J Neurol Surg A Cent Eur Neurosurg 2015; 76 - P043
DOI: 10.1055/s-0035-1564535

Low Risk of Stroke or Death among Patients with Recently Symptomatic Carotid Stenosis Awaiting Revascularization—A Pooled Analysis of Recent Randomized Trials

U. Fisch 1, S. von Felten 2, G. Roubin 3, W. Mali 3, O. Jansen 3, G. Howard 3, G. Fraederich 3, G. Chatellier 3, J. P. Becquemin 3, A. Algra 3, P. Ringleb 3, J. L. Mas 3, M. M. Brown 3, T. G. Brott 3, L. Bonati 4
  • 1Departement of Neurosurgery, University Hospital of Basel, Basel, Switzerland
  • 2Clinical Trial Unit, University Hospital of Basel, Basel, Switzerland
  • 3Carotid Stenosis Trialists Collaboration, United Kingdom
  • 4Departement of Neurology, University Hospital of Basel, Basel, Switzerland

Aims: Historical data suggest that patients with recently symptomatic carotid stenosis are at high risk of early recurrent stroke. Guidelines therefore recommend revascularization within 2 weeks of symptoms. We assessed the risk of stroke or death occurring before revascularization and their predictors in recent trials of symptomatic carotid stenosis. Methods: We pooled data of all individual patients with symptomatic carotid stenosis randomized to stenting (CAS) or endarterectomy (CEA) in the EVA-3S, SPACE, ICSS, and CREST trials. The outcome event (OE) was death or any stroke occurring between randomization and treatment by CAS or CEA, or up to 120 days after randomization among patients not undergoing treatment in this period. Results: A total of 4,707 patients were included in the analysis. Median time from qualifying event until randomization was 18 (interquartile range 7–50) days. Median time from randomization until treatment was 6 (2–11) days in the CAS group, and 7 (3–12) days in the CEA group (p < 0.001). A total of 31% of patients in the CAS group and 27% in the CEA group underwent revascularization within 14 days of the qualifying event. The OE occurred in 21 patients (CAS: 8, CEA: 13), all within 31 days of randomization (Kaplan–Meier estimate: 2.4%, standard error: 0.7%), including 18 nonfatal strokes, 1 fatal stroke, and 2 nonstroke-related deaths. In 2 of the patients, the date of the qualifying event was unknown, in 8 patients the OE occurred within 14 days of the qualifying event, and in 11 patients >14 days after the qualifying event. All patients with the OE had severe (70–99% degree) stenosis. No other baseline variables predicted the OE. Conclusions: Only 2.4% of patients had a recurrent stroke or died before receiving treatment by CEA or CAS. The risk is lower than might be expected from historical data, which may reflect advances in medical therapy. Patients at risk are those with severe degree of stenosis. Acknowledgments: This study was supported by the Stroke Association, UK.