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 Cerebrovascular

 


Learning Objectives and Goals

Content

 

Carotid
Carotid endarterectomy in asymptomatic patients
Catotid endarterectomy in symptomatic patients
Carotid angioplasty and stenting
Reversible posterior leukoencephalopathy syndrome
Evaluation of carotid artery stenosis
Initial evaluation and management of transient ischemic attack and minor stroke
Etiology and clinical manifestations of transient ischemic attack
Definition of transient ischemic attack
Treatment for specific causes of ischemic stroke and transient ischemic attack
Pathophysiology of symptoms from carotid atherosclerosis
Coronary artery bypass grafting in patients with cerebrovascular disease

Carotid re-stenosis
Evaluation of carotid stenosis following carotid endarterectomy or stent
Management of recurrent carotid stenosis following carotid endarterectomy or stent

Vertebrobasilar
Subclavian steal syndrome
Surgical management of subclavian steal
Endovascular management of subclavian steal
Vertebral artery dissection
Posterior circulation cerebrovascular syndromes

Intracranial
Management of tandem internal carotid stenosis
Intracranial large artery atherosclerosis
Moyamoya disease: Etiology, clinical features, and diagnosis
Moyamoya disease: Prognosis and treatment
Vascular malformations of the central nervous system

Peripheral Intervention
Carotid angioplasty and stenting

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Pre and Post Test Questions


Videos

 

 

 

Carotid Endartectomy with Shunt in an Obese Female (video will take a few minutes to download)

 

 

 

 

  

 

 

Anatomy


Key References

ASYMPTOMATIC CAROTID STENOSIS
1. Hobson, RW 2d, Weiss, DG, Fields, WS, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med 1993; 328:221. [VA ASYMPTOMATIC TRIAL]
2. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273:1421. [ACAS]
3. Halliday, A, Mansfield, A, Marro, J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363:1491. [ACST – MRC Trial]
4. Rothwell, PM, Goldstein, LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 2004; 35:2425
5. 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. [NASCET]
6. Barnett, HJM, Taylor, DW, Eliasziw, M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339:1415. [NASCET]
7. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351:1379. [ECST]
8. Roederer, GO, Langlois, YE, Jager, KA, et al. The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke 1984; 15:603..  [important early natural history study based on duplex]
9. Ederle, J, Featherstone, RL, Brown, MM. Randomized controlled trials comparing endarterectomy and endovascular treatment for carotid artery stenosis: a Cochrane systematic review. Stroke 2009; 40:1373.
10. Brott, TG, Hobson RW, 2nd, Howard, G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis [Epub ahead of print]. N Engl J Med 2010; :. 10.1056/nejmoa0912321 nejm.org  [CREST]
11. Yadav, JS, Wholey, MH, Kuntz, RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351:1493.
12. Sacco, RL, Adams, R, Albers, G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention. Stroke 2006; 37:577.
13. Abbott, AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke 2009; 40:e573.
14. Marquardt, L, Geraghty, OC, Mehta, Z, Rothwell, PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41:e11.


SYMPTOMATIC CAROTID STENOSIS
1. 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. [NASCET]
2. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet 1991; 337:1235. [ECST]
3. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351:1379. [ECST]
4. Rothwell, PM, Eliasziw, M, Gutnikov, SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361:107.
5. Barnett, HJM, Taylor, DW, Eliasziw, M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339:1415. [NASCET]
6. Paciaroni, M, Eliasziw, M, Sharpe, BL, et al. Long-term clinical and angiographic outcomes in symptomatic patients with 70% to 99% carotid artery stenosis. Stroke 2000; 31:2037.
7. Rothwell, PM, Eliasziw, M, Gutnikov, SA, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363:915.
8. Ferguson, GG, Eliasziw, M, Barr, HW, et al. The North American Symptomatic Carotid Endarterectomy trial. Surgical results in 1415 patients. Stroke 1999; 30:1751. [NASCET]
9. Cunningham, EJ, Bond, R, Mehta, Z, et al. Long-term durability of carotid endarterectomy for symptomatic stenosis and risk factors for late postoperative stroke. Stroke 2002; 33:2658.
10. Rothwell, PM, Eliasziw, M, Gutnikov, SA, et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 2004; 35:2855.
11. Blaisdell, WF, Clauss, RH, Galbraith, JG, et al. Joint study of extracranial arterial occlusion. IV. A review of surgical considerations. JAMA 1969; 209:1889.
12. Rerkasem, K, Rothwell, PM. Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery. Stroke 2009; 40:e564.
13. Gasecki, A, Eliasziw, M, Ferguson, GG, et al. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: Results from NASCET. J Neurosurg 1995; 83:778. [NASCET]
14. Benavente, O, Eliasziw, M, Streifler, JY. Prognosis after transient monocular blindness associated with carotid artery stenosis. N Engl J Med 2001; 345:1084.
15. Gasecki, A, Eliasziw, M, Ferguson, GG, et al. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: Results from NASCET. J Neurosurg 1995; 83:778. [NASCET]


