From the Guidelines
The perioperative risk of stroke in patients with intracranial carotid disease should be estimated to be less than 6% for carotid endarterectomy (CEA) to be recommended, as stated in the 2024 ESC guidelines 1. This risk estimation is crucial in determining the appropriateness of surgical intervention for patients with symptomatic carotid artery stenosis. The guidelines recommend performing CEA for symptomatic 70%–99% internal carotid artery (ICA) stenosis if the documented 30-day risk of procedural death/stroke is less than 6% 1. Key factors influencing this risk include the severity of stenosis, the presence of symptoms such as previous strokes or transient ischemic attacks (TIAs), and the timing of surgery relative to these events. For instance, patients with symptomatic disease are at a higher risk compared to asymptomatic patients, and the risk increases with the severity of stenosis, particularly for those with more than 70% stenosis. To manage this risk, optimal medical therapy (OMT) is recommended for all symptomatic ICA stenosis patients 1, and considerations such as delaying elective surgery for at least 3 months after a recent stroke or TIA, careful blood pressure management during surgery, and intraoperative neuromonitoring for high-risk patients can be beneficial. The most recent guidelines prioritize a perioperative risk assessment to guide decision-making for surgical interventions like CEA, emphasizing the importance of a multidisciplinary approach to minimize morbidity and mortality in patients with intracranial carotid disease. Given the emphasis on minimizing risks, the recommendation to perform CEA within 14 days in symptomatic ICA stenosis patients, if indicated, underscores the need for timely intervention while carefully assessing the individual's risk profile 1. Ultimately, the decision to proceed with surgical intervention must be based on a comprehensive evaluation of the patient's condition, weighing the potential benefits against the estimated risks, with a focus on optimizing outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Perioperative Risk of Stroke in Patients with Intracranial Carotid Disease
- The perioperative risk of stroke in patients with intracranial carotid disease is a significant concern, particularly in those undergoing surgical procedures 2, 3.
- Patients with a history of cerebrovascular disease, including intracranial carotid disease, should be evaluated by a neurologist to assess their risk of perioperative stroke 2.
- Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke, including those with intracranial carotid disease 2.
Risk Factors for Perioperative Stroke
- Advanced age, hypertension, atherosclerosis, diabetes mellitus, cardiac disease, and clotting disorders are all risk factors for perioperative stroke 3.
- The risk of stroke around the time of operative procedures is fairly substantial, and patients initially at risk for vascular events are those most likely to have this risk heightened by invasive procedures 3.
Treatment Options for Carotid Stenosis
- Carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) are two treatment options for carotid stenosis, but the choice of treatment depends on various factors, including the patient's overall health and the severity of the stenosis 4, 5, 6.
- CAS may be associated with a higher risk of periprocedural stroke or death compared to CEA, particularly in older patients 6.
- However, beyond the periprocedural period, CAS is as effective as CEA in preventing recurrent stroke 6.
Management of Perioperative Stroke
- The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention, and patients undergoing surgery should be initiated on beta blockade +/- amiodarone to prevent postoperative AF 2.
- Intravenous and endovascular thrombolysis/therapies are viable options in selected patients with perioperative stroke, under the guidance and expertise of a neurologist 2.