Q. Neurology
A 71 year old man goes for a screening test in one of the mobile units that screen patients for a fee in community based services.
It is a well known service that finds that the patient has a problem with his left carotid artery.
He comes to you as a protocol followed for follow up of an abnormal result.
You request a full carotid study. It shows that the patient has a stenosis of 70% on the right side.
What should you tell the patient?
1. Such community based programs have not proven to be of benefit to outcome in carotid stenosis in asymptomatic individuals.
2. Schedule for Carotid endarterectomy
3. Conduct a cardiac evaluation to schedule CABG if necessary during the same hospitalization
4. Report the screening program to the state medical board.
The correct answer is 1. This is explained in the writing below.
2. Consensus against both endarterectomy and routine screening for asymptomatic carotid
artery stenosis. Canadian Stroke Consortium
Perry JR, Szalai JP, Norris JW
Archives of Neurology. 1997 Jan;54:258: Issue: 1
Role of carotid endarterectomy for asymptomatic patients is controversial.
Validated evidencebased guidelines are needed.
Canadian Stroke Consortium, an independent body of cerebrovascular disease experts, reviewed evidencebased guidelines developed by the Canadian Task Force on the Periodic Health Examination
They found a high level of interrater agreement for all guidelines using
multiple statistical measures. Members agreed that evidence is insufficient to
endorse carotid endarterectomy for asymptomatic patients with angiographically proven
stenosis of more than 60% (kappa = 0.70, P < .01). Reasons cited included concern over
the reproducibility of low surgical morbidity rates in the community at large, the
questionable clinical benefit conferred by surgery, and the lack of proven
reduction in the risk of major disabling stroke. Screening the general population for
asymptomatic stenosis was unanimously rejected. Also, screening even
patients with risk factors or proven atherosclerosis at other sites was not endorsed
(kappa = 0.91 and kappa = 0.79, respectively, both P < .01). CONCLUSIONS: There
is insufficient evidence to recommend carotid endarterectomy for asymptomatic patients.
Evidence is also insufficient to endorse a screening strategy even for patients with risk
factors for carotid disease. While stroke prevention remains a critical goal,it is
not recommend that it be accomplished by screening or by performing carotid surgery in
asymptomatic patients.
Editor's Note: The above concept has been overturned in 1998-1999 and then again proven to be true in 2000-2001. "Good old medicine!"