Progression to Carotid Occlusion: More Benign Than We Thought?

Summary and Comment |
September 29, 2015

Progression to Carotid Occlusion: More Benign Than We Thought?

  1. Seemant Chaturvedi, MD

A retrospective observational study suggests that stroke is rare in patients with asymptomatic internal carotid artery stenosis, even when occlusion occurs.

  1. Seemant Chaturvedi, MD

Patients with asymptomatic internal carotid artery (ICA) stenosis are at increased risk for stroke, but the stroke rate appears to be decreasing with modern, multifaceted medical therapy. One of the fears with medical management of patients with asymptomatic stenosis is progression to total vessel occlusion, with a chance for a potentially devastating stroke. To examine the risk for stroke in such patients, researchers analyzed a single-institution carotid ultrasound database.

Overall, 316 previously asymptomatic patients were identified who developed an ICA occlusion during the 23-year study period (1990–2012). Mean age was 66.4 years, 71% were men, and 78% had hypertension. Most (80.4%) of the vessel occlusions occurred before 2002 to 2003, when intensive medical therapy based on plaque area measurements came into use. The decrease in ICA occlusion rates during the study period was statistically significant. Only one patient (0.3%) had a stroke at the time of ICA occlusion. Significant predictors of ipsilateral stroke, transient ischemic attack, or stroke-related death were age, male sex, and total plaque area. During long-term follow-up, among patients with a known cause of death, myocardial infarction and cancer were the leading etiologies for death.

Comment

This study shows a somewhat surprising low rate of stroke in asymptomatic patients who develop ICA occlusion. The findings illustrate a strong protective effect of intensive medical therapy, which typically includes aggressive statin use, antiplatelet therapy, blood pressure control, and lifestyle modification. Whether intensive medical therapy has advanced to the point where carotid revascularization is no longer needed in asymptomatic patients will be determined by ongoing trials such as CREST 2.

Editor Disclosures at Time of Publication

  • Disclosures for Seemant Chaturvedi, MD at time of publication Consultant / Advisory board Abbott Vascular; Boehringer Ingelheim; Genentech Grant / Research support Pfizer Editorial boards Neurology; Stroke; Journal of Stroke and Cerebrovascular Diseases Leadership positions in professional societies American Academy of Neurology (Vice Chair of Vascular Neurology Section)

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Reader Comments (1)

mohan rao DM neuro Physician, Neurology, private practitioner

i also have a patient with 90 percent occlusion of rt. carotid artery who refused surgery as he is about 78 years old. i started him on 80mg of atorvastatin, folvite 5 mg, and clopidogrel with 75mg of aspirin. after 3 years the stenotic lesion improved in its patency and measured 80 percent of stenotic lesion compared to the earlier lesion.

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