Atherosclerotic carotid artery occlusion

  • William J. Powers

Opinion statement

Patients with acute stroke caused by atherosclerotic carotid artery occlusion (ACAO) should receive intravenous tissue plasminogen activator if they meet eligibility criteria. Patients with acute stroke caused by ACAO who are not eligible for intravenous tissue plasminogen activator should receive aspirin. Heparin or heparin-like drugs do not improve outcome and should not be used. Therapy for prevention of recurrent stroke in patients with ACAO should consist of lifestyle modifications, risk factor intervention, and aspirin. Other antiplatelet drugs should be considered in patients with contraindication to aspirin. Warfarin is not indicated. Extracranial-intracranial bypass surgery provides no benefit over medical therapy in preventing recurrent stroke in a general population of patients with ACAO or in any subgroups selected by clinical or arteriographic criteria. Extracranial-intracranial bypass surgery in patients selected by hemodynamic criteria should only be performed as part of a randomized controlled clinical trial. Other surgical or endovascular procedures have no proven value in treating or preventing stroke caused by ACAO. Asymptomatic carotid occlusion has a benign prognosis, and requires no specific treatment other than lifestyle modification and risk factor intervention.


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References and Recommended Reading

  1. 1.
    Pessin MS, Duncan GW, Mohr JP, Poskaner DC: Clinical and angiographic features of carotid transient ischemic attacks. N Engl J Med 1977, 296:358–362.PubMedCrossRefGoogle Scholar
  2. 2.
    Mead GE, Murray H, Farrell A, et al.: Pilot study of carotid surgery for acute stroke. Br J Surg 1997, 84:990–992.PubMedCrossRefGoogle Scholar
  3. 3.
    Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators [no authors listed]. N Engl J Med 1991, 325:445–453.Google Scholar
  4. 4.
    Hankey GJ, Warlow CP: Prognosis of symptomatic carotid occlusion: an overview. Cerebrovasc Dis 1991, 1:245–256.Google Scholar
  5. 5.
    Klijn CJM, Kappelle LJ, Tulleken CAF, van Gijn J: Symptomatic carotid artery occlusion: a reappraisal of hemodynamic factors. Stroke 1997, 28:2084–2093.PubMedGoogle Scholar
  6. 6.
    Grubb RL Jr, Derdeyn CP, Fritsch SM, et al.: Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 1998, 280:1055–1060. This prospective, blinded, longitudinal cohort study of 81 patients with symptomatic carotid artery occlusion demonstrated that those with increased oxygen extraction measured by PET were seven times more likely to suffer a subsequent ipsilateral stroke than those with normal oxygen extraction. The 2-year risk in the 39 patients with increased OEF was 26%. This study provided the scientific rational and the preliminary data necessary to design and implement the Carotid Occlusion Surgery Study.PubMedCrossRefGoogle Scholar
  7. 7.
    Klijn CJ, van Buren PA, Kappelle LJ, et al.: Outcome in patients with symptomatic occlusion of the internal carotid artery. Eur J Vasc Endovasc Surg 2000, 19:579–586.PubMedCrossRefGoogle Scholar
  8. 8.
    Derdeyn CP, Grubb RL Jr, Powers WJ: Cerebral hemodynamic impairment: methods of measurement and association with stroke risk. Neurology 1999, 53:251–259.PubMedGoogle Scholar
  9. 9.
    Ogasawara K, Ogawa A, Terasaki K, et al.: Use of cerebrovascular reactivity in patients with symptomatic major cerebral artery occlusion to predict 5-year outcome: comparison of xenon-133 and iodine-123-IMP single photon emission computed tomography. J Cereb Blood Flow Metab 2002, 22:1142–1148. This study demonstrated that methods of assessing cerebral hemodynamics and predicting stroke risk are not equivalent. Although quantitative cerebral blood flow measurements with xenon-133 were excellent predictors of subsequent stroke, side-to-side asymmetries of relative cerebral blood flow measured with iodine-123-IMP had no predictive value.PubMedCrossRefGoogle Scholar
  10. 10.
