XVII. European Stroke Conference
Nice, France

Oral Session:

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 8:00 - 8:10 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

01
UK CAROTID ENDARTERECTOMY AUDIT
A.W.Halliday    A.G.Rudd    P.M.Rothwell    T. Lees    J.F.Potter    A. Hoffman    R. Grant    D. Lowe    D. Kamugasha       
 

Royal College of Physicians/Clinical Effectiveness and Evaluation Unit

UNITED KINGDOM

Introduction We report an audit, by the Royal Colleges of Surgeons and Physicians, London targeting all hospitals (160) offering Carotid Endarterectomy (CEA), documenting all CEA cases performed between 1st Dec 2005 and 31st Dec 2007. Objectives 1.To determine variation between hospitals in the delivery of CEA (including delays and detailed process of care) 2.To assess 30-day mortality and morbidity Background There is strong evidence for CEA in the secondary prevention of stroke. In the UK 110,000 patients per annum suffer first stroke and 30,000 suffer transient ischaemic attacks. Between 10%-15% of these might benefit from CEA. Previously there has been little information on the quality of CEA services in the UK. Methods All consultants (396) undertaking CEA were eligible to participate in an audit of Organisation and Process. The data describes pre-operative investigations, surgical techniques, case selection criteria and post-operative assessment. Patient level data were collected at the time of surgery and at follow-up with all patients being included. The national target was to collect 4,000 cases by 31st Dec 2007. Current project status Two rounds of the Organisational Audit have been successfully completed. At 10th January 2008, 240 surgeons from 130 hospitals had submitted a total of 4367cases. Data are presented here from the Interim Report (August 2007) and was based on 2811 cases. Main reporting is scheduled for summer 2008. Results 83% of cases were for symptomatic carotid disease (42% TIA, 36% stroke, 19% amaurosis fugax, 3% other).The median number of CEAs performed annually is 15 with a rate of 6 procedures per 100 000 population, 25% of surgeons perform less than 10 CEAs per year. The median delay from referral to surgery is 45 days (IQR 20-89) Less than 25% of patients had surgery in less than 3 weeks Conclusion These results demonstrate unacceptable delays in the delivery of CEA in the UK. Work is underway to improve the efficiency of services and progress will be monitored by continuing data collection.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 8:10 - 8:20 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

02
Delay from symptoms to carotid endarterectomy
E.P.Johansson    P. Wester                                                        
 

Public Health and Clinical Medicine

SWEDEN

Objectives To investigate the time between cerebrovascular symptom and Carotid Endarterectomy (CEA), what prolongs this time and if and when the patients suffer additional cerebrovascular events. Materials and metods An obeservational single center study at Umeå Stroke Center which has northern Sweden (880.000 inhabitants) as catchment area. 275 patients with a ≥50% symptomatic carotid stenosis (NASCET-criteria) between January 1 2004 and March 31 2006; time between cerebrovascular symptom and CEA, time between different parts of the investigation chain, additional cerebrovascular symptoms before CEA and as perioperative complication were registered. Results. 128 patients underwent CEA. The median time between symptom and CEA decreased from 11.7 weeks in the beginning to 6.9 weeks at the end of the study. 7% were operated within 2 weeks and 11% between 2-4 weeks after their cerebrovascular symptom. The time delays were most pronounced between symptom onset and arrival at the Umeå Stroke Center from the secondary hospitals and between the decision to recommend CEA and the CEA. 28% of the patients who were intended for surgery suffered additional cerebrovascular events, 1.4% suffered a major stroke which excluded the indication of CEA. 3.0% of the CEA patients suffered a stroke with functional dependence within 30 days of the operation. Conclusions. The delay between symptom and CEA was substantially longer than the desired 2 weeks. Many patients suffered additional cerebrovascular events before CEA. The risk of a severe additional stroke before CEA was about the same as the risk of a severe complication from the CEA. Keywords Carotid Stenosis, Cartotid Endarterectomy, Stroke

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 8:20 - 8:30 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

