SYMPOSIUM RECOMMENDATIONS FOR STROKE MANAGEMENT

1
- SYMPOSIUMRECOMMENDATIONS FOR STROKE
MANAGEMENT
European Federation of Neurological
Societies EFNS Copenhagn 2000
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RECOMMENDATIONS FOR STROKE MANAGEMENT

• Part 1 Organizing Modern Stroke Care Tom
  Skyhoj Olsen, Copenhagn (DEN)
• Part 2 Risk Factors and Primary
  Prevention Julien Bogousslavsky, Lausanne
  (SUI)
• Part 3 Acute Stroke Care - General
  Therapy Markku Kaste, Helsinki (FIN)
• Part 4 Acute Stroke Care - Specific
  Therapy Werner Hacke, Heidelberg (GER)
• Part 5 Rehabilitation and Secondary
  Prevention Jean-Marc Orgogozo, Bordeaux (FRA)

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RECOMMENDATIONS FOR STROKE MANAGEMENT

• Part 1 Organizing Modern Stroke Care Tom
  Skyhoj Olsen, Copenhagn (DEN)

4
RECOMMENDATIONS FOR STROKE MANAGEMENT

• Part 2 Risk Factors and Primary
  Prevention Julien Bogousslavsky, Lausanne
  (SUI)

5
RECOMMENDATIONS FOR STROKE MANAGEMENT

• Part 3 Acute Stroke Care - General
  Therapy Markku Kaste, Helsinki (FIN)

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RECOMMENDATIONS FOR STROKE MANAGEMENT

• Part 4 Acute Stroke Care - Specific
  Therapy Werner Hacke, Heidelberg (GER)

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RECOMMENDATIONS FOR STROKE MANAGEMENT

• Part 5 Rehabilitation and Secondary
  Prevention Jean-Marc Orgogozo, Bordeaux (FRA)

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Definitions of Levels of Evidencemodified from
Adams et al. 1994

• Level I Highest Level of Evidence
• Sources a) Primary endpoint of double blind RCT
  with adequate sample size
• b) Meta-analysis of qualitatively outstanding
  RCTs
• Level II Intermediate Level of Evidence
• Sources a) Randomised not blinded trials
• b) Small randomised trials
• c) Predefined secondary endpoints of large
  RCTs
• Level III Lower Level of Evidence
• Sources a) Prospective case series with
  concurrent or historical control
• b) Post hoc analyses of large RCTs
• Level IV Undetermined Level of Evidence
• Sources a) Small uncontrolled case series
• b) General agreement despite lack of evidence

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Acute Stroke Care-Emergency Diagnostic Tests

• Differentiation between different types of stroke
• Ruling out other brain diseases
• Assessing the underlying cause of brain ischemia
• Providing a basis for physiological monitoring of
  the stroke patient
• Identifying concurrent diseases or complications
  associated with stroke

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Emergency Diagnostic Tests

• Cranial computed tomography (CCT)
• distinguishes reliably between hemorrhagic and
  ischemic stroke
• early signs of ischemia detected as early as 2 h
  after stroke onset
• identifies hemorrhages almost immediately
• detects SAH in the majority of cases
• helps to identify other neurological diseases
  (e.g. neoplasms)

11
Emergency Diagnostic Tests

• Magnetic resonance imaging (MRI)
• only helpful in centres using modern MRI
  techniques
• diffusion- and perfusion-weighted MRI may help to
  differentiate between infarcted tissue and tissue
  at risk

12
Emergency Diagnostic Tests

• Electrocardiogram
• high incidence of heart involvement in stroke
  patients
• coincidence of stroke and myocardial infarction
• ischemic stroke may cause arrhythmias
• detection of atrial fibrillation as a possible
  cause of embolic stroke

13
Emergency Diagnostic Tests

• Ultrasound studies
• cw/pw- Doppler and/or duplex sonography of the
  extracranial cervical and the basal intracranial
  arteries
• identification of vessel stenosis, occlusion,
  state of collaterals, or recanalisation
• transesophageal echocardiography to screen for
  cardiogenic emboli (not in the ER but recommended
  within the first 24 h after stroke onset)

14
Emergency Diagnostic Tests

• Laboratory tests
• hematology
• clotting parameters
• electrolytes
• renal and hepatic chemistry
• cardiac enzymes
• basic parameters of infection