    Yamauchi H, Fukuyama H, Nagahama Y, et al.: Significance of increased oxygen extraction fraction in 5-year prognosis of major cerebral arterial occlusive diseases. J Nucl Med 1999, 40:1992–1998. This study confirms the validity of PET measurements of oxygen extraction to identify a group of patients with hemodynamic cerebrovascular disease at high risk for subsequent stroke.PubMedGoogle Scholar
  11. 11.
    Ogasawara K, Ogawa A, Yoshimoto T: Cerebrovascular reactivity to acetazolamide and outcome in patients with symptomatic internal carotid or middle cerebral artery occlusion: a xenon-133 single-photon emission computed tomography study. Stroke 2002, 33:1857–1862. This prospective, blinded study of 70 patients established xenon-133 single photon emission computed tomography measurements of cerebral blood flow before and after acetazolamide as a valid method to identify a group of patients with hemodynamic cerebrovascular disease at high risk for subsequent stroke. The annual risk of stroke in the 23 patients with poor hemodynamics was 17.4%.PubMedCrossRefGoogle Scholar
  12. 12.
    Powers WJ, Derdeyn CP, Fritsch SM, et al.: Benign prognosis of never-symptomatic carotid occlusion. Neurology 2000, 54:878–882.PubMedGoogle Scholar
  13. 13.
    Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group [no authors listed]. N Engl J Med 1995, 333:1581–1587.Google Scholar
  14. 14.
    Chen ZM, Sandercock P, Pan HC, et al.: Indications for early aspirin use in acute ischemic stroke: a combined analysis of 40 000 randomized patients from the Chinese Acute Stroke Trial and the International Stroke Trial. Stroke 2000, 31:1240–1249.PubMedGoogle Scholar
  15. 15.
    Brott T, Bogousslavsky J: Treatment of acute ischemic stroke. N Engl J Med 2000, 343:710–722.PubMedCrossRefGoogle Scholar
  16. 16.
    Gorelick PB, Sacco RL, Smith DB, et al.: Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA 1999, 281:1112–1120.PubMedCrossRefGoogle Scholar
  17. 17.
    Fletcher RH, Fairfield KM: Vitamins for chronic disease prevention in adults: clinical applications. JAMA 2002, 287:3127–3129.PubMedCrossRefGoogle Scholar
  18. 18.
    Randomized trial of a perindopril-based bloodpressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. PROGRESS Collaborative Group [no authors listed]. Lancet 2001, 358:1033–1041. This randomized trial of 6105 subjects who had a transient ischemic attack or stroke in the previous 5 years showed that the addition of an angiotensin-converting enzyme inhibitor (perindopril) and a diuretic (indapamide) reduced the risk of subsequent stroke from 14% to 10% over 4 years of follow-up with a 9/4 mm Hg reduction in blood pressure. Importantly, the beneficial effect was also seen in the group whose mean blood pressure at baseline was 136/79 mm Hg.Google Scholar
  19. 19.
    Post-stroke antihypertensive treatment study. PATS Collaborating Group [no authors listed]. Chinese Med J 1995, 108:710–717. This study of treatment with a diuretic alone (indapamide) confirms the results of PROGRESS (Perindoprol Protection Against Recurrent Stroke Study). It further emphasizes the major benefit of even small reductions in blood pressure. A reduction of 5/2 mm Hg reduced subsequent stroke from 12.3% to 10.8% over a mean follow-up of 2 years.Google Scholar
  20. 20.
    MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Heart Protection Study Collaborative Group [no authors listed]. Lancet 2002, 360:7–22. This randomized trial of 20,536 participants provides the first evidence that statins reduce the risk of subsequent vascular events in patients who have had a stroke.Google Scholar
  21. 21.
    Hess DC, Demchuk AM, Brass LM, Yatsu FM: HMG-CoA reductase inhibitors (statins): a promising approach to stroke prevention. Neurology 2000, 54:790–796.PubMedGoogle Scholar
  22. 22.
    Albers GW, Hart RG, Lutsep HL, et al.: AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: a statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Stroke 1999, 30:2502–2511.PubMedGoogle Scholar
  23. 23.
    Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Antithrombotic Trialist Collaboration [no authors listed]. BMJ 2002, 324:71–86.Google Scholar