03
Carotid Endarterectomy in Scotland ; 5 year trends in activity and outcomes
J.L.Bishop    A.R.Finlayson                                                        
 

Information Services, National Health Service Scotland

UNITED KINGDOM

Objectives : Carotid endarterectomy is an effective method of preventing major strokes in patients who have had a transient ischaemic attack. The numbers of operations performed in Scotland have been increasing over the last 5 years and this study presents an analysis of activity and subsequent outcomes. Methods : Routinely collected hospital discharge data relating to all carotid endarterectomy procedures carried out in Scotland between 2001 and 2005 were extracted. Patient characteristics (age, sex, length of stay, hospital) and 30 and 365-day post operative outcomes (death, subsequent stroke, readmission) were analysed. Follow up outcome analyses were made possible by the record linkage between hospital records and to death registration records, which is carried out routinely in Scotland. Statistical Process Control techniques were used to identify any unusual variation in hospital outcome rates. Results : Just under 2000 carotid endarterectomy procedures were carried out in Scotland between 2001 and 2005. The mean length of stay was 7 days (sd 20.3 days) with variation between hospitals. Mean age was 68 (sd 8.9) and 60% of patients were male. 1.8% of patients suffered a stroke or died within 30 days and 7.7% suffered a stroke or died with a year. Hospital outcomes plotted on control charts showed only a few outlying cases. Conclusions : Hospital outcomes rarely (if ever) provide a direct measure of quality. Instead, indicators serve as flags or pointers, and can identify potential opportunities for improvement by allowing comparisons to be made e.g. between different service providers, across a period of time. As the numbers of carotid endarterectomies in Scotland increases it will become more important to monitor patient outcomes at both hospital and clinician level. There is currently work underway to take this project forward and to include further patient characteristics such as co-morbidities and histories.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 8:30 - 8:40 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

04
Restenosis after carotid angioplasty and stenting, or endarterectomy in the EVA 3S randomised clinical trial
C. Arquizan    L. Trinquart    P.J.Touboul    A. Long    S. Feasson    B. Terriat    M.P.Gobin Metheil    B.      S. Cohen    J.-L.Mas
 

Centre Hospitalier Gui de Chauliac

FRANCE

Background. Few data exists on the rates of restenosis after carotid angioplasty and stenting (CAS). We assessed restenosis rates in the stenting and surgical arms of EVA-3S, a randomised trial comparing CAS to carotid endarterectomy (CEA) in patients with severe symptomatic carotid stenosis. Methods. 520 patients were randomized in the CEA (n=259) or the CAS (n=261) arms of the trial. Carotid ultrasound follow-up was performed at 1, 6, 12, 18, and 24 months, and every year thereafter, according to a predefined protocol. Carotid restenosis was defined as stenosis >= 50% (NASCET method) or occlusion, and severe restenosis as stenosis >=70% or occlusion. Cumulative restenosis rates were estimated at 1, 6, 12 and 24 months with associated 95%CI using Kaplan-Meier method. Treatment groups were compared using Wilcoxon non parametric test. Results: More patients had carotid restenosis after CAS than after CEA (Table) (p<0.01). At 6 months, 20 patients in the CAS group had a restenosis >=50% compared to 9 in the CEA group; at 1 year, the corresponding figures were 32 and 11 and at 2 years, 38 and 17. The rate of severe restenosis >=70% or occlusion was low. At 6 months, 1 patient had restenosis after CAS compared to 4 after CEA. At 1 year, the corresponding figures were 3 and 4 and at 2 years, 4 and 4. Five patients with restenosis were treated by CAS. A meaningful analysis of the relation between restenosis and recurrent stroke was not possible, because only a few patients had recurrent ipsilateral ischemic stroke during follow-up (perioperative stroke excluded). Conclusions: More patients had carotid restenosis >=50% (NASCET) after CAS than after CEA, but the rate of severe restenosis (>=70%) was low in both groups.

 
http://www.eurostroke.org/ni_graphics/t_aid3051.htm

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 8:40 - 8:50 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

05
Predictors for Sustained Hypotension after Extracranial Carotid Stenting
G. Xu    X. Liu    X. Fan    Q. Yin    Z. Zhang                                   
 

