2022-05-04 21:39:07
Journal Scan – This Month in Other Journals, May 2022
https://www.ajnrblog.org/2022/05/03/journal-scan-this-month-in-other-journals-may-2022/
1. Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022;21:273–83. Available from: http://dx.doi.org/10.1016/S1474-4422(21)00359-8
The benefit of carotid endarterectomy in patients with symptomatic carotid stenosis was established in the final two decades of the past century. In the NASCET trial, the 2-year risk of any ipsilateral stroke (including perioperative events) in patients with severe symptomatic carotid stenosis (≥70% narrowing of the lumen) was reduced from 26% to 9%. Modest benefit was also observed in patients with moderate stenosis (50–69%) by a reduction of stroke risk from 22.2% to 15.7% after 5 years. In the European Carotid Surgery Trial (ECST), endarterectomy prevented stroke only in patients with symptomatic carotid stenosis of 80% or greater, but measurement of the degree of stenosis on angiography differed between the trials. In a pooled analysis of NASCET, ECST, and the smaller Veterans Affairs trial, in which ECST angiograms were reanalyzed using the NASCET method, the absolute 5-year risk reduction from endarterectomy was 15.9% in patients with severe (≥70%) stenosis and 4.6% in patients with moderate (50–69%) stenosis. Thus, the number needed to treat would be six patients with severe symptomatic stenosis, or 22 patients with moderate symptomatic stenosis, had to be operated on to prevent one ipsilateral stroke after 5 years. Furthermore, extracranial-intracranial bypass surgery is not effective to prevent stroke in patients with carotid artery occlusion.
Among patients with symptomatic carotid stenosis, randomized controlled trials have consistently shown that the risk of periprocedural stroke or death is greater with stenting than with endarterectomy. However, this outcome was mainly caused by a higher risk of minor stroke occurring with stenting, and the extra events largely occurred in patients older than 70 years. Conversely, stenting reduces the risk of procedure-related myocardial infarction, cranial nerve palsy, and hematoma …
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