Welcome to the ESOC 2021 Virtual Conference Calendar

Background And Aims

Monitoring mild-to-moderate carotid stenosis on a regular basis is not clearly recommended. We aimed to investigate carotid stenosis progression rates and evaluate independent predictors of progression.

Methods

A retrospective study from 1990 to 2020, with 6,987 carotid artery ultrasounds in 1,281 patients with carotid stenosis between 30% and 69%. Baseline risk factors, previous symptom and presence of uni/bilateral stenosis was analized. Baseline carotid stenosis was dichotomized into 30-49% stenosis and 50-69% stenosis. Primary endpoint was progression of carotid stenosis defined as: baseline stenosis 30-49% that progressed to >=50% or baseline stenosis 50-69% that progressed to >=70%. Progression was estimated using Cox proportional hazard ratios and the Kaplan-Meier method.

Results

Mean age was 67.6±9.3 with a mean follow-up was 44.4 months and mean 5.4 studies per patient. The median observed progression time was 107.5 months for the unilateral 30%–49% baseline group, compared to 67.2 months for the bilateral 30%–49% group, 75.2 months in the unilateral 50-69% group and 8.9 months for the bilateral 50-69% group (p<0.001)(Figure). Peripheral vascular disease (HR 1.67[1.22-2.29],p=0.001), previous symptoms (HR 1.31[1.01-1.70],p=0.03) and baseline stenosis (bilateral and/or greater than 50%) (HR 1.40[1.23-1.61],p<0.001) were independent predictors of progression.

Conclusions

Among patients with mild-to-moderate carotid stenosis (30%-69%), presence of bilateral stenosis, stenosis between 50-69%, previous TIA or stroke, and peripheral vascular disease are independent risk factors of carotid progression. It would be worthwile to perform closer follow-up evaluations in those patients with high risk of progression.

Trial Registration Number

Not applicable

Group Name

On behalf of the Stroke Project of the Spanish Cerebrovascular Diseases Study Group

Background And Aims

To compare the results obtained with carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients with symptomatic carotid near-occlusion (SCNO).

Methods

We conducted a multicenter, nationwide, prospective study. Patients with angiography-confirmed SCNO were included. For this analysis, only patients who underwent revascularization (CEA or CAS) were considered. We assessed revascularization rate obtained immediately after the procedure, peri-procedural stroke or death, restenosis rate at 24 months follow-up, the cumulative incidence of ipsilateral ischemic stroke including periprocedural events, and mortality within 24 months after the presenting event.

Results

141 patients were included in the study (120 males [5.1%], mean age 68.71 [SD 9.05]). Revascularization was performed in 70 patients (CAS in 47 and CEA in 23). Complete revascularization was achieved in 58 patients (83%); 80.9% in the CAS group and 87% with CEA (p=0.524). Periprocedural stroke or death occurred in 5.7% (CAS=2.1%; CEA=13% [p=0.065]). Restenosis rate was 11.3%: 15% for patients undergoing CAS and 4.5% for CEA (p=0,213). The 24-month cumulative incidence of ipsilateral ischemic stroke was 10.2% (95% CI 3–17.4; n = 7), 6.3% (0 – 13.5%) in the CAS group and 17.4% (1.9 – 32.9) in the CEA, log-rank p = 0.141. Six patients died at 24 months, resulting in a cumulative mortality of 9.1% (2.2 – 16), 11.4% (2 – 20.8) in the CAS group and 4.5% (0 – 13.1) in the CEA group, log-rank p= 0.346.

Conclusions

Both CAS and CEA showed similar results in patients with SCNO. Periprocedural stroke or death tended to be lower in the CAS group.

Trial Registration Number

Not applicable

Group Name

ACST-2 Collaborators

Background And Aims

In patients with asymptomatic carotid stenosis, carotid endarterectomy (CEA) halves stroke risk over the next 10 years. CEA or carotid stenting (CAS) are now used to treat several hundred thousand patients each year. Whether CEA or CAS is superior in preventing stroke in the long term is unclear. The aim of ACST-2 is to compare 1) peri-procedural risks (myocardial infarction, stroke and death, and 2) stroke in subsequent years, particularly disabling or fatal stroke, between CEA and CAS.

Methods

Between September 2008 and December 2020, from 133 centres in 33 countries, 3638 patients (1084 women, 29.8%) with asymptomatic carotid stenosis were randomly allocated to CEA vs CAS. The median degree of stenosis was 80% (range 60-99%). 1290 (35.5%) patients had coronary artery diasease, 224 (6.1%) had atrial fibrillation, 1088 (29.9%) were diabetic, 234 (6.5%) had a history of remote (>6 months) ipsilateral carotid territory symptoms, and 524 (14.5%) had prior contralateral cerebrovascular symptoms. Medical therapy at randomisation included antiplatelet therapy (3244, 91%), anticoagulation (300, 8.4%), blood pressure lowering (3143, 88.3%) and lipid-lowering therapy (3045, 85.6%).

