Headache after carotid endarterectomy.

Forty-eight hours after undergoing a successful right carotid endarectomy a patient complained of headache in and behind the right eye radiating to the temple and forehead. The onset of headache was sudden, and the pain was severe and throbbing. After three weeks of regular four- to eight-hour attacks each day the headaches gradually became less frequent. Two months after operation they had disappeared completely. Headache as a complication of endarterectomy is rare, but typically it is vascular and subsides spontaneously in one to six months. If a predisposition to migraine were a precipitating factor many more cases would be expected. No possible explanation for for headache after carotid prearterectomy can account adequately for its apparent rarity.     

Comparison between carotid stenting and carotid endarterectomy in early outcome

Carotid artery stenting (CAS) is a widely used method in prevention of stroke for carotid artery stenosis as an alternative to surgical treatment. Initial studies reveal higher morbidity and mortality rates for CAS than acceptable standards for carotid endarterectomy (CEA). The aim of this study was to compare results in a series of CAS with concurrent risk-matched group of CEA patients. The study included two groups of 50 patients with internal carotid artery stenosis. We compared early outcome (30 days after procedure) in risk-matched groups of patients that underwent these procedures. Post procedural complications were equally frequent in both groups. There was no significant difference in perioperative complication rates (P = 0.871). Comparison of these two methods shows that CAS and CEA are competitive methods for treatment of carotid artery stenosis. Particularly in symptomatic patients with high risk for surgery CAS is alternative treatment.     

The appropriate use of carotid endarterectomy

FOR THE FIRST 30 YEARS AFTER CAROTID ENDARTERECTOMY WAS FIRST DEVELOPED, anecdotal evidence was used to identify patients with internal carotid artery disease for whom this procedure would be appropriate. More recently, the appropriateness of carotid endarterectomy for symptomatic patients and asymptomatic subjects has emerged from 7 randomized trials. Risk of stroke and benefit from the procedure are greatest for symptomatic patients with at least 70% stenosis of the internal carotid artery. Within this group, carotid endarterectomy is most beneficial for the following patients: otherwise healthy elderly patients, those with hemispheric transient ischemic attack, those with tandem extracranial and intracranial lesions and those without evidence of collateral vessels. Risk of perioperative stroke and death is higher in the following groups, although they still benefit: patients with widespread leukoaraiosis, those with occlusion of the contralateral internal carotid artery and those with intraluminal thrombus. Patients with 50% to 69% stenosis experience lesser benefit, and some other groups may even be harmed by carotid endarterectomy, including women and patients with transient monocular blindness only. The procedure is indicated for patients presenting with lacunar stroke and for those with a nearly occluded internal carotid artery, but the benefit is muted. Patients with less than 50% stenosis do not benefit. In the largest randomized trial of asymptomatic subjects, the perioperative risk of stroke and death was very low (1.5%), but the results indicated that a prohibitively high number of subjects (83) must be treated to prevent one stroke in 2 years. The subsequent literature reported higher perioperative risks (2.8% to 5.6%). In asymptomatic individuals nearly half of the strokes that occur may be due to heart and small-vessel disease. These limitations counter any potential benefit. Another trial is in progress and may identify subgroups of asymptomatic subjects who would benefit. Meanwhile, most individuals without symptoms fare better with medical care.The prevention of ischemic stroke by surgical means goes back half a century. After initial endorsement of carotid endarterectomy, confusion arose as to the appropriate selection of patients and the allowable risk from the procedure. In the past 2 decades large randomized trials have been used to evaluate the benefit of the procedure for patients with symptomatic and asymptomatic disease of the internal carotid artery. Sufficient time has now passed since the publication of these trials to analyze their impact on practice and to make recommendations about the application of carotid endarterectomy. There is strong evidence of benefit in some symptomatic patients, whereas other patients will not benefit and may even face harm. There is weak statistical and weaker clinical evidence that asymptomatic subjects will survive longer without experiencing stroke if they undergo endarterectomy than if they do not. The evidence supporting carotid angioplasty and stenting remains anecdotal and conflicting.The purpose of the present report is to provide a clinical roadmap to which symptomatic patients and asymptomatic subjects with carotid stenosis are candidates for endarterectomy. The risks and complications of endarterectomy are also reported. The outlook and benefit for symptomatic patients and asymptomatic subjects are so different that the evidence supporting appropriate use of endarterectomy in these 2 groups will be presented separately.     