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Emergency Diagnostic Tests

• EUSI Recommendations
• 1. CCT is the most important diagnostic tool in
  patients with suspected stroke (Level IV)
• 2.Early evaluation of physiological parameters,
  blood chemistry and hematology, and cardiac
  function (ECG, pulsoximetry, chest x-ray) is
  recommended in the management of acute stroke
  patients

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Emergency Diagnostic Tests

• EUSI Recommendations
• 3. Cardiac and Neurological ultrasound should be
  readily available (Level IV)

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Acute Stroke Care-General Management

• EUSI-recommendations include
• Pulmonary and airway care
• Blood pressure
• Body temperature
• Glucose metabolism
• Fluid and electrolyte management

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General Management

• Monitoring of vital and neurological functions
• continuous monitoring
• heart rate
• O2 saturation
• discontinuous monitoring
• Blood pressure (e.g. automatic inflatable
  sphygmomanometry)
• Clinical Vigilance / GCS, pupils
• Neurological (e.g. NIH and Scandinavian stroke
  scale)

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General treatment

• Pulmonary function and airway protection
• Adequate oxygenation important for preservation
  of the penumbra
• Improved blood oxygenation by administration of gt
  2 l O2 (SO2 -guided)
• Risk for aspiration in patients with
  pseudobulbar/bulbar paralysis and reduced
  vigilance side positioning, consider
  tracheotomia
• Consider hypoventilation by pathological
  respiration pattern
• Risk of airway obstruction (vomiting,
  oropharyngeal muscular hypotonia) mechanical
  airway protection

20
General treatment

• Blood pressure (BP)
• elevated in most of the patients with acute
  stroke
• Flow in the critical penumbra passively dependent
  on the mean arterial pressure
• Sufficient post-stenotic flow requires high blood
  pressure

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General treatment

• Blood pressure
• There are no controlled, randomised studies
  guiding BP management
• Recommended target BP in patients with prior
  hypertension 180 / 100-105 mmHg
• Recommended target BP in previously normotonic
  patients 160-180 / 90-100 mmHg
• Avoid and treat hypotension or drastic reductions
  in BP

22
General treatment

• Blood pressure
• Indications for immediate antihypertensive
  therapy in acute stroke
• Non-ischemic cause for stroke
• Cardiac insufficiency
• Aortic dissection
• Acute renal failure
• Hypertensive encephalopathy

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General treatment

• Body temperature
• Facts
• Fever negatively influences neurological outcome
  after stroke
• Experimentally, fever increases infarct size
• Many patients with acute stroke develop a febrile
  infection after stroke
• Although no controlled trial supporting treatment
  of an elevated temperature, consider to treat
  fever when the body temperature reaches 37.5C
  rectally

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General treatment

• Glucose metabolism
• Facts
• Pre-existent diabetic metabolic derangement can
  be worsened
• High glucose levels in the acute phase of stroke
  may increase the size of the infarction and
  reduce functional outcome
• Hypoglycemia worsens outcome as well
• Hypoglycemia can mimic an acute ischemic
  infarction

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General treatment

• Fluid and electrolyte management
• Serious electrolyte abnormalities are rare after
  ischemic stroke but frequent after ICH and SAH
• Balanced electrolyte and fluid status are
  important to avoid
• plasma volume contraction
• raised hematocrit
• impaired rheologic properties

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General treatment

• EUSI Recommendations
• 1. Neurological status and vital functions should
  be monitored
• 2. Glucose and body temperature should be
  monitored and corrected, if elevated (Level III)
• 3. Do not treat hypertension in patients with
  ischemic stroke, if they do not have critically
  elevated BP levels (Level III)

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General treatment

• EUSI Recommendations
• 4. Secure airways and supply oxygen to patients
  with severe acute stroke (Level IV)
• 5. Monitoring and correction of electrolyte and
  fluid disturbances are advised (Level IV)

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Acute Stroke Care-Specific Treatment

• EUSI-recommendations include
• Acute anti-thrombotic therapy
• Thrombolytic therapy
• Defibrinogenating enzymes
• ASA
• Neuroprotection
• Treatment of elevated ICP and brain edema
• Medical treatment
• Surgical treatment

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Thrombolytic Therapy

• IV-Thrombolysis (rtPA)
• Facts (NINDS Pt. 1 2, ECASS I II, ATLANTIS)
• 3h time window approved in USA, CDN, MEX, I.V.
  0.9mg/kg, max 90mg
• Not yet approved in Europe
• Efficacy signal beyond 3h (meta-analysis)
• IV-Thrombolysis (SK)
• Facts (MAST-I, MAST-E, AST)
• Although some efficacy signal in early time
  windwow, SK currently abandoned

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Thrombolytic Therapy

• IA-Thrombolysis (rtPA, UK)
• Facts
• Only cases and some prospective uncontrolled case
  series
• IA-Thrombolysis (rPUK)
• Facts (PROACT I and II)
• Efficacy proven in small RCT, 6h window,
• Not approved, PROACT III?

