Gold Standard Treatment of Carotid Stenosis: Carotid Surgery or Stent?

In carotid stenosis, conflicting conclusions have been drawn about the correlation between plaque morphology, patients’ embolic risk and its treatment by carotid endarterectomy when compared with angioplasty and stenting. In a prospective interdisciplinary study of 468 patients with carotid artery stenoses, we compared plaque morphology, examined by ultrasound, with the histological diagnosis. High-intensity transient signals (HITS) were detected by transcranial Doppler during carotid endarterectomy and carotid stenting. Preoperative ultrasound examinations were found to have a sensitivity of 80% in detecting soft and hard plaques. The accuracy for estimating the degree of stenosis was 98%. In the case of stroke in progression and complete stroke, histological examination found ulcerations in 72% of patients, whereas ultrasound had detected these ulcerations in only 53%. A significantly higher number of transient ischemic attacks and strokes occurred in patients with soft plaques than in asymptomatic patients, who tend to present with hard plaques. The number of HITS during carotid angioplasty and stenting was 8–10 times higher than during operation. Patients with soft plaques seem to have a higher risk of postoperative permanent neurological deficit. Dangerous plaque formation with thrombotic or ulcerous material was not accurately detected by ultrasound. Therefore the risk of embolisation cannot be predicted efficiently by means of Duplex scanning, which, however, is especially important for carotid stenting.