Diagnosis and management of transient ischaemic attack and ischaemic stroke in the acute phase

Dear Editor

Re: Diagnosis and management of transient ischaemic
attack and ischaemic stroke in the acute phase. McArthur, et al. BMJ
2011;342:(Published 31 March 2011)

In their clinical review the Authors state that the care for both
stroke and transient ischaemic attack (TIA) has improved in recent years,
but they recognize that despite this it remains an important cause of
death and disability. From a medical perspective they quite correctly
stress the need for early diagnosis, appropriate investigation, and
specialist care. However, they make little or no mention of carotid
revascularization, by surgical carotid endarterectomy or endovascular
means, as an important early proven treatment in selected patients(1).

There is robust evidence that patients with acute ischaemic stroke or TIA,
in the presence of an ipsilateral moderate or severe carotid stenosis,
benefit from early carotid endarterectomy to reduce the risk of recurrent
ipsilateral stroke(1,2). Indeed the recent report from the "United Kingdom
Audit of Vascular Surgical Services and Carotid Endarterectomy" again
highlights concerns about the delay from symptoms to treatment, stating
that many patients are not being treated within the timeframe set by NICE
or the National Stroke Strategy, and recommends there is significant room
for improvement in this area(3,4). In this respect this article on the
management of TIA and Stroke in the acute phase fails to stress the value
of proper multidisciplinary team assessment including consideration extra-
cranial causes of stroke such as carotid stenosis. It is important we
raise awareness amongst those managing acute stroke of the importance of
early assessment for symptomatic carotid stenosis using duplex ultrasound
scanning and when diagnosed the need for urgent referral (less than 48
hours) to vascular surgery for consideration of carotid revascularization.

The accumulating clinical evidence stresses the need for early carotid
revascularization in those patients with TIA or stroke due to symptomatic
carotid stenosis, who have stable or improving neurological symptoms(2).
Perhaps by highlighting this proven evidence based treatment amongst
physicians managing acute TIA and stroke we may reduce the currently
excessive delays in diagnosis and onward referral for treatment, and
reduce the current excessive risk of recurrent stroke in the early post-
stroke recovery period.

1. Rothwell PM, Eliasziw M, Gutnikov SA et al for the Carotid
Endarterectomy Trialists' Collaboration. Analysis of pooled data from the
randomised controlled trials of endarterectomy for symptomatic carotid
stenosis. Lancet 2003; 361: 107-116.

2. Rothwell PM, Giles MF, Chandratheva A et al. Effect of urgent
treatment of transient ischaemic attack and minor stroke on early
recurrent stroke (EXPRESS Study): a prospective population-based
sequential comparison. Lancet 2007; 370: 1432-42.

3. Prepared on behalf of The Clinical Standards Department Royal
College of Physicians of London. UK Audit of Vascular Surgical Services
& Carotid Endarterectomy. July 2010 Public Report.

4. Department of Health. National Stroke Strategy London 2007.
www.dh.gov.uk/stroke

Denis W Harkin MD FRCS FEBVS

Senior Lecturer & Consultant Vascular Surgeon

Royal Victoria Hospital Belfast