Exploration of a zero-tolerance regime on cerebral embolism in symptomatic carotid artery disease

Summary Background: Current protocols stress the importance of short-term diagnosis and treatment in recent TIA or minor stroke. The risk of a recurrent event can be predicted with embolus detection. Studies have shown that the presence of micro-emboli is associated with an increased risk of recurrent events. We explored in our patient population the effect of a zero-tolerance regime for cerebral embolism on outcome. Methods: Patients with a recent TIA or minor stroke were assigned to a study group or control group. Both groups were treated according to European Stroke guidelines, including prompt start of anti-thrombotic therapy, statins and short-term carotid arteries duplex scanning. The study group was subjected to TCD (Delica 9 series, Shenzen Delicate Electronics Co., LTD., China) embolus detection as soon as possible (EDS, SMT Medical, Wuerzburg, Germany). If emboli were detected, treatment was started immediately to stop cerebral embolization. This was achieved by either an altered drug regimen (clopidogrel) or angioplasty or carotid endarterectomy within one or two days. If carotid intervention was indicated in the control group, it was performed within two weeks, according to European guidelines. Results: 133 patients were enrolled in the study with three months follow-up. 61 patients were subjected to the control group, 72 patients were enrolled in the study group. Recurrent events occurred in 10.2% and 3.0%, respectively (p = 0.145). Conclusion: The current study shows a non-significant reduction in recurrent events in the study group. Probably sample size in this pilot study was insufficient to detect a significant decline. Nevertheless, the results show that embolus detection is feasible and the zero-tolerance regime may enhance the outcome of TIA and minor stroke patients. The findings support the start of a multicenter randomized trial to assess the clinical value of emboli detection in TIA and stroke care.