carotid endarterectomy in stroke prevention update
DESCRIPTION
Neurocritical Care lecture on the role of carotid artery surgery in stroke prevention, reviewing the latest studies and evidence-based updates, along with neurosurgical techniques.TRANSCRIPT
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Carotid Endarterectomy in Stroke Prevention
Denise Crute, MD, FACSMount Sinai School of Medicine
© Dr. Denise Crute 2013
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Stroke Prevention Recognition and
diagnosis Awareness of new
techniques Familiarity with
appropriate treatments
Paralysis – Manrov Vornam
© Dr. Denise Crute 2013
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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
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Stroke Diagnosis: Ischemic Infarction 70% to 80% of all
strokes Delayed
appearance on CT Emergency care Critical care
© Dr. Denise Crute 2013
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Stroke Diagnosis: Ischemia TIA (Transient
Ischemic Attack) Stroke-in-
evolution
© Dr. Denise Crute 2013
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Stroke Diagnosis: Hemorrhage Subdural Hematoma (SDH) Epidural Hematoma (EDH) Intraventricular Hemorrhage (IVH)
© Dr. Denise Crute 2013
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Stroke Diagnosis: Hemorrhage Subarachnoid Hemorrhage Intracerebral Hemorrhage
© Dr. Denise Crute 2013
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Stroke Treatment and Prevention Carotid Endarterectomy Stenting TPA Craniotomy Craniectomy
© Dr. Denise Crute 2013 Operating Hands, Bipolar, Denise Crute , MD
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Carotid Stenosis Common carotid
artery Anterior circulation Internal Carotid
Artery External Carotid
Artery Plaque formation
© Dr. Denise Crute 2013
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Carotid Stenosis Extra cranial
carotid occlusive disease
Flow reduction through reduced lumen
Embolic source
© Dr. Denise Crute 2013
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Carotid Endarterectomy Surgical correction of extra-cranial internal
carotid occlusive disease
© Dr. Denise Crute 2013Operative approach for CEA Denise Crute , MD
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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
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Carotid Endarterectomy Intraoperative
monitoring EEG Local anesthesia Cerebral oximetry
© Dr. Denise Crute 2013 Operative technique for CEA, Denise Crute , MD
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Carotid Endarterectomy
ACAS Trial NASCET Study ECST Collaborative
Group CREST results
© Dr. Denise Crute 2013 Operative closure for CEA, Denise Crute , MD
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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
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Carotid Endarterectomy: ACAS Surgery beneficial Clear benefit when:
>60% asymptomatic stenosis Surgical risk <3% Life expectancy at least 5 years
© Dr. Denise Crute 2013
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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
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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
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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
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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 pack-
years tobacco
© Dr. Denise Crute 2013
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Carotid Endarterectomy
70% stenosis 70 years Time is brain Prevention Treatment
© Dr. Denise Crute 2013
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Stroke Prevention Patient lifestyle Recognize
ischemia Awareness of new
techniques Familiarity with
appropriate treatments
Paralysis – Manrov Vornam© Dr. Denise Crute 2013