PAPER F National Collaborating Centre for Chronic Conditions at the Royal College of Physicians

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Polly Eaton
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1 6.3 Early carotid imaging in acute stroke or TIA Evidence Tables IMAG4: Which patients with suspected stroke/tia should be referred for urgent carotid imaging? Reference Ahmed AS, Foley E, Brannigan AE et al. Critical appraisal of the application of carotid duplex scanning. Irish Journal of Medical Science. 2002; 171(4): Ref ID: 2495 Study type Evidence level Number of patients Patient characteristics Intervention Comparison Length of follow-up N=816 Patients undergoing carotid ning Patients population: Female ratio 5:4, mean age 65.9 yrs for females and 67.6 yrs for males. symptoms (TIA, cerebrovasc ular accident, amaurosis fugax, dysphasia) No specific carotid symptoms (dizziness, syncope, confusion, vertigo and others) NA Outcome measures Clinical variables/ disease associated with carotid stenosis Source of funding *Variables associated with carotid stenosis 350/816 patients were referred with definite carotid symptoms and a TIA was the most common referral indication in this group (N=205). 66 patients were referred following a stroke, 48 for amourosis fugax and 30 with dysphasia. A total of 466 patients were referred with ill-defined or non-carotid symptoms. In total, 677/816 patients had stenosis < 50%, 115/816 had stenosis > 50% < 79% and 24/826 had stenosis > 80%. 17% patients referred with carotid symptoms had a stenosis >50<79% compared with 11% of those with non-carotid symptoms. The difference was statistically significant (p<0.05). For severe occlusive disease on duplex imaging (80 to 99% stenosis), 15/350 (4%) had been referred with definite carotid symptoms, as compared with 9/466 (2%) of those with ill-defined symptoms. The different was statistically significant (p<0.05). Hill SL, Holtzman G, Retrospectiv e case N=5807 scans Patients referred for carotid ning. Duplex scan results NA NA Clinical variables/ disease associated with carotid

2 Martin D et al. Severe carotid arterial disease: A diagnostic enigma. American Surgeon. 2000; 66(7): Ref ID: 1461 series 3 (N=5001 patients) Indications for referral included TIA, dizziness, carotid bruit, preoperative and postoperative endarterectomy, known carotid disease Patient population: 54% female (statistically more females than males) stenosis Out of the patients with severe carotid arterial disease, 525 patients (11%) with an internal carotid artery stenosis >70%. There statistically more males than females (283 vs 242; p=0.0002). * Clinical variables/ disease associated with carotid stenosis There were three symptoms or indications out of 13 there were statistically associated with patients who had internal carotid stenosis of >70% (N=525), bruit (p<0.001), known carotid disease (p<0.001), postoperative endarterectomy (p<0.001). Internal carotid stenosis (>70%). Occluded carotid (N=252) was statistically associated with stroke (p<~0.001), known carotid disease (p<0.001), postoperative endarterectomy (p<0.011). Occluded carotid and internal carotid artery stenosis >70% (N=726) was statistically associated with a bruit (p<0.001), known carotid disease (p<0.001) and post operative endarterectomy (p<0.001). *Comorbid conditions Internal carotid artery stenosis >70% was statistically associated with smoking, high blood pressure, diabetes, peripheral vascular disease, myocardial infarct and hyperlipidemia (all p<0.001). Occluded carotid stenosis was associated with smoking (p<0.06), high blood pressure (p<0.03), diabetes (p<0.004), peripheral vascular disease (p<0.001), myocardial infarct (p<0.001) and a past history of stroke (p<0.002) and hyperlipidemia (p<0.001). Occluded carotid and internal carotid artery stenosis >70% was statistically associated with smoking (p<0.001), high blood pressure (p<0.03), diabetes (p<0.007),l infarct peripheral vascular disease (p<0.001), myocardial infarct (p<0.001), past history of stroke (p<0.001) and hyperlipidemia (p<0.001). By combining patients with severe carotid disease (N=525) and patients with carotid occlusion (n=252) there were statistically more males than females (56% vs 44%; p<0.0001). A carotid bruit (p<0.001), known carotid disease (p<0.001), and post operative endarterectomy (p<0.001) were statistically associated with severe carotid disease. The following comorbid conditions were statistically associated with severe carotid disease were smoking (p<0.001), diabetes (p<0.007), peripheral vascular disease (p<0.001), myocardial disease (p<0.001), a past history of stroke (p<0.001) and hyperlipidemia (p<0.001).