Jinling Hospital, Nanjing University Schoole of Medicine

CHINA

Proposes: To analyze the risk factors for sustained homodynamic changes after carotid angioplasty and stenting (CAS). Methods: Patients who received CAS in a general hospital were enrolled as subjects. All patients were monitored with blood pressure and electrocardiography shortly before, during and after CAS. The data of blood pressure as well as other clinical parameters were retrieved and analyzed. Patients were grouped according to their post-procedure blood pressure levels: without hypotension, brief hypotension (systolic blood pressure <90 mm Hg or a mean arterial blood pressure <50 mm Hg, lasted less than 24 hours) and prolonged hypotension (lasted longer than 24 hours). Cox proportional hazard regression model was utilized to analyze the risk factors for sustained post-procedure hypotension. Results: There were 105 CAS patients enrolled in the study, among whom, 83（79.0%）were male and 22（21.0%）were female. Their ages ranged 48-79 (65.3±14.1). After CAS procedures, 29 patients（27.6%）had brief hypotension; 16（15.2%）patients had sustained hypotension which lasted longer than 24 hours. The mean durations of the prolonged hypotension were 3.8±3.2 days. Univariate analysis indicated that advanced age (>75 years), history of hypotension before procedure, stenosis>/=70%, pre-dilatation, implantation of laser-carving stent and procedure time lasting more than 1.5 hours were all related to post-procedure hypotension. By Cox proportional hazard regression analysis and adjusted with age and sex, history of hypotension before procedure (OR=4.53; 95% CI=1.39-9.72; P = 0.008), stenosis≥70% (OR=4.09; 95% CI=1.27-8.97; P = 0.014), post-dilatation(OR=3.57; 95% CI=1.13-7.25; P = 0.025) and procedure time lasting more than 1.5 hours (OR=4.87; 95% CI=1.81-9.55; P = 0.004) were independently associated with post-procedure hypotension. Conclusion: Prolonged hypotension may present as a major complication after CAS. It may be more frequent in patients with history of hypotension, severer stenosis, and in patients with post-dilatation and prolonged procedure duration.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 8:50 - 9:00 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

06
Emergency Clot Removal Therapy by Aspiration and Extraction for Probable Acute Embolic Carotid Occlusion
T. Mori    H. Tajiri    T. Iwata    M. Nakazaki                                          
 

Shonan Kamakura General Hospital

JAPAN

Introduction: It is difficult to achieve successful recanalization of embolic total occlusion of the carotid artery (CA), as large amount of clots is embedded in the CA. The purpose of our retrospective study was to investigate the feasibility, safety, and effectiveness of clot removal therapy (CRT) by aspiration and extraction (CRTAE) in patients with probable embolic total occlusion of the carotid artery (CA). Methods: Inclusion criteria for retrospective analysis were patients with (1) sudden onset of symptoms, (2) serious neurological symptoms of NIHSS score more than 5, (3) onset-to-CRT time shorter than 6 hours, (4) no cerebral hemorrhage on CT scans or extensive high signal-intensity on MR diffusion-weighted images, (5) no visualization of the carotid artery on MR angiograms, and (6) decrease of cerebral blood flow displayed by MR perfusion-weighted images (PWI). CRTAE was performed with inserting a 9Fr balloon-guide catheter to the affected CA for temporary occlusion during procedures. Clots were aspirated simply with a 10-ml syringe through a balloon-guide catheter under proximal flow control. Unless clots were aspirated, they were extracted with a microsnare or a filter-type catheter, sometime disrupted by a balloon catheter. When atheromatous occlusion was diagnosed during procedures, stenting was performed. Recanalization rate, complications and neurological status were evaluated. Neurological status was accessed by NIHSS on admission and on the 7th day after CRTAE. Results: Between 2004 and 2007, nineteen patients underwent CRTAE for probable embolic carotid occlusion. Their median onset-to-CRT time was 2.75 hours. Their median NIHSS score was changed form 17 on admission to 7 on the 7th day (p=0.15, Wilcoxon signed ranks test). Successful recanalization was achieved in 11 of 19 patients (57.8%), and their median NIHSS score was improved from 16 on admission to 4 on the 7th day (p<0.005, Wilcoxon signed ranks test). Particularly in 3 of the 11 patients, clots were removed by aspiration only and complete recanalization was achieved. In 2 of the 11 patients, stenting following CRTAE was performed. In eight patients without any recanalization, median NIHSS score was changed from 18.5 on admission to 26 on the 7th day (n.s., Wilcoxon signed ranks test), 2 of the 8 patients died within 7 days after stroke onset. Neither procedural complications nor hemorrhagic transformation following CRTAE occurred. Conclusion: Emergency CRT by aspiration and extraction may be feasible, safe and effective to recanalize probable embolic carotid occlusion, to improve neurological status soon in acute ischemic stroke patients.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 9:00 - 9:10 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

