| WHAT IS A STROKE? |
| We all know that the functioning of our brain is the most important activity of our body. Brain function controls our movement, our awareness, and our thoughts. It defines who we are and how we relate to the world around us. Any brain injury is very serious and may alter many aspects of our lives. |
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| WHAT IS STROKE (CVA)? |
Stroke ( Cerebral Vascular Accident or CVA) is permanent injury to the brain which is usually caused by heart or vascular problems.
In the USA:
-Stroke is the third major cause of death.
-Stroke is the major cause of disability.
-This year, 1,000,000 people will suffer a stroke.
-There are 5 million survivors of stroke. |
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| WHAT IS A “MINI-STROKE” OR TIA? |
The symptoms of stroke (CVA) are quite variable and include: facial or extremity numbness, weakness or paralysis, confusion, speech difficulty, visual disturbance, loss of coordination, or severe headache.
TIA (Transient Ischemic Attacks) or so-called “mini-strokes” are serious:
Although symptoms usually last < 24 hours:
-50% have permanent brain injury by MRI
-20% have a major stroke in 1 year
-6% die within 6 months with stroke
-22% have disability within 1 year
-Recovery may be worse for TIA+CVA than CVA alone
TIA’s are grave, potentially disabling events which should not be minimized . TIA’s signal the chance to prevent more serious stroke. |
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| WHAT ARE THE CAUSES OF STROKE? |
Stroke may be due to hemorrhage (15%) caused by a burst blood vessel in the brain. Ischemic stroke (85%) is caused by blockage of blood flow to the brain caused by a blood clot.
ISCHEMIC STROKE: A blood clot forming directly in a brain artery (thrombus) accounts for 25% of ischemic stroke. More commonly (75% ), a blood clot travels from the heart or carotid arteries to occlude a brain artery (embolus). |
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| WHAT IS EMBOLIC STROKE? |
| A clot which forms in the heart or carotid arteries may dislodge and move (an embolus) to the brain. The location of where the embolus stops is variable. Therefore, there are many types of symptoms with strokes. When an embolus lodges in an artery; blood flow ceases; brain dysfunction occurs; and brain tissue dies. |
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| FINDING THE CARDIAC CAUSE OF EMBOLIC STROKE |
Disorders of the heart which cause stroke may be diagnosed by echocardiography. These problems include PFO, valve disease, heart attack, and muscle disease. Atrial fibrillation, a rhythm disturbance of the heart, is a significant risk for stroke. Ambulatory 24 hour heart monitoring helps diagnose this treatable problem.
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| CAROTID ARTERY DISEASE A MAJOR CAUSE OF STROKE |
The carotid arteries are the major blood supply to the brain. Vertebral arteries are smaller and feed the posterior part of the brain. Narrowing of the internal carotid artery is a major cause of stroke. Atherosclerotic narrowing or blockage of these arteries is caused by inheritance, smoking, high blood pressure, high cholesterol, and diabetes.
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| CAROTID ARTERY STENOSIS OR NARROWING |
Many patients have carotid artery stenosis (narrowing) without any symptoms. If the stenosis is severe, the risk of stroke is 6% each year. 80% of strokes occur without any warning. Patients with symptoms (stroke or TIA) have a repeat stroke risk of 10% at 1 year and 40% by 5 years. Clot traveling from the plaque at the site of narrowing (embolus) is the main cause of stroke. Therefore, even milder narrowing (50%) may cause stroke in patients with symptoms. |
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| HOW IS CAROTID ARTERY DISEASE DIAGNOSED? |
| When carotid disease is suspected, noninvasive testing is the first step. When carotid disease is suspected, noninvasive testing is the first step. Magnetic Resonance Angiography (MRA) detects narrowing in the carotid and intra-cranial arteries using an MRI scanner. |
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| CAROTID STENOSIS DIAGNOSIS CAROTID ANGIOGRAMS |
Non-invasive tests like CUS (ultrasound) and MRA (magnetic imaging) are attractive tests due to safety, lower cost, and minimal discomfort. However, these tests are indirect , external measurements and may over- or underestimate the severity of disease of the carotid artery. Carotid angiograms are a more reliable, but more invasive way of diagnosing carotid artery disease.