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Thrombolytic Therapy

• EUSI Recommendations (for centers offering
  thrombolysis)
• 1. I.V. rtPA (0.9mg/kg max 90mg, 10 bolus,
  followed by 60 min infusion) is recommended
  within 3 hours after stroke onset (Level I)
• 2. The benefit from the use of I.V. rtPA beyond 3
  hours is smaller, but present in selected
  patients (Level I)
• 3. I.V. rtPA is not recommended when time of
  onset is uncertain

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Thrombolytic Therapy

• EUSI Recommendations (for centers offering
  thrombolysis)
• 4. I.V. SK outside of the setting of acontrolled
  clinical trial is dangerous and not indicated for
  the management of persons with ischemic stroke
  (Level I)
• 5. Intra-arterial treatment of acute M1 occlusion
  in a 6 h time window using rPUK results in a
  significantly improved outcome (Level II)
• 3. Acute BA-occlusion may be treted with I.A,
  therapy in selected centers (Level IV)

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Defibrinogenating Therapy

• ANCROD
• Treatment of acute ischemic stroke with I.V.
  Ancrod in a 3 h time window results in
  significantly improved outcome (primary endpoint
  only (STAT)
• Futility analysis of 6 h trial (ESTAT) led to
  premature termination of the trial

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Defibrinogenating Therapy

• EUSI Recommendation
• 1. Ancrod given in a 3 h time window
  significantly improves outcome after acute
  ischemic stroke (Level II)

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Platelet Inhibitors

• ASA
• only substance tested in acute (lt48 h) stroke
  (IST, CAST)
• CT not required for randomisation
• small but significant reduction of mortality and
  recurrence of stroke in combined analysis of both
  trials

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Platelet Inhibitors

• EUSI-recommendation
• 1. Aspirin 100-300 mg/day may be given to an
  unselected stroke population (Level II)

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Therapeutic Anticoagulation

• Unfractionated heparin
• no formal trial available testing standard I.V.
  heparin
• IST showed no benefit for sc heparin treated
  patients, increased risk of ICH
• Low molecular weight heparins
• Postive effect seen in small pilot trial (Kay
  1995) was not found in subsequent trial (fisBIS)
• Heparinoid (Orgaran)
• TOAST trial negative

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Therapeutic Antioagulation

• EUSI-recommendation
• 1. There is no recommendation for the general use
  of heparin, low molecular weight heparines or
  heparinoids after ischemic stroke (Level I)
• 2. Full dose heparin may be used in selected
  indications such as AF, other cardiac sources
  with high risk of re-embolism, arterial
  dissection, or high grade arterial stenosis
  (Level IV)
• 3. Administration for DVT-prophylaxis see general
  treatment

39
Neuroprotection

• Up to now, not a single neuroprotective substance
  has been shown to influence outcome after stroke.
• Currently there is no recommendation to treat
  patients with neuroprotective drugs after
  ischaemic stroke (Level I)

40
Elevated Intracranial Pressure and Brain Edema
Treatment

• Medical therapy
• Basic management
• Head positioning lt30
• Pain relief and sedation
• Normothermia
• Osmotic agents
• Glycerol
• Mannitol
• Hypertonic saline
• Barbiturates, hyperventilation and THAM-buffer

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Elevated Intracranial Pressure and Brain Edema
Treatment

• Surgical Therapy
• Ventricular drainage
• Posterior fossa space occupying infarction
• Thalamic infarction (rare)
• Decompressive surgery
• Posterior fossa space occupying infarctian
• Malignant MCA/hemispheric infarction
• Encouraging reduction of mortality with decent
  outcome i prospective case series
• RCT (HEADFIRST) starts recruiting

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Elevated Intracranial Pressure and Brain Edema
Treatment