07
High prevalence of significant symptomatic vertebral or basilar stenosis in posterior circulation TIA or minor stroke: population-based study
L. Marquardt    A. Chandratheva    O.C.Geraghty    W. Kuker    P.M.Rothwell                                   
 

University of Oxford

UNITED KINGDOM

BACKGROUND: Recent work has shown that the risk of recurrent stroke in patients with posterior circulation TIA or minor stroke is higher than that in patients with carotid territory events. This high risk could be due to a greater prevalence of significant large artery stenosis in patients with posterior circulation events. METHODS: In the first-ever population-based study, we imaged the vertebral and basilar (VB) arteries using contrast-enhanced MRA in all patients presenting with posterior circulation TIA or minor ischaemic stroke in the Oxford Vascular Study. We compared the prevalence of =/>50% apparently symptomatic VB stenosis in patients with posterior circulation events with the prevalence of =/>50% apparently symptomatic carotid stenosis on ultrasound imaging in patients with carotid territory events. RESULTS: Of 387 consecutive patients with carotid events, 357 (92.2%) had carotid imaging, of whom 41 (11.5%) had =/>50% apparently symptomatic carotid stenosis. Of 101 consecutive patients with posterior circulation events, 93 (92%) had VB imaging, of whom 24 (25.8%) had =/>50% apparently symptomatic VB stenosis. Most non-imaged patients were too elderly or frail to attend hospital. Symptomatic VB stenosis was proportionately more common than symptomatic carotid stenosis (OR=2.68, 95%CI 1.46-4.90, p=0.0005). There were no significant differences in age, sex and vascular risk factors of patients with versus without VB stenosis. CONCLUSIONS: The prevalence of =/>50% VB stenosis in posterior circulation TIA or minor stroke is substantially greater than the prevalence of =/>50% carotid stenosis in carotid territory events, suggesting that randomised trials of interventional treatment would be feasible.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 9:10 - 9:20 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

08
Cerebral microbleeds after carotid revascularisation – a prospective MRI study
L.H.Bonati    L. Jongen    F. Fluri    S. Haller    A. Waaijer    S. Wetzel    P. Lyrer    M.M.Brown    W. Mali    S. Engelter
 

Stroke Research Group Department of Brain Repair and Rehabilitation UCL Institute of Neurology

UNITED KINGDOM

Background: About one in ten strokes occurring within 30 days of treatment of carotid stenosis is caused by intracranial haemorrhage. However, the frequency of silent brain haemorrhage in carotid interventions is unclear. Silent haemorrhage may be an expression of subclinical reperfusion damage following carotid revascularisation. Methods: We performed T2*-weighted gradient echo MRI in 79 patients, 1-3 days before and 30 +/- 3 days after revascularisation of symptomatic carotid stenosis (endarterectomy or stenting), to detect brain haemorrhage before and after the intervention. White matter changes before treatment were semi-quantitatively assessed on fluid-attenuated inversion recovery imaging (FLAIR) using the age related white matter changes (ARWMC) score. Diffusion weighted imaging (DWI) was performed to detect ischaemic brain lesions 1-3 days before and 1-3 days after treatment in 72 of these patients (91%). Results: In 9 patients (11%) small haemorrhagic lesions consistent with microbleeds were present at baseline. After the intervention, five patients (6%) had a single new microbleed in the territory of the treated carotid artery (deep white matter [n=2], cortical-subcortical junction [n=1], basal ganglia [n=1] and internal capsule [n=1]). No new microbleeds occurred contralaterally (p=0.029). No microbleeds were located at the site of ischaemic brain lesions. Patients with pre-existing microbleeds had higher ARWMC scores (p=0.026). Post-procedural microbleeds were not associated with patient age, blood pressure, diabetes, degree of carotid stenosis, presence of pre-procedural microbleeds or degree of white matter changes. No patient with a post-procedural microbleed had a hyperperfusion syndrome or symptoms or signs attributable to the lesion. Discussion: Asymptomatic brain haemorrhage after carotid revascularisation may occur in the form of single microbleeds in the territory supplied by the treated carotid artery. Reperfusion damage may play a role in the pathogenesis of these microbleeds.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 9:20 - 9:30 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