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| WHAT IS A CAROTID ANGIOGRAM? |
| An angiogram is an invasive diagnostic test using small tubes or catheters which are inserted through the skin at the groin (or arm) to take pictures of the arteries of the body. Contrast medium (or “dye”) is injected in small amounts from outside of the body through the catheter and into the artery studied. A carotid angiogram (or arteriogram) gives clear pictures of the arteries in the neck (carotid and vertebral) and the arteries inside the head. |
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| CAROTID STROKE PREVENTION WHAT ARE MY OPTIONS? |
TREATMENT WITH MEDICINES
TREATMENT WITH SURGERY
TREATMENT WITH CATHETERS |
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| WHAT ARE MY OPTIONS? MEDICINES FOR CAROTID DISEASE |
Medicines are indicated for all patients with any type of vascular disease and all three types should be used even after surgery or catheter treatments. Benefits : reduction of risk of stroke, heart attack, heart failure, and death. Disadvantages: cost, inconvenience, side effects.
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| WHAT ARE MY OPTIONS? SURGERY |
| Since the plaque in the wall of the carotid artery obstructs blood flow and causes clot formation, surgical techniques for plaque removal seem attractive. CEA (or Carotid End Arterectomy) is a safe and durable operation for treatment of carotid artery narrowing. |
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| IS CEA SURGERY BETTER OR WORSE THAN MEDICINES? |
All treatments for stroke prevention carry a treatment risk of causing stroke. CEA is proven to have a lower stroke risk than medicines in two situations:
SYMPTOMATIC PATIENTS:
Carotid stenosis severity of >50% (NASCET STUDY)
ASYMPTOMATIC PATIENTS:
Carotid stenosis severity of >70% (ACAS STUDY)
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| WHAT ARE THE RISKS OF CEA SURGERY? |
The risks of CEA depend upon the severity of previous brain injury, artery anatomy, and other medical conditions (coronary artery disease, heart failure, radiation Rx, etc.).
OPERATION RISKS
-death (0.5-2.0% ), major stroke (1%)
minor stroke (3%), heart attack (1-7%)
cranial nerve injury (5%), bleeding,
hematoma, pain/discomfort, scarring
LATE COMPLICATIONS
-death, stroke, re-narrowing of artery |
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| WHAT ARE MY OPTIONS? CAROTID ARTERY STENTS |
| There are many different surgical procedures which physically treat arteries from the outside of the blood vessel. CEA, bypass surgery, aneurysm surgery, peripheral vascular surgery are some examples. Catheter based technologies are less invasive treatments which treat the arteries from the inside of the vessel through small tubes or catheters. Once completed, the catheter is removed without the need for sutures or prolonged recovery. Stents are used in all forms of arterial disease treatment. |
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| HOW DO CAROTID ARTERY STENTS WORK? |
| Like a culvert which holds material away from water flow under a road, a stent has radial strength to hold plaque and arterial wall material away for improved blood flow. Balloon catheters are commonly used to open the blockage to facilitate stent placement in the carotid artery. Carotid stents are cage-like, metal cylinders mounted on the ends of catheters which can be easily placed in a narrowing inside the artery. Self-expanding carotid stents are most commonly used. |
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| WHAT IS DISTAL PROTECTION DURING CAROTID STENTING? |
| The plaques which narrow carotid arteries are often soft and contain platelet-rich clot material. The plaques which narrow carotid arteries are often soft and contain platelet-rich clot material. DPD (Distal Protection Devices) are filtration systems to capture the emboli released by the stent procedure. |