Results

The results will be presented at ESOC 2021. The number of major events in the periprocedural period and during follow-up (4.85, IQR 2.41-7.76 years) provide good statistical power to detect differences in outcomes, and will provide a reliable assessment of durability to 5 years.

Conclusions

ACST-2 is the largest trial to compare CEA and CAS for stroke prevention in asymptomatic carotid stenosis. Its findings will provide guidance to clinicians worldwide when assessing patients for caroid interventions.

Trial Registration Number

ISRCTN21144362

Background And Aims

Recent trials showed that a low-density lipoprotein cholesterol (LDL-C) <1.80mmol/L (<70mg/dL) was associated with a reduced risk of major adverse cardiovascular events (MACE) in Caucasian ischemic stroke patients with atherosclerosis. However, it remains uncertain whether the findings can be generalised to Asians, or that similar LDL-C targets should be adopted in stroke patients without significant atherosclerosis.

Methods

We performed a prospective cohort study and recruited consecutive Chinese ischemic stroke patients with magnetic resonance angiography of the intra- and cervicocranial arteries performed at the University of Hong Kong between 2008-2014. Serial post-event LDL-C measurements were obtained. Risk of MACE in patients with mean post-event LDL-C <1.80 vs. ≥1.80mmol/L, stratified by presence or absence of significant (>50%) large artery disease (LAD), and by ischemic stroke subtypes, were compared.

Results

904 patients (mean age 69±12years, 60% men) were followed up for a mean 6.5±2.4years (mean 9 LDL-C readings/patient). Regardless of LAD status, patients with a mean post-event LDL-C <1.80mmol/L was associated with a lower risk of MACE [LAD+ve: multivariate-adjusted subdistribution hazard ratio (SHR) 0.65, 95% confidence interval (CI) 0.42-0.99; LAD-ve: 0.53, 0.32-0.88] (both p<0.05). Similar findings were noted in patients with ischemic stroke attributable to large artery atherosclerosis (0.48, 0.28-0.84), and in patients with other ischemic stroke subtypes (0.64, 0.43-0.95) (both p<0.05).

Conclusions

A mean LDL-C <1.80mmol/L was associated with a lower risk of MACE in Chinese ischemic stroke patients with and without significant LAD. Further randomised trials to determine the optimal LDL-C cut-off in stroke patients without significant atherosclerosis are warranted.

Trial Registration Number

Not applicable

Group Name

on behalf of the MR CLEAN Registry investigators

Background And Aims

The subtype of intracranial carotid artery calcification (intimal or medial; ICAC) influences the efficacy of endovascular treatment (EVT) in acute ischemic stroke. We explored whether ICAC subtype relates to collateral status as explanation for its influence on EVT efficacy.

Methods

We used data from 2680 patients included in the MR CLEAN Registry, a prospective registry including all consecutive patients with ischemic stroke undergoing EVT in the Netherlands. We evaluated baseline non-contrast CT-scans for presence of ICAC and ICAC subtype (intimal vs. medial pattern), and collateral status on baseline CT angiography using a visual grading scale from 0 (absent) to 3 (good). We investigated the association of ICAC pattern with good (grade 3) versus absent to moderate (0-2) collaterals using multivariable logistic regression models. The effect of ICAC pattern on the relation between collateral grade (0-3) and functional outcome (modified Rankin Scale, 0-6) was also tested using a multiplicative interaction term.

Results

We found that an intimal calcification pattern was significantly associated with good collaterals in comparison to patients with a medial pattern (aOR, 1.53 [95% CI: 1.16-2.02]), and also in comparison to patients with no calcifications (aOR, 1.36 [95% CI: 1.03-1.80]). Among patients with ICAC, the relationship between a higher collateral grade and better functional outcome was stronger in patients with an intimal pattern than in patients with a medial pattern (P interaction = 0.03).

Conclusions

Patients with intimal ICAC are more likely to have good collaterals and also benefit more from an extensive collateral circulation in terms of functional outcome after EVT.

Trial Registration Number

Not applicable

Background And Aims

The net benefit of CEA is determined partly by the risk of procedural stroke or death. Current guidelines recommend CEA if 30-day risks are <6% for symptomatic and <3% for asymptomatic stenosis. We aimed to externally validate models for procedural stroke or death after CEA in a large registry from the United States.

