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This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset.A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS).Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50).At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.

Introduction A carotid endarterectomy (CEA) has certain risks, of which peri-operative cardiovascular risk is one. Peri-operative neurological monitoring can be done with electroencephalography (EEG) and transcranial Doppler (TCD). No previous reports have been published demonstrating the actual changes in cerebral and cardiac activity during a peri-operative asystole. Report The case of a 70 year old man with a symptomatic (bilateral) carotid stenosis is described. The patient complained of amaurosis fugax in both eyes. Duplex ultrasound showed a stenosis of >70% in both carotid arteries. The most severe symptoms were on the right side, so a staged approach was chosen, starting with a right sided eversion CEA (eCEA). Peri-operatively, the patient experienced an asystolic cardiac arrest after external carotid artery revascularisation, requiring brief cardiopulmonary resuscitation, which was recorded on the EEG. Post-operatively, the patient recovered fully, with no post-operative neurological or cardiac sequelae. The (symptomatic) contralateral stenosis was treated conservatively with best medical therapy (BMT; dual antiplatelets and statin). The patient is currently in good clinical condition, 1.5 years later. Conclusion This case shows the unique EEG recording of a cardiological event during eCEA. The cause of asystole was most likely a vasovagal syncope as a result of the surgical procedure by iatrogenic damage to the carotid sinus fibres, causing impairment of the baroreflex and chemoreflex mechanisms, which is greater during eCEA. The unilateral eCEA and contralateral BMT in this symptomatic (bilateral) stenosis seemed appropriate when cardiological risk was increased but follow up ruled out any cardiological cause., Highlights • This report shows the unique electroencephalography (EEG) recording of an episode of peri-operative cardiac asystole during carotid endarterectomy. • Peri-operative EEG and transcranial Doppler gives detailed information on the course of an asystole with cardiopulmonary resuscitation.

Introduction Small, dense low-density lipoprotein (sdLDL) is strongly associated with symptomatic carotid artery stenosis, but is not routinely evaluated in ischemic stroke patients. A method using the logarithmic transformation of the ratio of the plasma concentration of triglycerides (TGY) to HDL-cholesterol (HDL-C)[(Log[TGY/HDL-C])] has been described as a surrogate marker for sdLDL termed the atherogenic index of plasma (AIP). Objective To determine if the AIP is independently associated with symptomatic carotid artery stenosis. Methods We conducted a single center case-controlled study using a sample of ischemic stroke patients and compared risk factors of patients with and without symptomatic carotid artery stenosis. A multivariate logistic regression model was used to determine if the AIP divided into four quartiles was independently associated with symptomatic carotid artery stenosis. This model was compared to three other lipid models. Associations between non-lipid variables and the AIP were also identified. Results 31 cases of ischemic stroke due to symptomatic carotid artery stenosis and 236 controls of ischemic stroke not due to carotid artery stenosis were identified. Of the four lipid models assessed, only the model including the AIP (model 4) was found to be significantly associated with symptomatic carotid artery stenosis. The odd's ratio (OR) for quartile 3 was 3.82 (95% CI 1.03–14.17) and the OR for quartile 4 was 4.13 (95% CI 1.09–15.54) using quartile 1 as a reference. Metabolic syndrome was the only variable associated with the AIP (OR 5.06 95% CI 2.6–9.7). Conclusion At our single center, the AIP was the only lipid parameter independently associated with symptomatic carotid artery stenosis; and metabolic syndrome was independently associated with the AIP. The AIP may serve as a useful surrogate of sdLDL in patients with symptomatic carotid artery stenosis.

Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA).A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage.Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002).Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.

Objective Persistent primitive hypoglossal artery (PPHA) is a rare type of persistent carotid-basilar anastomosis sometimes associated with other vascular lesions. We treated an extremely rare case of PPHA with concomitant ipsilateral symptomatic cervical internal carotid artery (ICA) stenosis and unruptured aneurysm. Case presentation A 67-year-old woman visited our institution with acute onset of diplopia. Magnetic resonance imaging revealed multiple acute infarctions in the right anterior and posterior circulations. Digital subtraction angiography demonstrated the right PPHA concomitant with ipsilateral cervical ICA stenosis and an unruptured ICA aneurysm with maximum diameter of 8 mm. The multiple infarctions were considered to result from artery-to-artery embolism due to microthrombi from the ICA plaque passed along the PPHA, so carotid endarterectomy was performed as the first step with preoperative modified Rankin Scale (mRS) grade 1. During the operation, the patient had impaired ICA perfusion due to internal shunt catheter migration into the PPHA followed by acute infarction in the right hemisphere causing mild left hemiparesis. The patient was transferred to the rehabilitation hospital with mRS grade 3. After 3 months of rehabilitation, the patient recovered to mRS grade 1 and clipping surgery for the unruptured right ICA aneurysm was performed as the second step with uneventful postoperative course. Conclusion The treatment strategy should be carefully considered depending on the specific blood circulation for such cases of PPHA with unique vasculature.

