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Previous Volume 342:1693-1701 June 8, 2000 Number 23 Next

	Full Text PDF Editorial by Kistler, J. P. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background The causes of stroke in patients with asymptomatic carotid-artery stenosis have not been carefully studied. Information about causes might influence decisions about the use of carotid endarterectomy in such patients.

Methods We studied patients with unilateral symptomatic carotid-artery stenosis and asymptomatic contralateral stenosis from 1988 to 1997. The causes, severity, risk, and predictors of stroke in the territory of the asymptomatic artery were examined and quantified.

Results The risk of stroke at five years after study entry in a total of 1820 patients increased with the severity of stenosis. Among 1604 patients with stenosis of less than 60 percent of the luminal diameter, the risk of a first stroke was 8.0 percent (1.6 percent annually), as compared with 16.2 percent (3.2 percent annually) among 216 patients with 60 to 99 percent stenosis. In the group with 60 to 99 percent stenosis, the five-year risk of stroke in the territory of a large artery was 9.9 percent, that of lacunar stroke was 6.0 percent, and that of cardioembolic stroke 2.1 percent. Some patients had more than one stroke of more than one cause. In the territory of an asymptomatic occluded artery (as was identified in 86 patients), the annualized risk of stroke was 1.9 percent. Strokes with different causes had different risk factors. The risk factors for large-artery stroke were silent brain infarction, a history of diabetes, and a higher degree of stenosis; for cardioembolic stroke, a history of myocardial infarction or angina and hypertension; and for lacunar stroke, age of 75 years or older, hypertension, diabetes, and a higher degree of stenosis.

Conclusions The risk of stroke among patients with asymptomatic carotid-artery stenosis is relatively low. Forty-five percent of strokes in patients with asymptomatic stenosis of 60 to 99 percent are attributable to lacunes or cardioembolism. These observations have implications for the use of endarterectomy in asymptomatic patients. Without analysis of the risk of stroke according to cause, the absolute benefit associated with endarterectomy may be overestimated.

Source Information

From the Department of Neurological and Psychiatric Sciences, University of Florence, Florence, Italy (D.I.); the Departments of Epidemiology and Biostatistics (M.E.) and Clinical Neurological Sciences (M.E., H.J.M.B.), University of Western Ontario, London, Ont., Canada; the John P. Robarts Research Institute, London, Ont., Canada (M.E., B.L.S., H.E.M., H.J.M.B.); the Department of Neuroscience, Geelong Hospital, Geelong, and the Department of Medicine, Melbourne University, Melbourne — both in Victoria, Australia (P.G.); and the Department of Neurology, State University of New York at Buffalo, Buffalo (R.K.T.C.).

Address reprint requests to Dr. Barnett at the John P. Robarts Research Institute, 100 Perth Dr., P.O. Box 5015, London, ON N6A 5K8, Canada, or at barnett{at}rri.on.ca.

Full Text of this Article

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Extract | Full Text  
N Engl J Med 2000; 343:1420-1421, Nov 9, 2000. Correspondence

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