CAROTID STENTING
1. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357:1729. [CAVATAS]
2. Ringleb, PA, Allenberg, J, Bruckmann, H, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368:1239. [SPACE]
3. Mas, JL, Chatellier, G, Beyssen, B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355:1660. [EVA-3S Trial]
4. Ederle, J, Featherstone, RL, Brown, MM. Percutaneous transluminal angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev 2007; :CD000515.
5. Bonati, LH, Jongen, LM, Haller, S, et al. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9:353.
6. Schnaudigel, S, Groschel, K, Pilgram, SM, Kastrup, A. New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature. Stroke 2008; 39:1911.
7. Reimers, B, Schluter, M, Castriota, F, et al. Routine use of cerebral protection during carotid artery stenting: results of a multicenter registry of 753 patients. Am J Med 2004; 116:217.
8. Roubin, GS, New, G, Iyer, SS, et al. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: A 5-year prospective analysis. Circulation 2001; 103:532.
9. Rapp, JH, Wakil, L, Sawhney, R, et al. Subclinical embolization after carotid artery stenting: new lesions on diffusion-weighted magnetic resonance imaging occur postprocedure. J Vasc Surg 2007; 45:867.
10. Vos, JA, van den, Berg JC, Ernst, SM, et al. Carotid angioplasty and stent placement: comparison of transcranial Doppler US data and clinical outcome with and without filtering cerebral protection devices in 509 patients. Radiology 2005; 234:493.
11. Hobson, RW, Howard, VJ, Roubin, GS, et al. Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase. J Vasc Surg 2004; 40:1106.
12. Chaturvedi, S, Matsumura, JS, Gray, W, et al. Carotid artery stenting in octogenarians: periprocedural stroke risk predictor analysis from the multicenter Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events (CAPTURE 2) clinical trial. Stroke 2010; 41:757.
13.  Lam, RC, Lin, SC, DeRubertis, B, et al. The impact of increasing age on anatomic factors affecting carotid angioplasty and stenting. J Vasc Surg 2007; 45:875.
14. Shin, SH, Stout, CL, Richardson, AI, et al. Carotid angioplasty and stenting in anatomically high-risk patients: Safe and durable except for radiation-induced stenosis. J Vasc Surg 2009; 50:762.
15. Jackson, BM, English, SJ, Fairman, RM, et al. Carotid artery stenting: identification of risk factors for poor outcomes. J Vasc Surg 2008; 48:74.
16. Howard, VJ, Voeks, JH, Lutsep, HL, et al. Does sex matter? Thirty-day stroke and death rates after carotid artery stenting in women versus men: results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in phase. Stroke 2009; 40:1140. [CREST]
17. Brott, TG, Hobson RW, 2nd, Howard, G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis [Epub ahead of print]. N Engl J Med 2010. 10.1056/nejmoa0912321 nejm.org [CREST]
18. Ederle, J, Dobson, J, Featherstone, RL, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375:985. [ICSS]
19. McCabe, DJ, Pereira, AC, Clifton, A, et al. Restenosis after carotid angioplasty, stenting, or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS). Stroke 2005; 36:281. [CAVATAS]
20. Yadav, JS, Wholey, MH, Kuntz, RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351:1493. [SAPPHIRE]
21. Gurm, HS, Yadav, JS, Fayad, P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 2008; 358:1572.

 

 


Related Images and Vascular Laboratory Studies

 

 

Duplex Criteria for Carotid Stenosis
(used at Mount Sinai, courtesy of Dr. Teodorescu)

 

Carotid Duplex Ultrasound Bilateral/Normal Common Carotid Artery

Normal Carotid Artery

Carotid Body Tumor

 

80-99% Internal Carotid Artery Stenosis

 Medial Fibroplasia
  

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