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Causes and severity of ischemic stroke in patients with internal carotid artery stenosis.

Abstract

CONTEXT

Therapeutic trials generally have not distinguished outcomes of stroke according to cause.

OBJECTIVE

To determine whether stroke and subsequent disability was of large-artery, lacunar, or cardioembolic origin in patients with different degrees of symptomatic and asymptomatic carotid stenosis.

DESIGN

Observational study of prospective data collected from the North American Symptomatic Carotid Endarterectomy Trial between 1987 and 1997.

SETTING AND PATIENTS

A total of 2885 patients from 106 sites in the United States and abroad (median age, 67 years; 70% male) who had symptomatic internal carotid artery stenosis.

MAIN OUTCOME MEASURE

Risk of stroke from each of the 3 causes at 5 years by territory and degree of stenosis.

RESULTS

During an average follow-up of 5 years, 749 patients had 1039 strokes, including 112 of cardioembolic, 211 of lacunar, 698 of large-artery, 17 of primary intracerebral hemorrhage, and 1 of subarachnoid hemorrhage origin. The 5-year risk of first stroke after entry into the trial in any territory was 2.6% of cardioembolic cause, 6.9% of lacunar cause, and 19.7% of large-artery cause. The proportion of cardioembolic strokes in the territory of the symptomatic artery was 12.0% and 6.9% in 60% to 69% and 70% to 99% arterial stenosis, respectively; large-artery strokes predominated (78.4%) at 70% to 99% arterial stenosis. With 70% to 99% arterial stenosis, the proportion of strokes of cardioembolic and lacunar origin was 43.5% and 21.6% in asymptomatic and symptomatic arteries, respectively. A total of 67.6% of cardioembolic, 16.7% of lacunar, and 33.0% of large-artery strokes in the territory of the asymptomatic artery were disabling or fatal.

CONCLUSIONS

Our data suggest that approximately 20% and 45% of strokes in the territory of symptomatic and asymptomatic carotid arteries with 70% to 99% stenosis, respectively, are unrelated to carotid stenosis. The cause of subsequent strokes in similar types of patients should be considered when making treatment decisions involving carotid endarterectomy for patients with asymptomatic carotid stenosis, since lacunar and cardioembolic strokes cannot be prevented by endarterectomy.

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  • Authors+Show Affiliations

    ,

    The John P. Robarts Research Institute, Department of Clinical Neurological Sciences, University of Western Ontario, London, Canada. barnett@rri.on.ca

    , , , , ,

    Source

    JAMA 283:11 2000 Mar 15 pg 1429-36

    MeSH

    Aged
    Carotid Artery, Internal
    Carotid Stenosis
    Endarterectomy, Carotid
    Female
    Follow-Up Studies
    Humans
    Male
    Risk
    Severity of Illness Index
    Stroke
    Survival Analysis

    Pub Type(s)

    Journal Article
    Research Support, U.S. Gov't, P.H.S.

    Language

    eng

    PubMed ID

    10732932

    Citation

    Barnett, H J., et al. "Causes and Severity of Ischemic Stroke in Patients With Internal Carotid Artery Stenosis." JAMA, vol. 283, no. 11, 2000, pp. 1429-36.
    Barnett HJ, Gunton RW, Eliasziw M, et al. Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA. 2000;283(11):1429-36.
    Barnett, H. J., Gunton, R. W., Eliasziw, M., Fleming, L., Sharpe, B., Gates, P., & Meldrum, H. (2000). Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA, 283(11), pp. 1429-36.
    Barnett HJ, et al. Causes and Severity of Ischemic Stroke in Patients With Internal Carotid Artery Stenosis. JAMA. 2000 Mar 15;283(11):1429-36. PubMed PMID: 10732932.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. AU - Barnett,H J, AU - Gunton,R W, AU - Eliasziw,M, AU - Fleming,L, AU - Sharpe,B, AU - Gates,P, AU - Meldrum,H, PY - 2000/3/25/pubmed PY - 2000/4/1/medline PY - 2000/3/25/entrez SP - 1429 EP - 36 JF - JAMA JO - JAMA VL - 283 IS - 11 N2 - CONTEXT: Therapeutic trials generally have not distinguished outcomes of stroke according to cause. OBJECTIVE: To determine whether stroke and subsequent disability was of large-artery, lacunar, or cardioembolic origin in patients with different degrees of symptomatic and asymptomatic carotid stenosis. DESIGN: Observational study of prospective data collected from the North American Symptomatic Carotid Endarterectomy Trial between 1987 and 1997. SETTING AND PATIENTS: A total of 2885 patients from 106 sites in the United States and abroad (median age, 67 years; 70% male) who had symptomatic internal carotid artery stenosis. MAIN OUTCOME MEASURE: Risk of stroke from each of the 3 causes at 5 years by territory and degree of stenosis. RESULTS: During an average follow-up of 5 years, 749 patients had 1039 strokes, including 112 of cardioembolic, 211 of lacunar, 698 of large-artery, 17 of primary intracerebral hemorrhage, and 1 of subarachnoid hemorrhage origin. The 5-year risk of first stroke after entry into the trial in any territory was 2.6% of cardioembolic cause, 6.9% of lacunar cause, and 19.7% of large-artery cause. The proportion of cardioembolic strokes in the territory of the symptomatic artery was 12.0% and 6.9% in 60% to 69% and 70% to 99% arterial stenosis, respectively; large-artery strokes predominated (78.4%) at 70% to 99% arterial stenosis. With 70% to 99% arterial stenosis, the proportion of strokes of cardioembolic and lacunar origin was 43.5% and 21.6% in asymptomatic and symptomatic arteries, respectively. A total of 67.6% of cardioembolic, 16.7% of lacunar, and 33.0% of large-artery strokes in the territory of the asymptomatic artery were disabling or fatal. CONCLUSIONS: Our data suggest that approximately 20% and 45% of strokes in the territory of symptomatic and asymptomatic carotid arteries with 70% to 99% stenosis, respectively, are unrelated to carotid stenosis. The cause of subsequent strokes in similar types of patients should be considered when making treatment decisions involving carotid endarterectomy for patients with asymptomatic carotid stenosis, since lacunar and cardioembolic strokes cannot be prevented by endarterectomy. SN - 0098-7484 UR - https://www.unboundmedicine.com/medline/citation/10732932/full_citation L2 - https://jamanetwork.com/journals/jama/fullarticle/vol/283/pg/1429 DB - PRIME DP - Unbound Medicine ER -