Incidence of Ischemic Stroke in Asymptomatic Severe Carotid Stenosis

May 26, 2022
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Authors:
Chang RW, Tucker LY, Rothenberg KA, et al.
Citation:
Incidence of Ischemic Stroke in Patients With Asymptomatic Severe Carotid Stenosis Without Surgical Intervention. JAMA 2022;327:1974-1982.
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • There is uncertainty about whether medical management or surgical intervention (carotid endarterectomy or carotid stenting) is superior for asymptomatic severe (70-99%) carotid stenosis.
  • This uncertainty is driven in part by improved modern medical therapy, which may be associated with a lower rate of incident ischemic stroke from carotid disease when compared to older study data.
  • The investigators of this retrospective study sought to define the risk of incident ischemic stroke among a more contemporary cohort of patients with asymptomatic severe carotid stenosis identified between 2008–2012.
  • Among 3,737 patients with ≥1 severely stenosed asymptomatic carotid, the yearly risk of ipsilateral ischemic stroke was low, at about 1%.

Study Questions:

What is the long-term risk of ipsilateral ischemic stroke among patients with severe asymptomatic carotid stenosis?

Methods:

Patients included in this retrospective analysis had 70-99% stenosis of ≥1 carotid artery identified between 2008–2012 and had no history of transient ischemic attack (TIA)/stroke within the prior 6 months. If a patient had bilateral asymptomatic severe stenosis, each artery was evaluated independently. The primary outcome was acute ischemic stroke ipsilateral to the severely stenosed carotid.

Results:

A total of 4,230 arteries with asymptomatic severe stenosis in 3,737 patients were included in the final analysis: 133 (3.1%) carotid-related ischemic strokes occurred in 129 (3.5%) patients over 4.1 mean years of follow-up. The annual ipsilateral stroke rate was 0.9% (95% confidence interval, 0.7-1.2%).

Conclusions:

In this retrospective study of patients with severely stenosed asymptomatic carotid stenosis without surgical intervention, the annual risk of ipsilateral stroke was about 1%.

Perspective:

It is uncertain whether medical management or surgical intervention (carotid endarterectomy or carotid stenting) is superior for patients with asymptomatic severe carotid stenosis. In this retrospective study, the yearly risk of carotid-related stroke among these patients was only about 1%. Given this low yearly risk, the complication rate of surgical intervention for asymptomatic disease would have to be extremely low to provide a favorable risk-benefit profile. The currently recruiting multicenter CREST-2 trial (NCT02089217), in which patients with asymptomatic severe carotid stenosis are randomized to medical therapy versus intervention, will help clarify the best approach for these patients.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Interventions and Vascular Medicine

Keywords: Asymptomatic Diseases, Brain Ischemia, Carotid Arteries, Carotid Stenosis, Constriction, Pathologic, Endarterectomy, Carotid, Ischemic Attack, Transient, Ischemic Stroke, Risk Factors, Secondary Prevention, Stroke, Vascular Diseases


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