The Source for Neurovascular News and Education

March 29, 2024

Key Points:

  • Study examines shifts in carotid revascularization after ischemic stroke from 2005 to 2013
  • Time to revascularization diminished dramatically, but delays still exist

 

Great strides have been made in the provision of carotid revascularization within 14 days following an ischemic stroke, an evidence-based time frame set by American Heart Association (AHA) guidelines. Continued improvement is still needed, however, according to research published online December 6, 2016, ahead of print in Stroke.

To determine whether ever more patients are receiving timely care, Michael Reznik, MD, of Weill Cornell Medicine and Columbia College of Physicians and Surgeons (New York, NY), and colleagues analyzed validated International Classification of Diseases, Ninth Revision, Clinical Modification codes and administrative claims data from nonfederal hospitals in California, Florida, and New York.

The researchers identified 16,298 patients with ischemic stroke who underwent carotid endarterectomy (CEA) or stenting (CAS) within 90 days between 2005 and 2013.

During the study period, there was a substantial reduction in the time to revascularization for stroke patients, and the proportion of patients who underwent revascularization within the recommended 14-day time frame nearly doubled (table 1).

 

Table 1. Changes in Time to Treatment

 

2005

2013

P Value

Days From Stroke to Revascularization, Median (IQR)

25 (5-48)

6 (3-17)

.001

Proportion Revascularized ≤ 14 Days (95% CI)

40% (37%-43%)

73% (71%-76%)

.001

 

“It is certainly encouraging that more carotid revascularization procedures are occurring in a timely manner,” Dr. Reznik told NVX in an email. “However, our study highlights that there is still more work to be done in terms of making sure that as many eligible patients as possible receive these procedures in the timeframe recommended by current AHA guidelines.”

He speculated that a combination of factors likely prevents a larger proportion of patients from being revascularized on time, including “regional access to appropriately trained surgeons and interventionalists (especially in areas with fewer resources), regional disparities in overall access to healthcare, local variations in practice, and practitioners who remain unaware of current guidelines.”

Education Is Key

According to Dr. Reznik, education is the key to further reducing the time to revascularization. He recommended redoubling efforts to increase awareness of evidence-based guidelines, with emphasis placed on “both inpatient- and outpatient-based referrals for these procedures when they are indicated, with outreach to providers of all specialties who may be involved in such decisions.”

Some physicians may still hesitate to intervene in a timely manner, he noted. This is particularly the case for patients with multiple comorbidities (especially if lower-risk CAS is unavailable), patients with larger strokes in whom the acute risks of reperfusion injury and hemorrhage may be elevated, and those whose anatomy makes the intervention technically challenging. “Further studies aimed at addressing these procedures in certain higher-risk populations may be helpful in allaying physician concerns,” he suggested.

Perry Ng, MD, of Centura Health Physician Group (Denver, CO), reached the same conclusion about the findings. “Continued education about the high risk of recurrent stroke in the ensuing days to weeks after the initial event attributable to carotid stenosis would help increase the rate of early revascularization,” he told NVX. In addition, he noted, “the availability of endovascular stroke thrombectomy to reduce stroke volume in carefully selected patients would negate some of the concern of reperfusion injury after CEA/CAS in patients who would have otherwise had a much larger stroke volume.”

Dr. Ng advocated for centralization of stroke services in stroke centers capable of lytic therapy, mechanical thrombectomy, CEA, and CAS as a means of facilitating access to the most appropriate treatment and thus minimizing stroke volume.

 


Source:

Reznik M, Kamel H, Gialdini G, et al. Timing of carotid revascularization procedures after ischemic stroke. Stroke. 2016;Epub ahead of print.

 

Disclosures:

Drs. Reznik and Ng report no relevant conflicts of interest.