Introduction Cerebral white matter changes (WMC) are associated with increased 30-day perioperative risk of stroke in patients undergoing carotid artery stenting (CAS). However, there is no data showing their impact on postoperative long-term stroke recurrence or survival. It remains unknown whether this effect is independent of classic cardiovascular risk factors or not. We tried to assess the effects of WMC on long-term stroke recurrence after CAS in patients with symptomatic carotid stenosis. Methods A database of patients with symptomatic carotid stenosis who had undergone CAS was sampled in a single Chinese medical center from 2007 to 2014. Copies of baseline brain imaging were analyzed by two investigators to evaluate the severity of WMC. We analyzed the association between WMC and stroke recurrence after CAS by reviewing case histories and conducting telephone interviews, with a mean follow-up time of 28 months. Results 107 patients with an average age of 66 years fulfilled the inclusion criteria, of which 70 were examined with CT and the remainder by MRI. In our cohort, 91.6% of the participants were male. There were 29 patients with diffuse WMC. In univariate analysis, patients with diffuse WMC had more contralateral occlusion than those with non-diffuse WMC. In patients with diffuse WMC, more stroke recurrences were observed compared with those with non-diffuse WMC (hazard ratio [HR] 3.516; 95% CI 1.176, 10.510, P = 0.024). Conclusions In patients with symptomatic carotid artery stenosis, diffuse WMC were a risk factor for stroke recurrences after CAS. Larger studies are warranted to confirm this finding and explore the potential clinical impact of WMC so as to better determine treatment strategies for patients with symptomatic carotid artery stenosis.

Improved long-term survival of malignancy has drawn increased attention to late cerebrovascular toxicity after neck radiotherapy. Recently, neck radiotherapy has been found as a significant risk factor of carotid artery stenosis and ischemic stroke; however, long-term adverse effects of radiation in large arteries remain unknown. Here, we described an autopsied case with recurrent ischemic stroke associated with ipsilateral carotid artery stenosis several decades after neck radiation therapy. Pathologically, there were intima-media fibrosis, endothelial cell loss, and decreased expression of thrombomodulin in irradiated carotid artery stenosis. Our findings support the hypothesis that long-term radiation-induced vascular injury in large arteries is morphologically different from atherosclerotic change. Furthermore, endothelial cell injury may promote fibrin thrombus formation through decreased expression of thrombomodulin, which may cause ischemic stroke associated with radiation-induced carotid artery stenosis.

Background Free-floating thrombus in the internal carotid artery (ICA) has traditionally been treated via an open surgical approach through a longitudinal incision and exposure similar to that for carotid endarterectomy (CEA). In this case report, we present a novel use of transcarotid artery revascularization (TCAR) for the treatment of recurrent carotid stenosis associated with free-floating ICA thrombus. Case Description We describe a 67-year-old female who presented with a diagnosis of right hemispheric stroke in evolution and prior history of right CEA and a mechanical mitral valve. Imaging confirmed high-grade recurrent stenosis of the right ICA with free-floating thrombus. TCAR was utilized to repair both the recurrent stenosis and the thrombus. Conclusions Redo CEA in the face of recurrent stenosis is a challenging clinical scenario, which in this instance, was further complicated by the presence of free-floating thrombus and active anticoagulation due to a mechanical mitral valve. This case report describes the successful management of ICA thrombus and restenosis with the novel use of TCAR.

Backround & purpose Perioperative neck hematoma (PNH) requiring re-intervention is an important complication after carotid endarterectomy (CEA). There are limited data regarding the potential risk factors associated with PNH. The aim of this prospective, multicenter study was to document the rate of PNH in symptomatic carotid artery stenosis (sCAS) patients treated with CEA within the first 14 days of cerebrovascular symptom onset and to identify possible predictors of this complication. Methods Patients with non-disabling (mRS ≤ 2) acute ischemic stroke or transient ischemic attack due to sCAS (≥70%) underwent CEA at three stroke-centers during a seven-year period. PNH requiring surgical re-intervention or transfusion during a 30-day follow-up period was determined by the attending surgeon but was also confirmed by an independent neurologist. Results A total of 280 patients with sCAS underwent CEA within 14 days of ictus. PNH occurred in 10 cases (3.6%; 95%CI: 1.4%–5.8%). Pretreatment with therapeutic anticoagulation (TA) and history of atrial fibrillation were more prevalent in patients with PNH (20% vs. 3.1%, p= 0.047 & 30% vs. 8.2%, p = 0.05 respectively). Elapsed time between symptom onset and carotid surgery, pretreatment with dual antiplatelets, intravenous thrombolysis or prophylactic anticoagulation were not related to PNH in univariable analyses. Pretreatment with TA was independently associated with higher likelihood of PNH [OR: 10.69, 95%CI (1.74–65.72), p = 0.011] in multivariate logistic regression models adjusting for potential confounders. Conclusion PNH is uncommon in patients with sCAS that are operated during the first 14 days of ictus. Pretreatment with TA appears to be associated with higher risk of PNH.