Methods

We conducted a systematic search for prediction models for procedural outcomes after CEA. We validated these models with data from patients who underwent CEA in the American College of Surgeons National Surgical Quality Improvement Program. We assessed discrimination and calibration. We determined the number of patients with predicted risks that exceeded recommended thresholds of procedural risks to perform CEA.

Results

After screening 788 reports, 17 prediction models were included. In the external validation cohort of 26,293 patients who underwent CEA, 717 (2.6%) developed a stroke or died within 30-days. C-statistics varied between 0.52 and 0.64 using all patients, between 0.51 and 0.59 using symptomatic patients, and between 0.49 to 0.58 using asymptomatic patients. The Ontario Carotid Endarterectomy Registry (OCER) model that included symptomatic status, diabetes mellitus, heart failure and contralateral occlusion as predictors, showed fair discrimination and the best concordance between predicted and observed risks. This model identified 4.5% of symptomatic and 2.1% of asymptomatic patients with procedural risks that exceeded recommended thresholds.

Conclusions

Of the 17 externally validated models, the OCER model had most reliable predictions of procedural stroke or death after CEA and can inform patients about procedural hazards.

Trial Registration Number

Not applicable

Background And Aims

To investigate the impact of timing on the safety and efficacy of stenting for ICAS, we reviewed high-volume randomized controlled trials or prospective cohort studies of stenting for intracranial atherosclerotic artery stenosis (ICAS) after the SAMMPRIS trial.

Methods

We included randomized controlled trials or prospective cohort studies since 2011 (the publication of the SAMMPRIS trial), evaluating the outcomes of intracranial stenting for ICAS patients. The primary outcomes were perioperative and 1-year stroke or death rate. The interaction of timing and outcomes were shown on trend plots. Overall meta-analysis and subgroup analysis by timing of intracranial stenting were conducted.

Results

Fourteen studies with a total of 1,950 patients were included. The perioperative and post-operative stroke or death rates decreased with the time of stenting to the qualifying events. The perioperative stroke rate was significantly higher in patients treated within 21 days after the qualifying events, compared to those beyond 21 days (IRR = 1.60, 95%CI: 1.10–2.33; p = 0.014), similar relationships were obtained for both post-procedural (IRR = 1.61, 95%CI: 1.02–2.55; p = 0.042) and 1-year (IRR = 1.51, 95%CI: 1.10–2.08; p = 0.012) stroke or death rate.

FIGURE. The trend of rate of stroke or death with timing of intracranial stenting. (A) Peri-procedural outcome. (B) Post-procedural outcome. (C) 1-year total outcome.

Conclusions

The timing of intracranial stenting may influence the safety and efficacy outcomes of stenting. Intracranial stenting within 21 days from the qualifying events may confer a higher risk of stroke or death. More studies are needed to confirm the impact of timing and the proper cut-off value.

Trial Registration Number

Not applicable

Background And Aims

Systemic inflammation may be important in the development of carotid atherosclerosis. Previous research suggested important sex-dependent differences for the value of inflammatory markers for risk stratification of stroke patients with internal carotid artery stenosis (ICAS). We investigated whether blood leukocytes and thrombocytes were associated with presence of ≥50% ICAS in an acute stroke setting and whether this association was indeed sex-dependent.

Methods

Patients included in the Preventive Antibiotics in Stroke Study (PASS) were evaluated for the predictive value of leukocyte and thrombocyte count for ICAS. In PASS patients with ischemic stroke or TIA were randomized between four days of ceftriaxone intravenously or standard stroke care alone. Logistic regression analysis was performed adjusting for NIHSS and other covariates.

Results

From July 2010 to March 2014, 2550 patients were included in PASS. 1413 of 2550 patients (55%) were evaluated in this sub study. Female patients showed a mean of 8.55 x 10⁹/L (95% CI 8.29-8.75) for leukocytes and 259 x 10⁹/L (95% CI 252-265) for thrombocytes. Men showed a mean of 8.29 x 10⁹/L (95% CI 8.1-8.46) for leukocytes and 224 x 10⁹/L (95% CI 219-229) for thrombocytes. Multivariate logistic regression analysis showed that leukocytes were independently associated with ICAS ≥50% in male patients (OR 1.094 95%CI 1.024 – 1.169, p=0.008), but not in female patients (OR 1.041, 95%CI 0.995 – 1.136, p=0.360). Interaction p-values were >0.05. Thrombocytes were not associated with ICAS.

Conclusions

Blood leukocyte count independently predicts ICAS in men after acute stroke, but not in women.

Trial Registration Number

ISRCTN66140176