Seemant Chaturvedi

COMPLICATION RATES FOR CAROTID ENDARTERECTOMY : A CALL TO ACTION

The efficacy of carotid endarterectomy (CEA) for selected patients with high-grade stenosis of the extracranial carotid artery has now been established through a series of randomized, controlled trials.1 2 3 4 5 6 The reduction in stroke risk afforded by this prophylactic procedure is highly dependent on perioperative complication rates.7 Combined stroke and death rates much exceeding 3% for patients with asymptomatic stenosis and 6% for patients with symptomatic stenosis would eliminate the benefit in stroke reduction gained through the operation.8 A systematic review of the risks of stroke and death due to CEA based on 25 studies published since 1980 estimated 30-day complication rates of 3.35% for asymptomatic stenosis and 5.18% for symptomatic stenosis (including mortality rates of 1.3% and 1.8%, respectively).9 This review included studies based on a variety of methodologies. A companion review based on 51 studies of complication rates for patients undergoing CEA for symptomatic carotid stenosis found that the risk of surgery varied systematically with the methods and authorship of the report.10 The risk of stroke and/or death was highest in studies in which the patient was assessed by a neurologist after surgery (7.7%) and lowest in studies with a single author affiliated with a surgery department (2.3%). On the basis of data from the National Hospital Discharge Survey reflecting the years 1971 through 1982, it was estimated that …

Anticoagulants and antiplatelet agents in acute ischemic stroke Report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a Division of the American Heart Association)

Stroke remains a common and costly problem worldwide, but substantial advances have been made in recent decades in understanding stroke mechanisms, risk factors, and therapies. Because thrombosis plays an important role in the pathogenesis of ischemic stroke, drugs that interfere with hemostasis and clot formation such as anticoagulants and platelet antiaggregants commonly are used in the management of cerebrovascular disease. Considerable evidence supports the use of certain antithrombotic drugs in stroke prevention. However, because of limited supportive data, the use of these agents in patients with acute ischemic stroke remains controversial. In this report, we examine the published evidence relevant to the effects of anticoagulants and antiplatelet agents on acute ischemic stroke mortality, morbidity, and recurrence rates as well as associated ancillary benefits and risks of those treatments on the rates of deep vein thrombosis, pulmonary embolus, and cardiovascular complications. As part of these analyses, we also sought to determine whether there was evidence supporting differential efficacy of these drugs according to ischemic stroke subtypes. To prepare this report, experienced neurologists with a special interest in stroke diagnosis and management were appointed by the Quality Standards Subcommittee (QSS) and the Therapeutics and Technology Assessment (TTA) Subcommittee of the American Academy of Neurology, and the Stroke Council and Science Advisory and Coordinating Committee (SACC) of the American Heart Association (AHA). The QSS, TTA, Stroke Council and SACC are each charged with the responsibility of preparing evidence-based reports pertaining to medical practice issues including stroke. To facilitate the process of joint guideline development, a Steering Committee, chaired by representatives of the AAN and the American Stroke Association of the AHA, was appointed to discuss potential topics of wide interest to the stroke community. Choosing the role of anticoagulants and antiplatelet agents in acute ischemic stroke as the first topic, a Joint Writing …