Carotid Endarterectomy in Asymptomatic Patients With Limited Life Expectancy
The benefit from carotid endarterectomy in asymptomatic individuals has been less impressive than for patients with symptomatic carotid stenosis. This is reflected in various guidelines that recommend careful selection of patients with life expectancy being one of the variables to consider. Wallaert and colleagues studied patients undergoing isolated carotid endarterectomy for asymptomatic carotid stenosis in the American College of Surgeons National Surgical Quality Improvement Program Registry between 2007 and 2009. Asymptomatic carotid stenosis was defined by absence of documented cerebrovascular accident or transient ischemic attack. Studied life-limiting conditions with a predicted 5-year mortality exceeding 40% were cancer, advanced liver disease, symptomatic congestive heart failure, dialysis dependence, severe chronic obstructive pulmonary disease as well as age ≥90 years, do-not-resuscitate status, and patients designated as America Society of Anesthesiologists Class IV.
Of 12 631 asymptomatic patients undergoing carotid endarterectomies, 20.0% (2525) were performed in patients with at least one life-limiting condition. Among these, severe chronic obstructive pulmonary disease and America Society of Anesthesiologists Class IV were the most common conditions (10.1% and 10.2%, respectively). Carotid endarterectomy rates were <1% for each of the remaining defined categories. Compared with patients without a life-limiting condition, the 30-day stroke, death, and combined stroke/death rates were significantly higher in patients with life-limiting conditions (P<0.001). After adjustment for other baseline comorbidities, the presence of a life-limiting condition was independently associated with 30-day stroke/death (OR, 2.8; 95% CI, 2.1–3.8; P<0.001). Similar results were obtained when analyzing patients designated as America Society of Anesthesiologists Class IV or with severe chronic obstructive pulmonary disease separately from other life-limiting conditions. Despite its limitations, this study highlights that a large proportion of patients undergo prophylactic carotid endarterectomy may not survive to realize the small long-term benefit of surgery for stroke prevention, particularly in light of improved best medical therapy (which is unknown in this study) since publication of the large asymptomatic carotid endarterectomy trials.
See p 1781.
Leukoaraiosis Predicts Parenchymal Hematoma After Mechanical Thrombectomy in Acute Ischemic Stroke
Severe leukoaraiosis (LA) has been associated with poor outcome after large artery occlusion as well as thrombolysis-related intracranial hemorrhage. Shi and colleagues retrospectively analyzed consecutive patients with stroke treated for large arterial occlusion with a Merci Retriever (with or without adjunct therapy) over a 6-year period. Included were 105 patients treated within 8 hours from symptom onset and pretreatment fluid-attenuated inversion recovery MRI available for review. The extent of LA was visually rated and dichotomized into Fazekas scores of 0 to 1 (absent to mild) versus 2 to 3 (moderate to severe). Presence of hemorrhagic transformation or subarachnoid hemorrhage was assessed on 24-hour CT. Approximately 25% of included patients had moderate to severe LA in the deep white matter. These patients were older and had more frequently severe neurological deficits hypertension, atrial fibrillation, and cardioembolic stroke etiology than patients with absent to mild LA. Time to intervention, recanalization rates, and use of fibrinolytics were similar between groups. Patients with severe deep white matter LA had worse modified Rankin Scale scores at discharge (5.0 versus 4.0; P=0.02) and higher rates of in-hospital mortality (48% versus 11.5%; P<0.001). Moderate or severe deep white matter LA was the only independent predictor of hemorrhagic transformation on the multivariate logistic analysis (OR, 3.43; 95% CI, 1.23–9.57; P=0.019). Hemorrhagic transformation was significantly more frequent in patients with deep white matter LA. In particular, parenchymal hemorrhages (European Cooperative Acute Stroke Study definition) were twice as frequent in patients with severe deep white matter LA (42% versus 19%, P=0.03) and parenchymal hemorrhage 2 were even 4 times as frequent (23.1% [6 of 26 patients] versus 5.1% [4 of 79 patients]; P=0.02). Similar to prior work by us and others, this study highlights that if confirmed in prospective randomized trials, pre-existing LA may be an easily assessable marker allowing for treatment-related risk stratification in hyperacute anterior circulation large artery stroke.
See p 1806.
Poor Prognosis in Warfarin-Associated Intracranial Hemorrhage Despite Anticoagulation Reversal
Several small prospective, nonrandomized trials have shown successful urgent warfarin reversal with 4-factor prothrombin complex concentrates (PCCs). Indeed, some guidelines suggest PCC over fresh-frozen plasma as a first-line agent for urgent international normalized ratio (INR) reversal in anticoagulant-related hemorrhage due to its faster action and favorable side effect profile. However, whether PCCs are truly superior to fresh-frozen plasma for anticoagulant-associated intracranial hemorrhage (ICH) remains to be shown. Dowlatshahi and colleagues analyzed data from the Canadian multicenter registry that monitors PCC use for anticoagulant-associated ICH at 3 tertiary care stroke centers since Octaplex (a 4-factor PCC) was licensed in Canada for urgent INR correction in patients receiving warfarin therapy. The defined primary outcomes included INR correction, thrombotic events, and in-hospital mortality. Rapid INR correction was defined as an INR <1.5 within 1 hour of PCC infusion. Poor outcome was defined as a modified Rankin Scale score of 4 to 6. One hundred forty-one patients received PCC for various ICH types including 71 (50%) for intraparenchymal ICH. The authors found that PCC therapy reversed anticoagulation in 71.8% of patients within 1 hour of treatment. A total of 23.6% did not reach the target INR of <1.5. Thrombotic event rates were 2% over 7 days. The authors comment that the observed 42.3% mortality rate in patients with intraparenchymal anticoagulant-associated ICH after PCC therapy was lower than the 62% and 67% reported in 2 prior anticoagulant-associated ICH studies. Although not definitive, these results suggest that PCC can rapidly and safely correct the INR and thereby possibly shift the expected outcome of an anticoagulant-associated ICH to that of a noncoagulopathic ICH. Notably, in the current analysis, presentation to PCC treatment was 213 minutes (median), CT to treatment 100 minutes (median), and the total used PCC dose 1000 U (median). As the authors point out, the relatively low PCC dose likely contributed to the observed incomplete reversal rates. Also, using the analogy to thrombolysis in ischemic stroke, the door-to-needle time could be shortened, which may contribute to additional outcome improvements.
See p 1812.
- © 2012 American Heart Association, Inc.