PP-389 Large randomised trials have established carotid endarterectomy (CEA) as the standard treatment for symptomatic severe carotid artery stenosis. Carotid artery stenting (CAS) has been increasingly used for possible alternative treatment to CEA. In this study we aimed to compare the

Background and purpose The best embolic protection strategy has not yet been established for carotid-artery stenting (CAS). We report here a new simplified approach using a balloon guiding catheter, inspired by stroke therapy, in patients harboring symptomatic ICA atherosclerotic stenosis or web. In addition, we describe the 3 angiographic patterns and clinical outcomes associated with this technique, called the simple flow blockage (SFB) technique. Materials and methods This is a retrospective study with data extraction from a monocentric prospective clinical registry of consecutive patients admitted for symptomatic ICA stenosis or web. The primary study outcome (composite endpoint) was the rate of occurrence of death, symptomatic stroke or acute coronary syndrome within 30 days of intervention. Results Seventy-five symptomatic patients with > 50% carotid artery atherosclerotic stenosis or web were included. All procedures were successfully performed. The composite endpoint occurred in 3 patients (4.0%, 95%CI, 0.0 to 11.3): 1 had symptomatic ischemic stroke, 1 had reperfusion syndrome with symptomatic intracranial hemorrhage and 1 had acute coronary syndrome. Three angiographic patterns after proximal balloon inflation were observed: complete contrast column stagnation in the ICA (38.7%), retrograde washout of the ICA from the intracranial circulation towards the external carotid artery (35.5%), antegrade washout of contrast medium towards the intracranial circulation (25.8%). The median procedure length was 40 minutes. New asymptomatic ischemic lesions were observed in 22.5% on DWI-MRI. Conclusion The SFB technique allows fast and safe procedures in CAS. A favorable angiographic pattern after proximal balloon inflation was observed in 74.2% of cases.

Atherosclerosis as well as the subsequent progression towards cardiovascular events are considered to, at least partially, be a consequence of chronic inflammatory activity. Therefore, we decided to evaluate the impact of short-term immunosuppressive treatment on plaque characteristics in patients with symptomatic carotid artery stenosis. Twenty-one patients were randomized to receive either 1000 mg. Mycophenolate mofetil (MMF) BD or placebo for at least 2 weeks prior to undergoing carotid endarterectomy (CEA). The serial sections of the CEA specimens were immunostained for activated T-cells (CD3(+)CD69(+)), regulatory T-cells (CD3(+)FOXP3(+)) and macrophages (CD68). In addition, gene expression pro. ling was performed by Illumina gene-array. Immunostaining revealed a reduction of activated T-cells in nine MMF-treated patients compared to 11 placebo-treated control patients (19.7% vs. 28.1%; p

Objective The objective of this study was to define outcomes after carotid endarterectomy (CEA) in patients with symptomatic carotid artery stenosis (CAS) when patients are operated on within 14 days after onset of symptoms. Methods Clinical data of consecutive patients who underwent CEA between 2003 and 2012 for symptomatic CAS were reviewed. Patients were classified into group 1, CEA ≤14 days of minor stroke or transient ischemic attack, and group 2, CEA >14 days. Primary end point was stroke/death; secondary end points were stroke, death, and myocardial infarction. Results There were 233 patients (32% female; mean age, 72 ± 9.1 years) who underwent 238 CEAs. Group 1 included 57 CEAs in 56 patients; 11 CEAs were performed at 0 to 2 days, 23 at 3 to 7 days, and 23 at 8 to 14 days. Group 2 included 181 CEAs in 177 patients. One death (group 2) and five strokes (group 1, four; group 2, one) occurred at 30 days (stroke/death, 2.6%), more in group 1 vs group 2 (7.1% vs 1.1%; P = .03). In group 1, three strokes occurred when the patients were operated on within 2 days (27% [3/11]), more than at 3 to 7 days (0% [0/22]) or 8 to 14 days (4.3% [1/23]; P = .008). Patients operated on between days 3 and 14 had similar stroke/death rate to those operated on after 14 days (2.2% vs 1.1%; P = .49). Myocardial infarction occurred in six patients (2.5%; group 1, 0% [0/57]; group 2, 3.3% [6/177]; P = .34). Median follow-up was 7.0 years (interquartile range, 4.6-9.9 years). Freedoms from stroke/death were similar between groups (hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.75-1.99; P = .42), 69% for group 1 and 76% for group 2 at 5 years. Age ≥80 years, high surgical risk, and no preoperative P2Y 12 antagonist use predicted stroke/death. Freedoms from any stroke were similar in groups (HR, 2.46; 95% CI, 0.95-6.41; P = .06); survivals were also similar (HR, 1.12; 95% CI, 0.67-1.87; P = .67) at 5 years. Conclusions In this single-center study, CEA in symptomatic patients had a 30-day stroke/death rate of 2.6%. Age ≥80 years and high surgical risk predicted late stroke or death; taking P2Y 12 antagonists was associated with late stroke. High stroke rates when patients were operated on immediately support CEA after 2 days in symptomatic patients with CAS.