Carotid endarterectomy: recommendations for management of transient ischaemic attack and ischaemic stroke. Association of British Neurologists.
Authors: M. M. Brown, P. R. Humphrey
Journal: BMJ (1992)

Although carotid surgery was first performed in the toms within the previous six months.Patients who early 1950s, the benefit of surgery has only recently have had a major carotid ischaemic stroke may also be been convincingly established by two large inter-considered if they make a good recovery within six national multicentre randomised trials.The collab-months and stand to lose useful function from a further orators in the European carotid surgery trial and the stroke in the same territory.A careful clinical history is North American symptomatic carotid endarterectomy required to decide whether the symptoms are com- trial have published data showing the value of carotid patible with an event in the carotid artery territory and endarterectomy in patients with severe stenosis to prevent inappropriate angiography or surgery.(70-99% linear reduction in diameter) who have had These decisions are not always straightforward and recent cerebrovascular symptoms in the carotid artery the assessment should preferably be undertaken by a territory.' 2 In both studies the risk of ischaemic stroke neurologist or physician with a special interest in over two or three years after surgery was reduced by cerebrovascular disease.Symptoms which may suggest 75% (table I).The risk of perioperative severe stroke or a carotid origin include amaurosis fugax, retinal infarc- death was 3. 7% in the European trial and 2 -1/% in the tion, dysphasia, hemiparesis, hemisensory loss, con- North American trial.Allowing for the initial surgical structional dyspraxia, and spatial disorientation.risk, the patients allocated to surgery started to do Patients with isolated dizziness or blackouts and better than patients in the non-surgical group after symptoms that can definitely be attributed to the about 10 months in the European trial or six months in vertebrobasilar circulation are not likely to be appropthe North American trial.riate for endarterectomy.Asymptomatic patients may The European trial also showed that endarterectomy not benefit from surgery and should be considered for had no significant benefit in patients with mild carotid carotid endarterectomy only if they are thought to be at stenosis (less than 30%), mainly because of a low event considerable risk of stroke from other planned major Division of Clinical rate in this group.The North American trial did not surgery, although no clear data on this group are Neuroscience, St George's include patients with mild stenosis.The value of available on which to base this advice.Hospital Medical School, carotid endarterectomy in symptomatic patients with Fitness for surgery-Patients considered for carotid London SW17 ORE moderate stenosis of 30-69% is still uncertain and both endarterectomy should be fit for surgery, but there are Martin M Brown, senior studies are continuing to randomise patients with this no firm criteria for making this decision.Age is no lecturer in neurology degree of stenosis.There is no evidence that asympto-definite barrier.The carotid surgery trials included Department of Neurology, matic patients with severe stenosis should be operated patients up to, and even over, the age of 80. Elderly Walton Hospital, Liverpool on, although other trials are examining this problem.patients should therefore be investigated for carotid Peter R D Humphrey, stenosis if they are reasonably fit.Recent myocardial consultant neurologist infarction and unstable angina are definite contra- Selection of patients indications to surgery.Poorly controlled hypertension Correspondence to: Symptoms-All patients with transient ischaemic is a relative contraindication (systolic pressures Dr Brown attacks or minor ischaemic strokes should be consid-> 160 mm Hg were associated with adverse surgical BA'J11992;305:1071-4 ered as potential candidates for carotid endarterectomy outcome in the European trial).if they have had appropriate carotid territory symp- Routine investigation-Screening investigations forTABLE i-Balanice of risks anid benefits of endarterectorny in patienits with severe carotid stenosis.Values are vascular risk factors and other causes of stroke are * 5trokes lasting more than seven days in European carotid surgery trial or any stroke in North American the appropriate carotid territory.Magnetic resonance symptomatic carotid endarterectomy trial.End of seudy=three years in European trial and two years in North imaging is an altemnative investigation which is more t SD=3 3,p<001.tSE=3 8,p<O001.sensitive to the presence of old haemorrhage.