Opinion statement
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Proper therapy for patients with internal carotid artery stenosis requires a precise pathophysiologic diagnosis that includes characterization and localization of ischemic disease of the brain and knowledge of the arterial disease and the collat-eral cerebral circulation. Noninvasive techniques such as duplex ultrasound and transcranial Doppler, magnetic resonance angiography, and CT angiography allow precise determination of the stroke subtype and parent arterial pathology.
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Antiplatelet agents prevent the formation of thrombus on carotid artery athero-sclerotic plaque. 3-Hydroxy-3-methyglutaryl coenzyme A reductase inhibitors may help stabilize carotid plaques by altering the plaque morphology and reducing inflammation. Carotid endarterectomy, which is the only procedure proven to be beneficial for patients with asymptomatic disease, should be considered primary intervention. Until ongoing trials for interventional procedures are completed, carotid artery angioplasty and stenting should be considered only in patients with contraindications to carotid endarterectomy.
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It can be argued that an ideal clinical trial in a high-risk population has not yet been completed. This factor has become even more important with the develop-ment of stenting procedures. We have long advocated a trial of only treating patients with hemodynamically significant stenotic lesions (70% to 99%).
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References and Recommended Reading
Fisher CM: Occlusion of the internal carotid artery. Arch Neurol Psychiatry 1951, 65:346–377.
Fisher CM: Concerning recurrent transient cerebral ischemic attacks. Can Med Assoc J 1962, 86:1091–1099.
Morre SA, Stooker W, Lagrand WK, et al.: Microorganisms in the etiology of atherosclerosis. J Clin Pathol 2000, 53:647–654.
Kistler JP, Ropper AH, Heros RC: Therapy of ischemic cerebral vascular disease due to atherothrombosis. N Engl J Med 1984, 311:27–34; 100–105.
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995, 273:1421–1428. This is the clinical trial that most affected practice in the United States, dramatically increasing the rates of surgery for patients with asymptomatic disease. Reviewing the details of the clinical trial provides insight into the limited generalizability of the results and the modest benefit relative to surgery for symptomatic carotid disease.
Suwanwela N, Can U, Furie KL, et al.: Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Stroke 1996, 27:1965–1969.
Can U, Furie KL, Suwanwela N, et al.: Transcranial Doppler ultrasound criteria for hemodynamically significant internal carotid artery stenosis based on residual lumen diameter calculated from en bloc endarterectomy specimens. Stroke 1997, 28:1966–1971.
Molloy J, Markus HS: Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis. Stroke 1999, 30:1440–1443.
Markus H, Cullinane H: Severely impaired cerebrovascular reactivity predicts stroke and TIA risk in patients with carotid artery stenosis and occlusion. Brain 2001, 124:457–467.
Silvestrini M, Vernieri F, Pasqualetti P, et al.: Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA 2000, 283:2122–2127.
Kistler JP, Furie KL: Carotid endarterectomy revisited [editorial]. N Engl J Med 2000, 342:1743–1745. A review of the issues surrounding surgery for asymptomatic stenosis related to data from the NASCET investigators..
Kistler JP, Lees RS, Miller A, et al.: Correlation of spectral phonoangiography and carotid angiography with gross pathology in carotid stenosis. N Engl J Med 1981, 305:417–419.
Pessin MS, Hinton RC, Davis KR, et al.: Mechanisms of acute carotid stroke. Ann Neurol 1979, 6:245–252.
Houser OW, Sundt TM Jr, Holman CB, et al.: Atheromatous disease of the carotid artery: correlation of angiographic, clinical and surgical findings. J Neurosurg 1974, 41:321–331.
Roederer GO, Langlois YE, Jager KA, et al.: The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke 1984, 15:605–613.
Chambers BR, Norris JW: Outcome in patients with symptomatic neck bruits. N Engl J Med 1986, 315:860–865.
Meissner I, Wiebers DO, Whisnant JP, O’Fallon WM: The natural history of asymptomatic carotid artery occlusive lesions. JAMA 1987, 258:2704–2707.
Kistler JP, Buonanno FS, Gress DR: Carotid endarterectomy —specific therapy based on pathophysiology. N Engl J Med 1991, 325:505–507.
Bogousslavasky J, Regli F, Van Melle G: Risk factors and concomitants of internal carotid artery occlusions or stenosis. A controlled study of 159 cases. Arch Neurol 1985, 42:864–867.
Heyman A, Wilkinson WE, Heyden S, et al.: Risk of stroke in asymptomatic persons with cervical arterial bruits: a population study in Evans County, Georgia. N Engl J Med 1980, 302:838–841.
Wolf PA, Kannel WB, Sorlie P, McNamara P: Asymptomatic carotid bruit and risk of stroke: the Framingham study. JAMA 1981, 245:1442–1445.
Ropper AH, Wechsler LR, Wilson LS: Carotid bruit and the risk of stroke in elective surgery. N Engl J Med 1982, 307:1388–1390.
Barnett HJM: Carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med 1993, 328:276–279.
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991, 325:445–453.
Barnett HJM, Taylor DW, Eliasziw M, et al.: Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998, 339:1415–1425.
Barnett HJM, Eliasziw M, Meldrum HE, Taylor DW: Do the facts and figures warrant a 10-fold increase in the performance of carotid endarterectomy on asymptomatic patients? Neurology 1996, 48:603–608. important critical review of surgery for asymptomatic carotid stenosis, reviewing the assumptions and limitations of the ACAS trial. This helps put the clinical trial results into perspective and emphasizes the need to be selective in choosing patients for surgery..
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Furie, K.L., Topcuoglu, M.A., Kelly, P.J. et al. Asymptomatic internal carotid artery origin stenosis. Curr Treat Options Cardio Med 3, 441–447 (2001). https://doi.org/10.1007/s11936-001-0033-6
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DOI: https://doi.org/10.1007/s11936-001-0033-6