• EUSI-recommendations
• 1. Osmotherapy is recommended for patients whose
  condition is deteriorating secondary to increased
  ICP, including those with herniation syndromes
  (Level III)
• 2. Surgical decompression of large cerebellar
  infarctions that compress the brainstem is
  justified (Level III)
• 3.Surgical decompression of large hemispheric
  infarction can be life-saving (Level III)

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Stroke Units

• Definition
• Hospital or part of a hospital that (nearly)
  exclusively takes care of stroke patients
• Specialised staff with multidisciplinary approach
  to treatment and care
• Core disciplines medical treatment, nursing,
  physiotherapy, occupational therapy, speech and
  language therapy, social work

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Stroke Units

• Facts (Stroke Unit Trialists Collaboration)
• Acute treatment in a stroke unit results in
  significant reduction in mortality, death,
  dependence, or need of institutional care in
  comparison to a general medical ward

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Stroke Units

• Types of stroke units
• 1. Acute stroke unit
• acute treatment lt 1 week (2-3 days)
• 2. Combined acute and rehabilitation stroke unit
• acute phase reha for several weeks / months
• 3. Rehabilitation stroke unit
• admission after 1to 2 weeks after stroke onset
• 4. Mobile stroke team
• offers stroke care and treatment on a variety of
  wards

46
Stroke Units

• EUSI Recommendations
• 1. Stroke patients should be treated in
  specialised stroke units (Level I)

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Rehabilitation

• Early rehabilitation
• 40 of stroke patients need active reha services
• active rehabilitation should start as soon as
  possible
• if the patient is unconscious, rehabilitation is
  passive to prevent contractions and other
  immobilisation-associated complications

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Rehabilitation

• Rehabilitation programs
• - Assessment for the degree of disability
  (motor, cognitive, sensory, visual)
• - Assessment of the ability to respond to
  rehabilitation (financial burden, chances to
  return to social activities and work and to live
  alone, need of help)
• - adaptation of the intensity of the
  rehabilitation to status and the degree of
  disability

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Rehabilitation

• Rehabilitation programs
• - daily documentation of the patients progress
• - teaching and involvement of the patient and
  his family members
• - home visitation as early as possible (smoothing
  the transit, increasing motivation)
• - planning the transfer to a specialised
  rehabilitation hospital if a longer reha period
  is expected

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Rehabilitation

• ideal multidisciplinary stroke team for adequate
  rehabilitation
• - stroke physician and nurses experienced in
  stroke management
• - physiotherapist, speech therapist and
  occupational therapist trained in stroke
  rehabilitation
• - neuropsychologist and social worker accustomed
  to stroke rehabilitation

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Rehabilitation

• EUSI Recommendations
• 1. Rehabilitation should be initiated early after
  stroke (Level I)
• 2. Every patient should have access to evaluation
  for rehabilitation (Level III)
• 3. Rehabilitation services should be provided by
  a multidisciplinary team (Level III)

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Primary Prevention

• Conditions and lifestyle factors identified as a
  risk for stroke
• arterial hypertension
• myocardial infarction
• atrial fibrillation
• diabetes mellitus
• elevated cholesterol levels
• carotid artery disease
• smoking
• alcohol use
• physical activity

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Primary Prevention

• Hypertension
• Facts
• most prevalent and modifiable risk factor for
  stroke
• significant reduction of stroke incidence with a
  decrease of 5 mmHg in diastolic BP or teatment of
  isolated systolic BP elevation

54
Primary Prevention

• Diabetes mellitus
• Facts
• independent risk factor for ischemic stroke
• strict control of blood glucose not established
  for stroke prevention
• elevated blood glucose at stroke onset worsens
  mortality and functional outcome

55
Primary Prevention

• Hypercholesterolemia
• Facts
• no strong association between serum cholesterol
  levels and stroke
• reduction in the relative risk of stroke with
  pravastatin therapy
• reduction of stroke mortality by statin therapy
  controversial

56
Primary Prevention

• Cigarette smoking
• Facts (Cohort studies)
• independent risk factor for ischemic stroke in
  men and women
• 6-fold risk compared to non-smokers
• 50 risk reduction by stop of smoking

57
Primary Prevention

• Alcohol consumption
• decreased risk by moderate consumption (men
  20-30 mg/die)
• increased risk for both ischemic and hemorrhagic
  stroke by heavy alcohol consumption

58
Primary Prevention

• Physical activity
• Facts
• vigorous exercise is associated with a decreased
  risk of stroke
• this effect may be mediated by reduction in body
  weight, BP, cholesterol and increased glucose
  tolerance