  24. 24.
    Mohr JP, Thompson JL, Lazar RM, et al.: A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001, 345:1444–1451. This blinded, randomized trial demonstrated no benefit of warfarin over aspirin for the prevention of recurrent noncardioembolic stroke in general or in any subgroup.PubMedCrossRefGoogle Scholar
  25. 25.
    Bath PM, Lindenstrom E, Boysen G, et al.: Tinzaparin in acute ischaemic stroke (TAIST): a randomized aspirincontrolled trial. Lancet 2001, 358:702–710. This trial of acute anticoagulation in 1486 patients with acute ischemic stroke showed no benefit of low molecular weight heparin over aspirin. It is the most recent of many trials that have failed to find a benefit of heparin or heparin-like drugs in the treatment of acute ischemic stroke.PubMedCrossRefGoogle Scholar
  26. 26.
    Swanson RA: Intravenous heparin for acute stroke: what can we learn from the megatrials? Neurology 1999, 52:1746–1750.PubMedGoogle Scholar
  27. 27.
    Adams HP Jr, Bendixen BH, Leira E, et al.: Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999, 53:122–125.PubMedGoogle Scholar
  28. 28.
    Yokota C, Hasegawa Y, Minematsu K, Yamaguchi T: Effect of acetazolamide reactivity on [corrected] long-term outcome in patients with major cerebral artery occlusive diseases. Stroke 1998, 29:640–644.PubMedGoogle Scholar
  29. 29.
    August P: Initial treatment of hypertension. N Engl J Med 2003, 348:610–617.PubMedCrossRefGoogle Scholar
  30. 30.
    Powers WJ: Acute hypertension after stroke: the scientific basis for treatment decisions. Neurology 1993, 43:461–467.PubMedGoogle Scholar
  31. 31.
    Grotta JC, Norris JW, Kamm B: Prevention of stroke with ticlopidine: who benefits most? TASS Baseline and Angiographic Data Subgroup. Neurology 1992, 42:111–115.PubMedGoogle Scholar
  32. 32.
    Hass WK, Easton JD, Adams HP Jr, et al.: A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. N Engl J Med 1989, 321:501–507.PubMedCrossRefGoogle Scholar
  33. 33.
    Mohr JP: Results of the warfarin aspirin recurrent stroke study. Paper presented at the 27th International Stroke Conference. San Antonio, TX; February 9, 2002.Google Scholar
  34. 34.
    Diener HC, Cunha L, Forbes C, et al.: European Stroke Prevention Study II: dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996, 143:1–13.PubMedCrossRefGoogle Scholar
  35. 35.
    Albers GW, Amarenco P, Easton JD, et al.: Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 2001, 119(suppl):300S-320S.PubMedCrossRefGoogle Scholar
  36. 36.
    A randomized, linded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee [no authors listed]. Lancet 1996, 348:1329–1339.Google Scholar
  37. 37.
    Yusuf S, Zhao F, Mehta SR, et al.: Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001, 345:494–502.PubMedCrossRefGoogle Scholar
  38. 38.
    Gorelick PB: Results of the African-American antiplatelet stroke prevention study. Paper presented at the 28th International Stroke Conference. Phoenix, AZ; February 9, 2003.Google Scholar
  39. 39.
    Weisberg LA: The efficacy and safety of ticlopidine and aspirin in non-whites: analysis of a patient subgroup from the Ticlopidine Aspirin Stroke Study. Neurology 1993, 43:27–31.PubMedGoogle Scholar
  40. 40.
    Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. EC/IC Bypass Study Group [no authors listed]. N Engl J Med 1985, 313:1191–1200.Google Scholar
  41. 41.
    Japanese EC-IC Bypass Trial (JET Study)-Study Design. JET Study Group [no authors listed]. Surg Cereb Stroke (Jpn) 2002, 30:97–100.Google Scholar
  42. 42.
    Adams HP Jr, Powers WJ, Grubb RL Jr, et al.: Preview of a new trial of extracranial-to-intracranial arterial anastomosis: the Carotid Occlusion Surgery Study. Neurosurg Clin N Am 2001, 12:613–624.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2003

Authors and Affiliations

  • William J. Powers
    • 1
  1. 1.Room 2218F, Washington University School of Medicine, East Building Imaging CenterSt. LouisUSA

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