Stroke associated with a threefold increased future mortality in CREST

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Strokes, particularly those classified as severe, were uncommon after carotid intervention in the CREST trial. Strokes, however, were associated with significant morbidity and future mortality, a new analysis of the trial has shown. In the sub-analysis, published online ahead of print in Circulation, the authors stated that these strokes may be preventable.

“Stroke occurs more commonly after carotid artery stenting than carotid endarterectomy. Details regarding stroke type, severity, and characteristics have not been previously reported,” the investigators, led by Thomas G Brott, Mayo Clinic, Jacksonville, USA, wrote. In the sub-analysis, the group described the strokes occurring in CREST (Carotid revascularization endarterectomy versus stenting trial).

CREST is a randomised, open-allocation, controlled trial with blinded endpoint adjudication. Stroke was a component of the primary composite outcome. Patients who received their assigned treatment within 30 days of randomisation were included. Stroke was adjudicated by a panel of board-certified vascular neurologists with secondary central review of clinically-obtained brain images. Stroke type, laterality, timing, and outcome were reported.


A periprocedural stroke occurred among 81 of the 2,502 patients randomised and among 69 (3%) of the 2,272 in this analysis (patients who received their assigned treatment within 30 days of randomisation). The results of the sub-analysis showed that strokes were predominantly minor (81%, n=56), overwhelmingly ischaemic (90%, n=62), in the anterior circulation (94%, n=65), and ipsilateral to the treated artery (88%, n=61). There were seven haemorrhages, occurring 3–21 days post-procedure, and five were fatal. Major strokes occurred in 13 (0.6%) of the 2,272 patients. The estimated four-year mortality after stroke was 21.1% compared to 11.6% for those without stroke. The adjusted risk of death at four years was higher after periprocedural stroke (HR=2.78, 95% CI 1.63–4.76).


The authors wrote that although stroke was uncommon after carotid intervention, it was independently associated with a near threefold increased future mortality. “The delayed timing of major and haemorrhagic stroke after revascularisation suggests that these strokes may be preventable. Minor stroke occurred most commonly and temporally at the time of carotid artery stenting suggesting that carotid artery stenting has potential for further improvement from expected advances in technology, technique, and training,” they said.

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