3 Hill SL, Holtzman GL, Berry R et al. The appropriate use of the in carotid arterial disease. American Surgeon. 1997; 63(8): Ref ID: 621 N=4764 (scans) Patient population: 2533 (54%) female. The average age of the female patients was 71 yrs (range 11 to 100) and for the male patients 69 yrs (range 18 to 94). All patients who underwent a between January 1992 to August 1995 NA NA Incidence of carotid arterial disease There were 13 reasons for ordering a in this study including dizziness (20%), TIA (19%), bruit (16%), preoperative evaluation (14%) and post-endarterectomy follow-up (13%). The remaining less common indications were syncope (9%), known carotid disease (8%), amarousis fugax (8%), confusion (8%), stroke (7%), dysphagia (4%), aphasia (2%) and seizure (o.5%). 286/4764 (6%) of patients had occlusion of the internal carotid artery. 1591/4764 (33%) with internal carotid artery stenosis, and 475/4764 (10%) had stenosis of greater than 70%. There were significantly more males than females in this group (212/2533 (8%) vs 263/2211 (12%); p<0.001). *Symptoms/variables related to carotid occlusions Three symptom complexes were statistically associated with a carotid stenosis of greater than 70%: the presence of a bruit, a history of known carotid disease and a history of carotid endarterectomy. Stroke, seizure, amaurosis fugax, confusion, preoperative evaluation, aphasia and dysphagia were not statistically associated with carotid artery disease. A history of smoking (24%; p=0.01), a history of peripheral artery disease (19%; p<0.001), hyperlipidaemia (p<0.001), history of myocardial infarction (p=0.002) and diabetes (p=0.04) were statistically associated with carotid artery stenosis of 70% or greater. Mead GE, Wardlaw JM, Lewis SC et al. Can simple clinical Prospective Case series 3 N=726 Patients with acute stroke, cerebral or retinal TIA or retinal strokes referred via hospital or outpatient clinic for carotid scanning. Colour ultrasound of the carotid arteries NA NA Associations with carotid stenosis and clinical variables/ disease

4 features be used to identify patients with severe carotid stenosis on ultrasound?[se e comment]. Journal of Neurology, Neurosurgery & Psychiatry. 1999; 66(1): Ref ID: /726 (13%) patients had severe carotid stenosis (70 to 99%). * Clinical variables/ disease associated with carotid stenosis Stepwise logistic regression showed significant positive associations between the presence of 70 to 99% and a <70% ipsilateral bruit (OR 11.2; 95%CI 7.0 to 18.8; p<0.001), diabetes mellitus (OR 2.3; 95% CI 1.1 to 4.7; p=0.02) and a previous TIA (OR2.4; 95%CI 1.2 to 4.0; p=0.005) and a significant negative association with a lacunar event (OR0.4; 95%CI 0.2 to 0.8; p=0.01). When complete occlusion occlusion was included in the severe stenosis group, logistic regression showed independent association with an ipsilateral bruit (OR 6.9; p<0.001), a previous TIA ()R2.3, p=0.002) and peripheral vascular disease (OR1.9, p<0.01) and an independent negative association a lacunar event (OR0.3; p<0.001). Strategy Sensitivity (%) Specificity (%) % of stenosis missed No. to screen to detect one severe stenosis Test all patients Ipsilateral bruit Diabetes Previous TIA Not lacunar event Any one of the above Any two of the above Any three of the above

5 Mead GE, Shingler H, Farrell A et al. disease in acute stroke. Age Ageing. 1998; 27(6): Ref ID 2497 N=305 Patients with acute stroke admitted to hospital. Patients were classified according to the Oxfordshire Community Stroke Project criteria (OCPS). 341 patients presented with focal neurological disease lasting between 24 hrs and 7 days and were classified as acute stroke. CT results were available for 107/305 patients: 140 of these showed an infarct (or multiple infarcts) and 30 showed no infarct. The OCSP classification devided the 305 patients into 100 with total anterior circulation infarct (TACI) (33%), 101 with posterior anterior circulation infarct (PACI) (33%), 80 with lacunar infarct (LACI) (26%) and 24 with posterior circulation infarct (POCIs) (8%). The median time from stroke onset to assessment was 2 days (range 0 to 7) arteries were initially examined using a portable continuous wave. Those with abnormal portable assessments underwent colour imaging. NA NA OCSP criteria as predictors of carotid disease * OCSP criteria as predictors of carotid disease Severe (70 to 99%) stenosis was found in 16 (16%; 95%CI 9 to 23%) of the PACI group, four (4%; 0 to 8%) of the TACI group and one (4%; 0 tp 8%) of the POCI group (χ² p<0.05). Complete carotid occlusion was found in 25 (25%) of the TACI group, 11 (11%) of the PACI group, 3 (4%) of the LACI group and none in the POCI group Severe carotid stenosis or occlusion was more frequent in the ipsilateral than the contralateral disease in the LACI and POCI groups. If the OCSP classification is used to detect patients with 70 to 99% carotid stenosis, then the sensitivity is 76% and the specificity of 70%

Redgrave JN, Coutts SB, Schulz UG et al. Systematic review of associations between the presence of acute ischemic lesions on

Redgrave JN, Coutts SB, Schulz UG et al. Systematic review of associations between the presence of acute ischemic lesions on 6. Imaging in TIA 6.1 What type of brain imaging should be used in suspected TIA? 6.2 Which patients with suspected TIA should be referred for urgent brain imaging? Evidence Tables IMAG1: After TIA/minor