High-risk asymptomatic carotid stenosis
Ulceration on 3D ultrasound vs TCD microemboli
Abstract
Objective:
We compared microemboli on transcranial Doppler (TCD) with carotid ulcerations on 3D ultrasound (US) as an additional method for identifying the small proportion of patients with asymptomatic carotid stenosis (ACS) who can benefit from revascularization such as endarterectomy or stenting.
Methods:
Patients with ACS (n = 253) with carotid stenosis >60% by Doppler ultrasound were studied prospectively with TCD embolus detection and 3D US to detect ulcers (the total number of ulcers in both internal carotids) and followed for 3 years.
Results:
Mean age was 69.66 (SD 8.51) years; 11 (4%) had ≥3 ulcers (Ulcer 3), 11 (6%) had microemboli, and 25 (10%) had microemboli or ≥3 ulcers. Ulcer 3 patients were more likely to have a stroke or death in 3 years (18% vs 2%; p = 0.03), regardless of the side on which the ulcers were found. The 3-year risk of stroke or death was 20% with microemboli vs 2% without (p = 0.003). The annual rate of ipsilateral stroke was 0.8%.
Conclusion:
Adding 3D US detection of ulcers doubles (to 10%) the proportion of patients with ACS who may benefit from endarterectomy or stenting. However, until 3-year event rates of stroke or death with endarterectomy or stenting reach <2%, 90% of patients with ACS would be better treated medically until they develop symptoms, ulcers, or emboli. Neurology® 2011;77:744–750
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Copyright © 2011 by AAN Enterprises, Inc.
Publication History
Received: December 28, 2010
Accepted: April 19, 2011
Published online: August 17, 2011
Published in print: August 23, 2011
Disclosure
A. Madani received research support from the Heart & Stroke Foundation of Ontario. Dr. Beletsky and Dr. Tamayo report no disclosures. Dr. Munoz performs TCD/embolus detection test (10% clinical effort) as a Research Associate for SPARC. Dr. Spence has received funding for travel from Merck Canada and Novartis; served as an Assistant Editor of Stroke; serves as a consultant for Boehringer Ingelheim; his team performs imaging studies and TCD (30% clinical effort) in his practice; and has received research support from the Heart & Stroke Foundation of Canada (Ontario), the Canadian Institutes for Health Research, and Merck Canada.
Authors
Author Contributions
A. Madani: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data, statistical analysis, study supervision. Dr. Beletsky: analysis or interpretation of data, acquisition of data. Dr. Tamayo: drafting/revising the manuscript, study concept or design, acquisition of data. Dr. Munoz: drafting/revising the manuscript, study concept or design, acquisition of data. Dr. Spence: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, statistical analysis, study supervision, obtaining funding.
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