Treatment of the unknown patient: insights from acute stroke.

When an unidentified patient who cannot communicate presents with symptoms and signs suggesting an acute stroke, the decision to thrombolyse is a particular challenge. In a time-pressured environment, clinicians need clear thought processes for diagnosis and treatment. Ethical considerations, diagnosis, identity and previous history, contraindications, time of symptom onset (EDICT) can help decision-making in this situation.

Long-term results of carotid artery stents to manage symptomatic carotid artery stenosis and factors that affect outcome.

BACKGROUND: Limited data are available about the long-term outcomes of the use of carotid artery stents in symptomatic patients and the impact of patient variables on the durability of endovascular carotid procedures. Outcome data previously reported from registry series mix symptomatic and asymptomatic patients. We present analysis of long-term follow-up, with independent neurological assessment, for patients with symptomatic high-grade carotid lesions undergoing stenting to identify patients at risk of recurrence. METHODS AND RESULTS: Prospectively collected data on 563 carotid stenting procedures in a single center were analyzed. Univariate and multivariate techniques were used to identify risk groups and beneficial technical adaptations. Ipsilateral stroke rates for all patients were 4.8%, 7.0%, and 9.5% at 30 days, 1 year, and 4 years, respectively. The rates improved to 2.7%, 4.1%, and 4.5% when patients were treated with optimal therapy. Retinal events had a lower risk of long-term recurrent ipsilateral stroke (hazard ratio=0.228, CI=0.082 to 0.632, P=0.004) than cerebral events. A recurrent or residual stenosis of >50% had a statistically significant effect on long-term stroke recurrence in multivariate analysis (hazard ratio=2.187, CI=1.173 to 4.078, P=0.014). CONCLUSIONS: Patients with retinal presentations are a lower risk group to treat. Residual stenosis or restenosis >50% has a statistically significant trend to an increased risk of recurrence for ipsilateral stroke in the long term in this population. In our patients, a combination of procedural modifications and pharmacological changes seems to improve outcomes.

Carotid artery stenosis: accuracy of noninvasive tests--individual patient data meta-analysis.

PURPOSE: To find clinically relevant estimates of the accuracy of noninvasive imaging-Doppler ultrasonography (US), computed tomographic (CT) angiography, magnetic resonance (MR) angiography, and contrast material-enhanced MR angiography-in diagnosing both severe and moderate symptomatic carotid artery stenosis; to ascertain the effect of prespecified clinical factors and clinical setting on diagnostic accuracy; and to estimate the probability of agreement between two noninvasive tests. MATERIALS AND METHODS: Original principal investigators obtained ethics approval for each data set. All data were anonymized. Individual patient data sets (IPDs) for noninvasive imaging tests were used to determine sensitivity, specificity, and agreement between the tests for symptomatic carotid artery stenosis; to compare ipsilateral with contralateral arteries; to compare IPDs with literature estimates; to compare routine audit and research data; and to determine the effect of age and sex on sensitivity and specificity. RESULTS: Contrast-enhanced MR angiography was the most accurate (sensitivity, 0.85 [30 of 35]; 95% confidence interval [CI]: 0.69, 0.93; and specificity, 0.85 [67 of 78]; 95% CI: 0.76, 0.92) for 70%-99% symptomatic stenosis. Sensitivity for a 50%-69% stenosis was poor, although data were limited. Sensitivity and specificity were generally lower in the ipsilateral than in the contralateral artery. IPD estimates were lower than literature values. Results of comparison of research with audit-derived data were inconclusive. Neither age nor sex affected accuracy. Agreement was better between two Doppler US tests and between two contrast-enhanced MR angiographic tests than it was between Doppler US and contrast-enhanced MR angiography, except for a 70%-99% symptomatic stenosis. CONCLUSION: Primary studies should distinguish ipsilateral from contralateral arteries and carefully describe the patients' characteristics and study environment. The literature overestimates noninvasive imaging accuracy. More data are needed to inform physicians in routine clinical practice.

Is there any benefit from staged carotid and coronary revascularization using carotid stents? A single-center experience highlights the need for a randomized controlled trial.

BACKGROUND AND PURPOSE: To assess the benefits of carotid artery stenting before coronary artery bypass surgery to reduce the risk of stroke occurring during the cardiac procedure. METHODS: A prospective cohort study was performed in patients undergoing carotid artery stenting before coronary artery bypass surgery, or combined bypass and valve replacement procedures, to assess the procedures effectiveness in stroke prevention. Outcome measures including 30-day post stenting and cardiac surgery neurological complication and all-cause mortality rates were assessed. RESULTS: A total of 52 patients were included. Two patients underwent aortic valve replacements at the same time as coronary revascularization. No neurological complications occurred because of the stenting procedure. One cardiac death not related to coronary artery bypass surgery occurred in the 30-day follow-up period for the stent procedure. An additional 6 (11.5%) outcome events (3 strokes and 3 deaths) occurred in the 30-day follow-up period after the cardiac procedure. Three patients died of cardiac causes while awaiting their cardiac bypass procedure. CONCLUSIONS: Our results are comparable to those in patients that undergo staged or combined carotid endarterectomy before cardiac surgery. Our small cohort study adds to the limited world literature on the subject but is not sufficiently powered to recommend alterations in practice.