Why Doctors Say Not to Wait for the First Stroke
Atherosclerosis is a slow, silent process, and when it affects the carotid arteries in the neck, it can lead to a sudden stroke with no warning. The article focuses on how to manage significant carotid narrowing, especially in people who have no symptoms yet, and says a large new study in the New England Journal of Medicine is reshaping preventive thinking.
Prof. Michael Yonash, an internal medicine and cardiology specialist at Herzliya Medical Center, explains that atherosclerosis is the gradual buildup of fatty plaque in blood vessel walls. He says it can begin at a young age and progress for years without symptoms. Blood flow to the brain depends on four arteries, including the two carotid arteries in the neck, and when narrowing becomes severe, plaque or a clot can break off, travel to the brain, and trigger a stroke.
Severe narrowing is usually found with a carotid Doppler ultrasound and then a CT angiography scan for confirmation and treatment planning. In people with critical narrowing, or after a stroke, treatment beyond medication is usually recommended. The harder question is what to do when there are no symptoms, and that is where the CREST-2 trial comes in.
CREST-2 was conducted at 155 centers in the United States, Canada, Spain and Israel, and included more than 2,400 patients with asymptomatic narrowing of at least 70%. It compared intensive medication alone, open surgery, and catheter-based treatment with a stent. The study found that stenting reduced stroke rates over four years compared with medication alone, while surgery showed no statistical advantage over conservative treatment or over stenting.
Yonash says catheter treatment starts as a diagnostic procedure through an artery in the groin or arm under local anesthesia, and if significant narrowing is found it becomes therapeutic immediately. A protective filter is inserted first to stop debris from reaching the brain, then the artery is widened with a balloon and a stent is placed. The procedure usually takes 30 to 45 minutes, and the patient stays under observation until the next day. He says the most common mistake is assuming that no weakness or speech problem means the arteries are fine, when in fact the disease remains silent. High-risk groups include people with diabetes, high blood pressure, smoking history, high cholesterol, or known atherosclerosis elsewhere, such as in the heart or leg arteries.
