national-clinical-guidelines-for-stroke-fourth-edition

D People with an acute non-disabling stroke with stable neurological symptoms or with
a TIA who have symptomatic carotid stenosis of 50–99% according to the NASCET
criteria should:
● be assessed and referred for carotid endarterectomy to be performed within 1 week
of onset of symptoms
● receive best medical treatment (control of blood pressure, antiplatelet agents,
cholesterol lowering through diet and drugs, and lifestyle advice including smoking
cessation).
E People with an acute non-disabling stroke or TIA who have carotid stenosis of less
than 50% according to the NASCET criteria should:
● not undergo surgery
● receive best medical treatment (eg control of blood pressure, antiplatelet agents,
cholesterol lowering through diet and drugs, and lifestyle advice including smoking
cessation).
F The process and outcomes of carotid interventions should be routinely measured
using national audit.
G Where patients have repeated attacks of transient neurological symptoms despite best
medical treatment, and an embolic source has been excluded, an alternative
neurological diagnosis should be considered.
H Carotid endarterectomy should be the treatment of choice for patients with
symptomatic carotid stenosis, particularly those who are 70 years of age and over.
I Carotid angioplasty and stenting should be considered in patients meeting the criteria
for carotid endarterectomy but are considered unsuitable for open surgery (eg high
carotid bifurcation, symptomatic re-stenosis following endarterectomy, radiotherapy
associated carotid stenosis).
4.4.2 Sources
A Rothwell et al 2007; Consensus
B National Institute for Health and Clinical Excellence 2008b
C Consensus
D–E National Institute for Health and Clinical Excellence 2008b
F–G Consensus
H–I Economopoulos et al 2011; International Carotid Stenting Study investigators et al
2010
4.4.3 Implications
4 Acute phase care
These recommendations will require significant streamlining of clinical pathways. They
may increase the total number of carotid endarterectomies undertaken in the UK but the
number of operations performed for asymptomatic disease should fall and certainly not
increase.
© Royal College of Physicians 2012 43