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| CAROTID ARTERY STENTING HOW DO DPD WORK? |
| Before a stent is placed in the carotid artery, a DPD -attached to a fine , flexible wire- is placed beyond the plaque. Most commonly, the DPD is a “wind sock” shaped filter with tiny pores which lets blood pass through but catches larger particles. After stent deployment, the filter and any captured material are withdrawn through the catheter and out of the body. |
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| STENTS AND DPD WHAT DO THEY LOOK LIKE? |
| Please watch the presentation to see photos of stents. Click Here. |
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| WHAT ARE THE RESULTS OF CAROTID STENTS? |
CAROTID ARTERY STENTING
RESULTS IN AN ENLARGED
ARTERY WITH REDUCED
PLAQUE IN THE ARTERIAL
BLOOD STREAM
CAROTID ARTERY
STENTING IMPROVES
RESTING BLOOD FLOW
TO THE BRAIN |
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| WHAT ARE THE RESULTS OF CAROTID STENTS AND DPD? |
| Advances in stent design, distal protection, and experience over the past ten years have dramatically improved the safety and efficacy of carotid stenting. DPD use has proven to be the major advance in preventing procedural stroke during carotid stenting. Since the introduction of regular use of DPD, stenting is much safer. |
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| THE CAROTID ANGIOGRAM DECIDING BEST THERAPY |
| IF A SIGNIFICANT CAROTID NARROWING IS ASSOCIATED WITH UNFAVORABLE ANATOMY DUE TO ANGLES, CURVATURE, CLOT, OR CALCIUM (ETC), THEN CEA SURGERY IS BEST. STENTING OF THE CAROTID ARTERY IS A GOOD OPTION IF ARTERY ANATOMY IS FAVORABLE. |
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| HOW DO CAROTID STENTS COMPARE WITH CEA SURGERY? |
CEA surgery is a relatively low risk, established operation. However, many medical conditions increase the risk of CEA. Carotid stenting is less invasive and may reduce risk in these patients. HIGH RISK conditions include: weakened heart muscle, coronary artery narrowing, prior CEA, neck surgery or radiation, location of carotid stenosis, carotid blockage on both sides of the neck etc.
CEA RISK LOW RISK HIGH RISK
DEATH 0.3% - 4.4%
MI 1.1% - 7%
STROKE 1.7% - 3.5%
Percent of patients experiencing a complication with CEA surgery |
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| THE SAPPHIRE STUDY HIGH RISK PATIENTS TREATED WITH STENTS OR CEA |
| Randomized research studies are the best way to eliminate bias a prove best medical care. The SAPPHIRE STUDY is a randomized study comparing carotid STENTS (+DPD) and CEA surgery in high risk patients. SAPPHIRE has shown that carotid stenting has a lower risk of MI, stroke, death, and cranial nerve injury than CEA surgery. These results are durable and persist beyond 1 year. |
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| CAROTID STENTING LOW RISK PATIENTS |
Patients with carotid artery disease usually have other heart or medical problems. However, some patients are lower risk for CEA surgery. The results of many stent studies in high risk patients are equal to results for CEA surgery for low risk patients. i.e. comparable to the ACAS and current guidelines (AHA/ACC).
The risks of carotid stenting are:
stroke : major (<1%), minor (3%)
death (<1%)
heart attack (1-3%),
re-narrowing (4%), pain,
bleeding |
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| IS OUR CAROTID STENT PROGRAM RIGHT FOR YOU? |
| OUR CATHETERIZATION LABORATORY BOASTS 7000 OVERALL PROCEDURES PER YEAR FOR EXTENSIVE EXPERIENCE IN ALL TYPES OF CATHETER-BASED PROCEDURES. Dr GARY S ROUBIN, DIRECTOR OF NEURO AND ENDOVASCULAR PROCEDURES, JOINS US WITH EXTENSIVE RESEARCH AND CLINICAL EXPERIENCE. Dr ROUBIN HAS PERFORMED OVER 1000 CAROTID PROCEDURES AND HAS TEN YEARS OF EXPERIENCE WITH THIS NEW TREATMENT OPTION. 4 IRB/FDA APPROVED CLINICAL STENT TRIALS AT OUR HOSPITAL ASSURE CAREFUL MONITORING OF RESULTS AND BEST AVAILABLE NEW TECHNOLOGY. |