09
BUrr holes in high Risk of Stroke Trial (BURST) - pilot study
E.J.van Dijk    A. van der Lugt    T. Soullie    H.J.Duckers    P.J.Koudstaal    A.J.Vincent                            
 

Erasmusm MC

THE NETHERLANDS

Background - No surgical therapy has been proven effective in patients with symptomatic carotid occlusion or intracranial carotid stenosis. Multiple burr hole operation is a relatively simple procedure, which is effective in patients with carotid stenosis caused by Moyamoya disease. The aim of our pilot study was to assess the safety and feasibility of this procedure in patients with symptomatic atherosclerotic carotid occlusion. Method - We recruited patients with proven carotid occlusion and persistent or paroxysmal ipsilateral symptoms. Five burr holes were made in the skull on the symptomatic side under local anesthesia and the dura mater was opened. Prior to surgery patients underwent digital subtraction angiography (DSA), magnetic resonance imaging and angiography (MRI/MRA) and perfusion weighted-MRI. All imaging was repeated after one year and MR images also after 6 months. Vascular growth factor (VEGF, FGF) levels and number of endothelial progenitor cells (EPC) were assessed at baseline. Results - Eight patients were included in the study. Patients had no operation related complains apart from mild headache. One patient suffered a cerebral infarct after follow-up DSA and one patient had transient cardiac arrhythmia during local anesthesia. One patient had no follow-up imaging because of cancer. Two patients had clear, three had any and two had no neovascularisation through the burr holes on DSA or MRA. A positive trend was observed between neovascularisation, vascular growth factors and EPCs. One patient with any and one without neovascularisation had progressive ischemia on MRI and functional decline. Discussion - Awake multiple burr hole procedure is safe in patients with symptomatic carotid occlusion. The majority of the patients had evidence of neovascularisation by DAS /MRA at 1-year follow-up. Further studies are needed to evaluate whether the rate and amount of neovascularisation is clinically relevant.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 9:30 - 9:40 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

10
Outcome following interventional or conservative management of unruptured brain arteriovenous malformations: prospective, population-based cohort study
C.J.Wedderburn    J. van Beijnum    J.J.Bhattacharya    C.E.Counsell    V. Papanastassiou    V. Ritchie    R.C.Roberts    R.J.Sellar    C.P.Warlow    R. Al-Shahi Salman
 

Division of Clinical Neurosciences, University of Edinburgh

UNITED KINGDOM

Background: Deciding whether to treat an unruptured brain arteriovenous malformation (AVM) depends on a comparison of the estimated lifetime risk of intracranial haemorrhage and the risks of interventional AVM treatment. Methods: We identified every adult presenting with an unruptured AVM in a prospective, population-based study, and compared the baseline characteristics and 3-year outcome of those who did and did not receive interventional treatment for their AVM. Results: At presentation, adults who were treated (n=63) were younger (mean 40 versus 55 years, p=0.000001), more likely to present with seizure(s) (odds ratio 2.4; 95% CI 1.1 to 5.0), and possessed fewer co-morbidities (median 3 versus 4, p=0.03) than those who were not treated (n=51). Despite these baseline imbalances, there was no difference between treated and untreated groups in progression to Oxford Handicap Scale (OHS) 2-6 or 3-6 in survival analysis. In a multivariable Cox proportional hazards analysis, the risk of poor outcome (OHS 2-6) was raised by interventional treatment (hazard ratio [HR] = 2.5, 95% CI 1.1 to 6.0) and increasing AVM nidus size (HR=1.3, 95% CI: 1.1 to 1.7), but there was no difference between treated and untreated groups in time to progression to an OHS of >/=2 which was sustained until the end of the third year of follow-up, nor the spectrum of dependence on the OHS at 1, 2 and 3 years of follow-up. Discussion: Increasing AVM size and interventional treatment were associated with worse short-term functional outcome for unruptured AVMs, but the longer-term effects of intervention remain uncertain. These findings support the need for A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA).

