CRESCENDO TRANSIENT ISCHEMIC ATTACKS - A SURGICAL IMPERATIVE

Purpose: In a randomized, prospective, multicenter trial at 16 medical centers, 189 of 5000 patients screened with cerebrovascular disease were identified as having angiographic internal carotid artery stenosis (>50%) corresponding to presenting symptoms of transient ischemic attacks (TIAs), transient monocular blindness, or recent, minor completed stroke. Methods: Patients were randomly assigned to carotid endarterectomy plus the best medical care (n = 91) versus the best medical care alone (n = 98). Results: After 1 year there was a significant reduction in stroke or crescendo attacks in the 91 patients who received carotid endarterectomy (7.7%) compared with 98 patients who did not undergo operation (19.4%) (p = 0.011). Twelve (12%) of the 98 patients with symptomatic carotid stenosis treated medically had crescendo TIAs, four had minor strokes, and three had major strokes. Crescendo TIAs were defined as disabling, recurrent transient cerebral or retinal ischemia characterized by an increased frequency, duration, or severity of events. The average time from randomization until the onset of crescendo TIAs was 2 months. Seven of the 12 patients in whom crescendo TIAs developed had stenosis greater than 90%), one had greater than 80% stenosis, and four had between 70% and 80% stenosis, with one of these four having contralateral occlusion. Another three patients had 50% or greater contralateral occlusion. Patients with crescendo TIAs were offered carotid endarterectomy, and all 12 had an uncomplicated, urgent procedure. On follow-up the 12 patients were symptom free at the study conclusion. Conclusions: Crescendo TIAs are disabling symptoms that occur in patients with high-grade carotid stenoses often within 3 months of the initial symptoms of ischemic cerebrovascular disease. The 12% of medically treated patients in whom crescendo TIAs developed had carotid endarterectomy, which abolished symptoms on follow-up.