What is the recommended treatment for patients presenting with hemispheric symptoms due to significant carotid stenosis?

Management of Hemispheric Symptoms from Carotid Stenosis

For patients presenting with hemispheric symptoms due to significant carotid stenosis, carotid endarterectomy (CEA) is recommended within 14 days of symptom onset, provided the procedural stroke/death risk is <6%. 1

Evaluation and Initial Management

• Imaging confirmation: Duplex ultrasound as first-line imaging, with CT angiography or MR angiography for further characterization if needed 1
• Immediate medical therapy:
  • Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for at least 21 days in the early phase of minor strokes 1
  • DAPT may be extended up to 90 days, considering bleeding risk 1
  • Long-term statin therapy 1

Revascularization Decision Algorithm

For Symptomatic Carotid Stenosis:

1. 70-99% stenosis: CEA is strongly recommended (Class I, Level A) 1

   • Procedural stroke/death risk must be <6% 1
   • Should be performed within 14 days of symptom onset 1

2. 50-69% stenosis: CEA should be considered (Class IIa, Level A) 1

   • Procedural stroke/death risk must be <6% 1

3. <50% stenosis: Revascularization is not recommended (Class III, Level A) 1

Alternative Approach - Carotid Artery Stenting (CAS):

• For high surgical risk patients with 70-99% stenosis: CAS should be considered (Class IIa, Level B) 1
• For patients <70 years with 70-99% stenosis: CAS may be considered (Class IIb, Level A) 1
• For symptomatic patients at high-volume centers: CAS may be considered as an alternative to CEA if documented death/stroke rate <6% 1

Timing of Intervention

• Perform revascularization within 14 days of symptom onset (Class I, Level B) 1
• Caution is advised within the first 48 hours after symptom onset due to increased risk of hemorrhagic transformation 1
• Higher-risk patients for urgent revascularization include those with:
  • Acute carotid occlusion
  • Persisting major neurological deficit
  • Middle cerebral artery infarction exceeding one-third
  • Evidence of pre-existing parenchymal hemorrhage
  • Signs of impaired consciousness 1

Post-Revascularization Management

1. Antiplatelet therapy:

   • After CAS: DAPT with aspirin and clopidogrel for at least 1 month 1
   • Long-term single antiplatelet therapy (aspirin or clopidogrel) after revascularization 1

2. Follow-up:

   • Duplex ultrasound surveillance within the first month after procedure 1
   • Annual follow-up to check cardiovascular risk factors and treatment compliance 1
   • Regular assessment of neurological symptoms 1

Special Considerations

• For patients with vertebral artery stenosis causing hemispheric symptoms, evidence is more limited, but endovascular interventions have largely replaced open surgery due to technical complexity 1
• For carotid dissection with hemispheric symptoms, anticoagulation or antiplatelet therapy for 3-6 months is reasonable, followed by antiplatelet therapy 1

Clinical Pitfalls to Avoid

1. Delaying intervention: Waiting beyond 14 days after symptom onset significantly reduces the benefit of revascularization 1

2. Inappropriate patient selection: Not all patients benefit from urgent revascularization, especially those with high risk of hemorrhagic transformation 1

3. Inadequate medical therapy: Failing to provide DAPT in the early phase of minor strokes can increase risk of recurrent events 1

4. Performing revascularization for stenosis <50%: This provides no benefit and exposes patients to procedural risks 1

5. Neglecting post-procedural surveillance: Failure to monitor for restenosis can lead to missed opportunities for preventing recurrent events 1