embolic stroke
  • 65. Primary Prevention
    • Atrial fibrillation: EUSI-recommendations
      • 1. Long-term oral anticoagulation therapy (target INR 2.5; range 2.0 - 3.0) should be considered for all AF patients who are at high risk for stroke (Level I)
      • 2. Patients aged less than 65 years with no cardiovascular disease or patients who are unable to receive anticoagulants should be offered 300 mg aspirin per day (Level I)
  • 66. Primary Prevention
    • Atrial fibrillation: EUSI-recommendations
      • 3. Although not yet established by randomised studies, patients over 65 years of age without risk factors could be offered both AC and aspirin 300 mg/ day (Level III)
      • 4. Although not yet established by randomised studies, patients over 75 years of age, warfarin may be used with a lower INR (target INR of 2.0; range 1.6. - 2.5) to decrease the risk of hemorrhage (Level III)
  • 67. Primary Prevention
    • Asymptomatic carotid artery stenosis
      • CEA is still a matter of controversy
      • 5-year relative risk reduction by CEA for carotid artery stenosis >65% of 50% (absolute reduction about 6%)
      • absolute risk reduction by medical treatment of 11%/ 5 years
  • 68. Secondary Prevention
    • Antithrombotic drugs
      • Aspirin: Facts
        • 25% risk reduction
        • optimal dose still matter of debate
        • no proven advantage by low (< 160 mg) versus medium (160 - 325) or high (500 - 1500 mg) doses
  • 69. Secondary Prevention
    • Antithrombotic drugs
      • Dipyridamole + aspirin:
        • ESPS II: risk reduction of stroke with a combination is significantly higher (37%) than with aspirin alone
  • 70. Secondary Prevention
    • Antithrombotic drugs
      • Clopidogrel
        • CAPRIE: Clopidogrel is slightly but significantly more effective than medium-dose aspirin
  • 71. Secondary Prevention
    • EUSI-recommendations
      • 1. Low- or medium-dose ASA (50-325 mg) should be given as first-choice agent to reduce stroke recurrence (Level I) .
      • 2. Alternatively, where available, the combination of ASA (25 mg) and dipyridamole (200 mg) twice daily may be given as first choice (Level I)
  • 72. Secondary Prevention
    • EUSI-recommendations
      • 3. Clopidogrel is slightly more effective than aspirin (Level I) . It may be prescribed as first-choice or when aspirin is not tolerated or efficacious, and in special indications, such as in high-risk patients (Level III)
  • 73. Secondary Prevention
    • EUSI-recommendations
      • 4. Patients starting treatment with thienopyridine derivatives should receive clopidogrel instead of ticlopidine since it has fewer side-effects (Level I);
      • patients who have already been treated with ticlopidine for a long time should be maintained on this regimen because the most severe side-effects (neutropenia and rash) appear at the beginning of treatment
  • 74. Secondary Prevention
    • EUSI-recommendations
      • 5. Patients who do not tolerate both ASA or clopidogrel may be treated with dipyridamol ret 2x200 mg daily (Level I)
  • 75. Secondary Prevention
    • Anticoagulation after thromboembolic stroke
      • Facts (EAFT)
        • oral anticoagulation with an INR of 2 - 3 reduces the risk of recurrent stroke in patients with AF
      • Oral anticoagulation is well established for other causes of embolism such as mechanical prosthetic valve replacement, rheumatic valvular heart disease, ventricular aneurysm, cardiomyopathy, or PFO
  • 76. Secondary Prevention
    • EUSI-recommendation
    • 1. Oral anticoagulation (INR 2.0 - 3.0) is indicated after stroke associated with AF (Level I)
      • 2. Patients with mechanical prosthetic valves should receive long-term anticoagulation therapy with a target INR between 3.0 and 4.0 (Level III)
  • 77. Secondary Prevention
    • EUSI-recommendation
      • 3. Patients with proven cardioembolic stroke should be anticoagulated if the risk of recurrence is high, with a target INR between 2.0 and 3.0 (Level III)
  • 78. Secondary Prevention
    • Carotid Endarterectomy (CEA)
      • Facts (NASCET, ECST)
        • surgery is efficacious for symptomatic patients with ipsilateral carotid stenosis > 70%
        • if perioperative complications exceed 2.5 %, the benefit of CEA will diminish; if it approaches 10%, the benefit will vanish entirely
        • there is also some risk reduction in male patients with 50 - 69% stenosis of the ipsilateral carotid artery
  • 79. Secondary Prevention
    • Percutaneous Transluminal Angioplasty (PTA)
      • Advantages
        • short hospital stay
        • avoidance of general anesthesia and surgical incision
        • ability to treat surgically inaccessible sites
      • PTA and stenting as most effective means of treating restenosis after CEA
      • preliminary results of controlled trials:comparable procedural risks compared to CEA
  • 80. Secondary Prevention
    • EUSI-recommendations
      • 1. CEA is indicated in symptomatic patients with stenosis of 70 - 90%. This is valid only for centres with a perioperative complication rate (all strokes and death) < 6% (Level I)
  • 81. Secondary Prevention
    • EUSI-recommendations
      • 2. CEA may be indicated in some patients with stenosis of 50 - 59% without a severe neurologic deficit. This is valid only for centres with a perioperative complication rate of < 6%. Males with recent hemispheric symptoms are the subgroup of patients most likely to benefit from surgery (Level I)
  • 82. Secondary Prevention
    • EUSI-recommendations
      • 3. CEA is not recommended for symptomatic patients with stenosis < 50% (Level I)
      • 4. CEA should not be performed in centres not exhibiting equally low complication rates like NASCET or ECST.
  • 83. Secondary Prevention
    • EUSI-recommendations
      • 5. CEA may be indicated for some patients with stenosis between 60 and 99%. Only patients with a low surgical risk (<3%) and a life expectancy of at least 5 years are likely to benefit from surgery (Level II)
  • 84. Primary Prevention
    • EUSI-recommendations
    • 6. Surgery for asymptomatic carotid stenosis is not generally recommended (Level II).
    • 7. It may be recommended in individual patients if the surgical risk is low
  • 85. Secondary Prevention
    • EUSI-recommendations
    • 8. Carotid PTA with or without stenting may be performed in patients with contra-indications to CEA (Level IV)
      • 9. Carotid PTA with or without stenting may be indicated in patients with stenosis at surgically inaccessible sites (Level IV)
      • 10. Carotid PTA and stenting may be indicated in patients with re-stenosis after initial CEA (Level IV)

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