59
Primary Prevention

• Antithrombotic drugs
• Facts
• trend to higher incidence of disabling strokes
  (hemorrhagic) by aspirin ingestion (325-500
  mg/die) in males
• no risk alteration in women
• risk reduction in MI for both men and women

60
Primary Prevention

• EUSI-recommendations
• 1. BP measurement should be an essential
  component of regular health care visits BP
  should be lowered to normal (140/85 mmHg) values
  by means of life-style and/or pharmacological
  treatment (Level I)
• 2. Although strict control of glucose or high
  cholesterol levels has not been proven to be
  associated with a decreased risk of stroke, it
  should be encouraged because of benefits in terms
  of other diseases (Level III)

61
Primary Prevention

• EUSI-recommendations
• 3. In coronary patients, treatment with
  simvastatin or pravastatin clearly reduces the
  risk of stroke (Level II). Statins should be
  prescribed in patients with CHD and high or
  moderate cholesterol levels the benefits of
  statins probably extend to patients with stroke
  and high cholesterol levels.
• 4. Cigarette smoking should be discouraged (Level
  II)

62
Primary Prevention

• EUSI-recommendations
• 5. Heavy use of alcohol should be avoided,
  while moderate consumption may be permitted
  (Level II)
• 6. Regular physical activity is recommended
  (Level II)
• 7. There is no scientific support for prescribing
  aspirin to reduce the risk of stroke in
  asymptomatic patients (Level I) however, aspirin
  may reduce the risk of MI (Level I)

63
Primary Prevention

• Atrial fibrillation (AF)
• Facts
• average stroke rate of 5 per year
• warfarin reduces the rate of ischemic strokes by
  25
• anticoagulation with an INR of 2.0 to 3.0 reduces
  the rate of ischemic and hemorrhagic events by
  80 when compared to below 2.0, where
  non-significant reduction in thromboembolic
  events is seen
• unacceptable risk for bleeding complications with
  an INR gt 5.0

64
Primary Prevention

• Atrial fibrillation
• Facts
• aspirin (300 mg) achieves a pooled risk reduction
  of 21
• aspirin is less efficacious than warfarin
• patients less than 65 years of age with lone AF
  are at low risk, whereas patients older than 65
  years are at moderate risk for embolic stroke

65
Primary Prevention

• Atrial fibrillation EUSI-recommendations
• 1. Long-term oral anticoagulation therapy (target
  INR 2.5 range 2.0 - 3.0) should be considered
  for all AF patients who are at high risk for
  stroke (Level I)
• 2. Patients aged less than 65 years with no
  cardiovascular disease or patients who are unable
  to receive anticoagulants should be offered 300
  mg aspirin per day (Level I)

66
Primary Prevention

• Atrial fibrillation EUSI-recommendations
• 3. Although not yet established by randomised
  studies, patients over 65 years of age without
  risk factors could be offered both AC and aspirin
  300 mg/ day (Level III)
• 4. Although not yet established by randomised
  studies, patients over 75 years of age, warfarin
  may be used with a lower INR (target INR of 2.0
  range 1.6. - 2.5) to decrease the risk of
  hemorrhage (Level III)

67
Primary Prevention

• Asymptomatic carotid artery stenosis
• CEA is still a matter of controversy
• 5-year relative risk reduction by CEA for carotid
  artery stenosis gt65 of 50 (absolute reduction
  about 6)
• absolute risk reduction by medical treatment of
  11/ 5 years

68
Secondary Prevention

• Antithrombotic drugs
• Aspirin Facts
• 25 risk reduction
• optimal dose still matter of debate
• no proven advantage by low (lt 160 mg) versus
  medium (160 - 325) or high (500 - 1500 mg) doses

69
Secondary Prevention

• Antithrombotic drugs
• Dipyridamole aspirin
• ESPS II risk reduction of stroke with a
  combination is significantly higher (37) than
  with aspirin alone

70
Secondary Prevention

• Antithrombotic drugs
• Clopidogrel
• CAPRIE Clopidogrel is slightly but significantly
  more effective than medium-dose aspirin

71
Secondary Prevention

• EUSI-recommendations
• 1. Low- or medium-dose ASA (50-325 mg) should be
  given as first-choice agent to reduce stroke
  recurrence (Level I).
• 2. Alternatively, where available, the
  combination of ASA (25 mg) and dipyridamole (200
  mg) twice daily may be given as first choice
  (Level I)

