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3 Asymptomatic Embolisation For Prediction Of Stroke In The


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3 Asymptomatic Embolisation For Prediction Of Stroke In The

  1. 1. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study<br />The Lancet Neurology, Early Online Publication, 28 May 2010<br />
  2. 2. Background<br />Whether surgery is beneficial for patients with asymptomatic carotid stenosisis controversial<br />Better methods of identifying patients who are likely to develop stroke would improve the risk—benefit ratio for carotid endarterectomy<br />Aimed to investigate whether detection of asymptomatic embolic signals by use of TCD could predict stroke risk in patients with asymptomatic carotid stenosis<br />
  3. 3. Methods<br />The ACES was a prospective observational study in patients with asymptomatic carotid stenosis of at least 70% from 26 centresworldwide<br />To detect the presence of embolic signals, patients had two1 h TCD recordings from the ipsilateral middle cerebral artery at baseline and one 1 h recording at 6, 12, and 18 mo<br />Patients were followed up for 2 yrs<br />The 1ryendpoint was ipsilateral stroke and TIA<br />All recordings were analysed centrally by investigators masked to patient identity<br />
  4. 4. Time Line<br />1 h TCD<br />1 h TCD<br />1 h TCD<br />1 h TCD<br />1 h TCD<br />(1wk)<br /> 0 6 12 18 24 mo<br />Primary End Point = Ipsilateral Stroke or TIA<br />Secondary End Point = Ipsilateral Stroke, <br /> Any Stroke, CV Death<br />
  5. 5. ACES = multicenter, international, prospective observation study (July 99 – August 07 )<br />Inclusion Criteria<br />At least 70 % asymptomatic carotid stenosis ( > 2 yr ), assessed by USG<br />Previous symptoms (> 2 yr) in the contralateral carotid artery territory or VB <br />(> 1 yr) After carotid endarterectomy<br />Exclusion Criteria<br />Other disease likely to limit life expectancy (< 3 yr)<br />Patient, physician, or surgeon unwilling to manage asymptomatic carotid stenosis medically<br />Absence of an acoustic window<br />Presence of non-biological prosthetic heart valves<br />
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  7. 7. Procedures<br />1 h TCD recording – Ipsilateral MCA<br />A standard TCD recording protocol – based on the recommendations of the International Consensus Group on Microembolus Detection<br />A 2 MHz transducer, at a depth 45 – 55 mm.<br />Axial sample volume of 5 mm<br />All embolic signal data were recorded onto digital audiotape and analysed centrally by Investigators who were masked to clinical information<br />Brain imaging (CT or MRI) was done<br />
  8. 8. Findings<br />482 pts were recruited, of whom 467 had evaluable recordings<br />Embolic signals were present in 77 of 467 pts at baseline<br />The hazard ratio(HR) for the risk of ipsilateral stroke and TIA from baseline to 2 yrs in pts with embolic signals compared with those without was 2·54 (95% CI 1·20—5·36; p=0·015)<br />For ipsilateral stroke alone, the HR was 5·57 (1·61—19·32; p=0·007)<br />
  9. 9. The absolute annual risk(ARR) of ipsilateral stroke or TIA between baseline and 2 yrs was 7·13% in pts with embolic signals and 3·04% in those without, and for ipsilateral stroke was 3·62% in pts with embolic signals and 0·70% in those without.<br />The HRfor the risk of ipsilateral stroke and TIA for pts who had embolic signals on the recording preceding the next 6-mo f/ucompared with those who did not was2·63(95% CI 1·01—6·88; p=0·049), and for ipsilateral stroke alone the HR was 6·37 (1·59—25·57; p=0·009)<br />Controlling for antiplatelet therapy, degree of stenosis, and other risk factors did not alter the results<br />
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  18. 18. Interpretation<br />Detection of asymptomatic embolisation on TCD can be used to identify pts with asymptomatic carotid stenosis who are at a higher risk of stroke and TIA, and also those with a low absolute stroke risk<br />Assessment of the presence of embolic signals on TCD might be usefulin the selection of pts with asymptomatic carotid stenosis who are likely to benefit from endarterectomy<br />
  19. 19. Funding<br />British Heart Foundation<br />