By Chris Berrie
BRUSSELS, BELGIUM -- August 29, 2007 -- Emergent carotid endarterectomy (CEA) is associated with a more favourable clinical outcome when compared with standard intravenous thrombolysis (IVT) in patients with acute ischaemic stroke (AIS) caused by an acute internal carotid artery occlusion (ICAo), say researchers. These benefits of emergent CEA are also more pronounced in younger patients with milder neurological deficit, they add.
A retrospective, hospital-based, two-centre study comparing recanalisation rates and 1-year clinical outcomes in patients treated with ICA and CEA was presented by Daniel Sanák, MD, Coinvestigator and Stroke Physician, Faculty of Medicine and Dentistry, University Hospital, Olomouc, Czech Republic, here on August 26th at the 11th Congress of the European Federation of Neurological Societies (EFNS).
AIS-caused ICAo is often associated with severe and persistent neurological deficit and a high mortality rate. Furthermore, high mortality and a high frequency of disability are seen in survivors without ICA recanalisation, with some 70% of patients showing poor clinical outcome after a stroke.
IVT performed within 3 hours of AIS onset is the current standard recanalisation treatment method, although the surgical opening of the occluded artery, known as CEA, can be used as an alternative. Dr. Sanák said, "We wanted to compare [these] two methods for treating internal carotid artery occlusion because this is associated very often with severe and persistent neurological deficit."
Clinical assessments were made according to patients' admission National Institutes of Health Stroke Scale (NIHSS) score, with classical outcome defined by the 1-year modified Rankin Scale (mRS). For the latter, an mRS >2 was defined as a poor outcome.
The IVT group was comprised of 20 patients (male, 55.0%) from one centre (Lausanne, Switzerland), with the CEA group being comprised of 29 patients (male, 69.0%) in the second study centre (Olomouc, Czech Republic).
Admission characteristics across the two treatment groups were not the same. Both the mean patient age and mean admission NIHSS scores were significantly higher in the IVT group: mean age, 70.9 versus 63.6 years (P =.033); mean admission NIHSS scores, 19.8 versus 10.2 (P <.001). While bearing these differences in mind, the recanalisation rate for the IVT group (15.0%) was significantly worse than that for the CEA group (86.2%; P <.0001). Similarly, a good 1-year clinical outcome with IVT (20%) was significantly less frequent than for CEA (48.3%; P =.044).
At the same time, within the admission NIHSS scores, the subgroup of patients with intermediate neurological deficit (NIHSS 10-20) was seen to occur at similar levels within the IVT and CEA patient groups (70.0% vs 48.3%; P =.131). Similarly, across these NIHSS-10 to -20 subgroups, the proportions of patient gender remained similar (57.1% males vs 71.4% females; P =.430) and the previous mean age difference was no longer significant, although it continued to show the same trend (mean age, 69.3 vs 59.9 years; P =.077).
When the 1-year clinical outcomes were then compared across these admission NIHSS-10 to -20 subgroups, the significance of the lower good outcome for IVT over CEA was also lost (14.3% vs 35.7%, respectively; P =.19).
Dr. Sanák stressed, "We show here, in the first study reported, that an endarterectomy performed quickly is safe and it is possible to perform it in patients with a stroke." The implications of the differences seen here between these two techniques for ICA recanalisation indicate that emergent CEA would be specifically beneficial in certain selected patients with AIS caused by acute ICAo, such as: those with an acute onset of stroke symptoms (without a strict time limit), those with an absence of signs of cerebral ischaemia (including early signs) in computer tomography brain scans performed immediately before surgery, and those able and willing to undergo the surgery.
In conclusion, keeping in mind the differences seen between the two patient groups, emergent CEA in these patients remains associated with a more favourable clinical outcome when compared with standard IVT, and particularly in younger subjects with milder neurological deficit.
[Presentation title: Ischaemic Stroke Due to Acute Internal Carotid Artery Occlusion: Comparison of 1-Year Clinical Outcome in Patients Treated by an Emergent Carotid Disobliteration Versus Intravenous Thrombolysis. Abstract P1029]
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