72
Secondary Prevention

• EUSI-recommendations
• 3. Clopidogrel is slightly more effective than
  aspirin (Level I). It may be prescribed as
  first-choice or when aspirin is not tolerated or
  efficacious, and in special indications, such as
  in high-risk patients (Level III)

73
Secondary Prevention

• EUSI-recommendations
• 4. Patients starting treatment with
  thienopyridine derivatives should receive
  clopidogrel instead of ticlopidine since it has
  fewer side-effects (Level I)
• patients who have already been treated with
  ticlopidine for a long time should be maintained
  on this regimen because the most severe
  side-effects (neutropenia and rash) appear at the
  beginning of treatment

74
Secondary Prevention

• EUSI-recommendations
• 5. Patients who do not tolerate both ASA or
  clopidogrel may be treated with dipyridamol ret
  2x200 mg daily (Level I)

75
Secondary Prevention

• Anticoagulation after thromboembolic stroke
• Facts (EAFT)
• oral anticoagulation with an INR of 2 - 3 reduces
  the risk of recurrent stroke in patients with AF
• Oral anticoagulation is well established for
  other causes of embolism such as mechanical
  prosthetic valve replacement, rheumatic valvular
  heart disease, ventricular aneurysm,
  cardiomyopathy, or PFO

76
Secondary Prevention

• EUSI-recommendation
• 1. Oral anticoagulation (INR 2.0 - 3.0) is
  indicated after stroke associated with
  AF (Level I)
• 2. Patients with mechanical prosthetic valves
  should receive long-term anticoagulation therapy
  with a target INR between 3.0 and 4.0 (Level III)

77
Secondary Prevention

• EUSI-recommendation
• 3. Patients with proven cardioembolic stroke
  should be anticoagulated if the risk of
  recurrence is high, with a target INR between
  2.0 and 3.0 (Level III)

78
Secondary Prevention

• Carotid Endarterectomy (CEA)
• Facts (NASCET, ECST)
• surgery is efficacious for symptomatic patients
  with ipsilateral carotid stenosis gt 70
• if perioperative complications exceed 2.5 , the
  benefit of CEA will diminish if it approaches
  10, the benefit will vanish entirely
• there is also some risk reduction in male
  patients with 50 - 69 stenosis of the
  ipsilateral carotid artery

79
Secondary Prevention

• Percutaneous Transluminal Angioplasty (PTA)
• Advantages
• short hospital stay
• avoidance of general anesthesia and surgical
  incision
• ability to treat surgically inaccessible sites
• PTA and stenting as most effective means of
  treating restenosis after CEA
• preliminary results of controlled
  trialscomparable procedural risks compared to CEA

80
Secondary Prevention

• EUSI-recommendations
• 1. CEA is indicated in symptomatic patients with
  stenosis of 70 - 90. This is valid only for
  centres with a perioperative complication rate
  (all strokes and death) lt 6 (Level I)

81
Secondary Prevention

• EUSI-recommendations
• 2. CEA may be indicated in some patients with
  stenosis of 50 - 59 without a severe neurologic
  deficit. This is valid only for centres with a
  perioperative complication rate of lt 6. Males
  with recent hemispheric symptoms are the subgroup
  of patients most likely to benefit from surgery
  (Level I)

82
Secondary Prevention

• EUSI-recommendations
• 3. CEA is not recommended for symptomatic
  patients with stenosis lt 50 (Level I)
• 4. CEA should not be performed in centres not
  exhibiting equally low complication rates like
  NASCET or ECST.

83
Secondary Prevention

• EUSI-recommendations
• 5. CEA may be indicated for some patients with
  stenosis between 60 and 99. Only patients with a
  low surgical risk (lt3) and a life expectancy of
  at least 5 years are likely to benefit from
  surgery (Level II)

84
Primary Prevention

• EUSI-recommendations
• 6. Surgery for asymptomatic carotid stenosis is
  not generally recommended (Level II).
• 7. It may be recommended in individual patients
  if the surgical risk is low

85
Secondary Prevention

• EUSI-recommendations
• 8. Carotid PTA with or without stenting may be
  performed in patients with
  contra-indications to CEA (Level IV)
• 9. Carotid PTA with or without stenting may be
  indicated in patients with stenosis at
  surgically inaccessible sites (Level IV)
• 10. Carotid PTA and stenting may be indicated in
  patients with re-stenosis after initial CEA
  (Level IV)