New Stroke Risk Scoring System to Help Avoid Unnecessary Surgeries

Atherosclerosis is a condition in which blood vessels become narrowed and hardened due to the accumulation of plaque, including in the carotid arteries, which transport blood from the heart to the brain. This condition can lead to serious health complications, such as strokes and heart attacks. Atherosclerosis is common, especially among individuals over the age of 65, smokers, and those with high cholesterol, hypertension, or a family history of heart or circulatory diseases. It is estimated that atherosclerosis in the carotid arteries contributes to up to 20% of strokes. Currently, many patients with this condition undergo surgery or stenting to prevent strokes. However, these procedures also carry risks, including the potential for stroke and other serious complications during the intervention. Now, a new scoring system designed to assess the risk of stroke in patients with narrowed arteries due to atherosclerosis could help reduce unnecessary surgeries and stent placements.

The Carotid Artery Risk (CAR) scoring system, developed by researchers at University College London (UCL, London, UK) and the University of Oxford (Oxford, UK), takes various factors into account, such as the degree of narrowing in the carotid artery and the patient's medical history, to determine who has a low to intermediate risk of stroke over the next five years. In the new collaborative study, published in The Lancet Neurology, UCL researchers found that the CAR scoring system could provide a safer alternative by identifying patients who could be effectively treated with a combination of medications and lifestyle modifications tailored to their individual risk factors—referred to as optimized medical therapy. The study evaluated the CAR score's effectiveness through a randomized clinical trial involving 428 patients across 30 centers in the UK, Europe, and Canada. All participants were over 18 and had significant narrowing of their carotid arteries, detected either before symptoms appeared or after a minor stroke occurred.

The researchers selected patients with symptoms based on their CAR scores to determine eligibility for the trial. Those with high scores were excluded and recommended for immediate surgery or stenting. The patients were then divided into two groups: one received only optimized medical therapy, while the other group received both optimized medical therapy and additional carotid surgery or stenting. Optimized medical therapy included a low-cholesterol diet, cholesterol-lowering medications adjusted to target levels, blood pressure-lowering treatments, antithrombotic therapy (to prevent blood clots), and regular check-ups to adjust medications as needed. Patients were monitored through regular visits, phone calls, and brain scans to detect any strokes. The results showed that, over two years, patients who received only optimized medical therapy had very low rates of recurrent strokes and heart attacks. In contrast, those who underwent additional surgery or stenting did not experience significant benefits, especially when considering the risks associated with these procedures.

“While further follow-up and additional trials are needed to confirm these findings, we recommend using the CAR score to identify patients with carotid narrowing who can be managed with optimized medical therapy alone,” said senior author, Emeritus Professor Martin Brown, UCL Queen Square Institute of Neurology. “This approach emphasizes personal assessment and intensive treatment of vascular risk factors, potentially sparing many patients from the discomfort and risks of carotid surgery or stenting. Additionally, this method could lead to substantial cost savings for health services.”