Carotid Endarterectomy in Stroke Prevention Update
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This document discusses carotid endarterectomy for stroke prevention. It provides background on strokes, defines different types of strokes, and outlines diagnostic techniques. The bulk of the document focuses on carotid endarterectomy, describing what it is, the history of the procedure, how it is performed, and results from major clinical trials demonstrating its effectiveness in reducing stroke risk compared to medical management alone for patients with significant carotid artery stenosis. The document emphasizes awareness of new techniques and treatments to prevent strokes.
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Carotid Endarterectomy in Stroke Prevention Update
- 1. Carotid Endarterectomy in Stroke Prevention Denise Crute, MD, FACS Mount Sinai School of Medicine © Dr. Denise Crute 2013
- 2. Stroke Prevention Recognition and diagnosis Awareness of new techniques Familiarity with appropriate treatments © Dr. Denise Crute 2013 Paralysis – Manrov Vornam
- 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. Stroke Diagnosis: Ischemic Infarction 70% to 80% of all strokes Delayed appearance on CT Emergency care Critical care © Dr. Denise Crute 2013
- 5. Stroke Diagnosis: Ischemia TIA (Transient Ischemic Attack) Stroke-inevolution © Dr. Denise Crute 2013
- 6. Stroke Diagnosis: Hemorrhage Subdural Hematoma (SDH) Epidural Hematoma (EDH) Intraventricular Hemorrhage (IVH) © Dr. Denise Crute 2013
- 7. Stroke Diagnosis: Hemorrhage Subarachnoid Hemorrhage Intracerebral Hemorrhage © Dr. Denise Crute 2013
- 8. Stroke Treatment and Prevention Carotid Endarterectomy Stenting TPA Craniotomy Craniectomy © Dr. Denise Crute 2013 Operating Hands, Bipolar, Denise Crute , MD
- 9. Carotid Stenosis Common carotid artery Anterior circulation Internal Carotid Artery External Carotid Artery Plaque formation © Dr. Denise Crute 2013
- 10. Carotid Stenosis Extra cranial carotid occlusive disease Flow reduction through reduced lumen Embolic source © Dr. Denise Crute 2013
- 11. Carotid Endarterectomy Surgical correction of extra-cranial internal carotid occlusive disease Operative approach for CEA Denise Crute , MD © Dr. Denise Crute 2013
- 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. Carotid Endarterectomy Intraoperative monitoring EEG Local anesthesia Cerebral oximetry © Dr. Denise Crute 2013 Operative technique for CEA, Denise Crute , MD
- 14. Carotid Endarterectomy ACAS Trial NASCET Study ECST Collaborative Group CREST results © Dr. Denise Crute 2013 Operative closure for CEA, Denise Crute , MD
- 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. 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. 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. 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. 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. 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. Carotid Endarterectomy 70% stenosis 70 years Time is brain Prevention Treatment © Dr. Denise Crute 2013
- 22. Stroke Prevention Patient lifestyle Recognize ischemia Awareness of new techniques Familiarity with appropriate treatments © Dr. Denise Crute 2013 Paralysis – Manrov Vornam