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 9:40 - 9:50 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

11
The Effect Of Antiplatelets During Or After Endovascular Coiling For Aneurysmal Subarachnoid Haemorrhage
W.M.van den Bergh    R.S.Kerr    A. Algra    G.J.Rinkel    A.J.Molyneux                                   
International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group

University Medical Centre Utrecht

THE NETHERLANDS

Background Antiplatelets (APTs) are often used during or after endovascular coiling of aneurysms in patients with subarachnoid haemorrhage (SAH). There is, however, no evidence that APTs improve outcome in these patients. Methods All 43 centres in the International Subarachnoid Aneurysm Trial (ISAT), comparing endovascular coiling with neurosurgical clipping in patients with ruptured intracranial aneurysms, were sent a questionnaire whether they never, sometimes or always used APTs during or after coiling. Risk ratios (RR) for coiling compared with clipping for poor outcome after 2 months and 1 year were calculated. These RRs were calculated separately for patients treated in hospitals that always used APTs during or after coiling and in patients treated in hospitals that used APTs never or sometimes. Results Nineteen centres responded, representing 1422 (66%) of the 2143 patients randomised in ISAT. Standard prescription of APTs during coiling was done in two responding centres (8% of coiled patients), whereas it was done after coiling in 6 centres (24%). The overall RR for poor outcome of coiling versus clipping was 0.67 (95% CI 0.57-0.79) after two months and 0.74 (0.62-0.89) after one year. For two months’ outcome RR was 0.82 (0.45-1.49) in hospitals that always used APTs during coiling versus 0.66 (0.55-0.78) in those that never or sometimes used APTs (ratio of RR’s 1.24, p=0.56). Similar observations were made for APT use after coiling. The ratio of RRs for one-year outcome was 1.01 (p=0.89) for APT use during coiling and 1.00 (p=0.77) for use after coiling. Conclusion The results of this study do not support the assumption that APTs during or after endovascular coiling improve outcome in patients with aneurysmal SAH.

Vascular - and Neurosurgery/Interventinal Neuroradiology
Date: Friday 16 May 2008  
Time: 9:50 - 10:00 -  Room: Erato/Uranie
Chair: R. Ackerman, USA and H. Sillesen, Denmark

12
Symptomatic bilateral carotid artery occlusion without major stroke: clinical symptoms and outcome
S. Persoon    C.J.M.Klijn    A. Algra    L.J.Kappelle                                          
 

University Medical Center Utrecht

THE NETHERLANDS

Background: Transient ischemic attacks (TIAs) or minor disabling stroke associated with bilateral internal carotid artery (ICA) occlusion are rare and information on the risk of recurrent stroke and other vascular outcome events is limited. Methods: We studied clinical features, long-term outcome and risk factors for recurrent stroke in 57 patients (46 men, 11 women; mean age 60 +/- 9 years) with bilateral ICA occlusion who presented with TIA, minor disabling stroke (modified Rankin ≤ 3) or ocular ischemic symptoms. All patients received optimal medical therapy. Follow-up was performed by telephone-interviews. Results: Thirty-six patients presented with unilateral minor disabling cerebral stroke, 12 with cerebral TIA and 9 with ocular ischemic symptoms only. Eleven (19%) patients showed clinical symptoms suggestive of a hemodynamic origin like limb shaking or precipitation by exercise. Mean follow-up was 70 months (range 5-198). Four patients had a recurrent ischemic stroke, resulting in an annual stroke rate of 1.2% (95% confidence interval (CI) 0.3-3.1). Twenty-four patients had a stroke or any other vascular outcome event, resulting in an annual rate of 7.2% (95% CI 4.6-10.7). Specific risk factors for recurrent stroke could not be identified. A history of ischemic heart disease (HR 4.6, 95% CI 1.8-11.3) was the only risk factor in multivariable analysis for stroke or any vascular outcome event. Discussion: Patients with signs or symptoms of transient or minor disabling cerebral or ocular ischemia associated with bilateral ICA occlusion have a relative low risk of recurrent ischemic stroke and a risk of vascular events that is comparable with that in patients with TIA or stroke in general.