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Carotid Endarterectomy in Stroke Prevention Update

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Neurocritical Care lecture on the role of carotid artery surgery in stroke prevention, reviewing the latest studies and evidence-based updates, along with neurosurgical techniques.

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Carotid Endarterectomy in Stroke Prevention Update

  1. 1. Carotid Endarterectomy in Stroke Prevention Denise Crute, MD, FACS Mount Sinai School of Medicine © Dr. Denise Crute 2013
  2. 2. Stroke Prevention Recognition and diagnosis  Awareness of new techniques  Familiarity with appropriate treatments  © Dr. Denise Crute 2013 Paralysis – Manrov Vornam
  3. 3. 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 © Dr. Denise Crute 2013
  4. 4. Stroke Diagnosis: Ischemic Infarction 70% to 80% of all strokes  Delayed appearance on CT  Emergency care  Critical care  © Dr. Denise Crute 2013
  5. 5. Stroke Diagnosis: Ischemia TIA (Transient Ischemic Attack)  Stroke-inevolution  © Dr. Denise Crute 2013
  6. 6. Stroke Diagnosis: Hemorrhage Subdural Hematoma (SDH)  Epidural Hematoma (EDH)  Intraventricular Hemorrhage (IVH)  © Dr. Denise Crute 2013
  7. 7. Stroke Diagnosis: Hemorrhage Subarachnoid Hemorrhage  Intracerebral Hemorrhage  © Dr. Denise Crute 2013
  8. 8. Stroke Treatment and Prevention Carotid Endarterectomy  Stenting  TPA  Craniotomy  Craniectomy  © Dr. Denise Crute 2013 Operating Hands, Bipolar, Denise Crute , MD
  9. 9. Carotid Stenosis Common carotid artery  Anterior circulation  Internal Carotid Artery  External Carotid Artery  Plaque formation  © Dr. Denise Crute 2013
  10. 10. Carotid Stenosis Extra cranial carotid occlusive disease  Flow reduction through reduced lumen  Embolic source  © Dr. Denise Crute 2013
  11. 11. Carotid Endarterectomy  Surgical correction of extra-cranial internal carotid occlusive disease Operative approach for CEA Denise Crute , MD © Dr. Denise Crute 2013
  12. 12. 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
  13. 13. Carotid Endarterectomy Intraoperative monitoring  EEG  Local anesthesia  Cerebral oximetry  © Dr. Denise Crute 2013 Operative technique for CEA, Denise Crute , MD
  14. 14. Carotid Endarterectomy ACAS Trial  NASCET Study  ECST Collaborative Group  CREST results  © Dr. Denise Crute 2013 Operative closure for CEA, Denise Crute , MD
  15. 15. 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  © Dr. Denise Crute 2013
  16. 16. Carotid Endarterectomy: ACAS Surgery beneficial  Clear benefit when:     >60% asymptomatic stenosis Surgical risk <3% Life expectancy at least 5 years © Dr. Denise Crute 2013
  17. 17. 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  © Dr. Denise Crute 2013
  18. 18. 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  © Dr. Denise Crute 2013
  19. 19. 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  © Dr. Denise Crute 2013
  20. 20. 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 packyears tobacco  © Dr. Denise Crute 2013
  21. 21. Carotid Endarterectomy 70% stenosis  70 years  Time is brain  Prevention  Treatment  © Dr. Denise Crute 2013
  22. 22. Stroke Prevention Patient lifestyle  Recognize ischemia  Awareness of new techniques  Familiarity with appropriate treatments  © Dr. Denise Crute 2013 Paralysis – Manrov Vornam

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