Cerebral function before and after carotid endarterectomy.

Twenty men had their cerebral function measured preoperatively and three months after carotid endarterectomy using the Halstead-Reitan neuropsychological test battery. Thirteen patients were cerebrally impaired preoperatively, but 12 of them improved appreciably after surgery. Changes in internal carotid arterial blood flow measured preoperatively showed no significant correlation with the improvement in neuropsychological status. We think that carotid endarterectomy carries an even better prophylaxis for the brain as a whole than had been thought.     

Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces

Background

Carotid endarterectomy (CE), when performed on appropriate patients, reduces the incidence of stroke, yet there are marked variations in rates of this procedure. We sought to determine reasons for the variation in CE rates in 4 Canadian provinces.

Methods

We identified all CEs performed in 4 Canadian provinces between January 2000 and December 2001, inclusive. From chart review and expert assessment, we determined the proportion of these procedures that were appropriate, inappropriate or of uncertain appropriateness, using the RAND/UCLA Appropriateness Method. We sought to determine the variation in rates by province and whether the variation was due to differences in type of hospital, surgical specialty or surgical volume.

Results

Overall, 1656 (52.3%) of the 3167 CEs studied were performed for appropriate indications. The proportions of appropriate procedures were 78.2% (176/225) in Saskatchewan, 58.7% (481/819) in Alberta, 49.1% (350/713) in Manitoba and 46.0% (649/1410) in British Columbia (p < 0.001 across provinces). Rates of appropriate procedures per 100 000 population ranged from 44.3 in Manitoba to 16.2 in Saskatchewan (p < 0.001 across provinces). CEs were more likely to be appropriate when performed by a neurosurgeon compared with all other surgeons (74.4% v. 49.4% were appropriate; p < 0.001), when performed by surgeons doing fewer than 31 procedures over 2 years compared with surgeons doing more than 31 (70.1% v. 49.5% were appropriate; p < 0.001) and when performed in hospitals doing fewer than 135 procedures per year compared with hospitals doing more than 135 (63.4% v. 49.1% were appropriate; p < 0.001). Overall, 10.3% of procedures were done for inappropriate reasons.

Interpretation

Our findings suggest some overuse (for inappropriate or uncertain indications) but also some underuse (low population rates in some regions). High rates of CE are associated with lower rates of appropriateness for both surgeons and hospitals. That 1 in 10 CEs is done inappropriately suggests the need for preoperative assessment of appropriateness.The efficacy of carotid endarterectomy (CE) to prevent stroke is well established.^1,2,3,4Clinical trials have shown that CE reduces the 5-year risk of stroke by 16.0% when performed because of symptomatic lesions causing more than 70% stenosis.⁵ The risk reduction is more modest (4.6% and 5.9%, respectively) in cases of symptomatic moderate (50% to 69%) stenosis or asymptomatic stenosis (> 60%).^4,5 However, concerns remain regarding the effectiveness of the procedure outside of clinical trials, when the potential benefit may be reduced.^6,7 Although national societies have issued guidelines on indications for CE,^8,9 in some cases CE is performed on patients who do not meet these guidelines.The RAND/UCLA (University of California at Los Angeles) Appropriateness Method,^10,11 developed in response to concerns about possible unnecessary use of procedures, is perhaps the most respected approach to defining appropriate care, combining best evidence and expert opinion.¹² The first study of the appropriateness of CE, published in 1988, showed that only one-third of procedures were appropriate.¹³ A Canadian study in 1997 showed similar results.¹⁴The role of health system factors in choosing patients appropriately for CE is not well explored. Administrative databases allow only limited appreciation of the decision-making process that leads to the operating room.Our objectives were to describe the variation in appropriateness of CE in 4 Canadian provinces, to document rates of appropriate CE in the provinces and to explore potential explanatory factors, such as hospital type, surgeon specialty and number of CEs performed each year per surgeon and per hospital.