Prevalence and outcome of symptomatic carotid lesions in young adults

Abstract Objective: To estimate the prevalence and outcome of symptomatic internal carotid artery lesions in young adults. Design: Multicentre hospital based observational study with five year follow up. Setting: Seven neurological departments in northern and central Italy. Subjects: 240 patients (115 men) aged 15-44 with a recent transient ischaemic attack or stroke in the carotid territory. Main outcome measures: (a) Prevalence of symptomatic internal carotid artery stenosis or occlusion detected by continuous wave Doppler ultrasonography at entry; (b) incidence rates of cerebral, cardiac, and non-vascular death; non-fatal stroke; and non-fatal myocardial infarction. Results: Carotid stenoses of 50-99% and occlusions were found in 38 patients (15.8%). Both conditions were significantly more frequent in patients aged over 35 and in those with hypertension, diabetes mellitus, and stroke at entry. The standardised mortality ratio at five years was 10.5 (95% confidence interval 5.0 to 19.3). Survival of patients with stenoses of 0-49% and occlusions was significantly better than that of patients with stenoses of 50-99%. Carotid stenosis of 50-99% was an independent predictor of death (hazard ratio 7.9; 95% confidence interval 2.2 to 29) and non-fatal stroke (hazard ratio 7.4; 1.5 to 37.4). Conclusions: The prevalence of carotid stenosis or occlusion in young adults after a cerebrovascular event is low. Though patients with high grade symptomatic carotid stenosis are at risk of non-fatal and fatal events, patients with internal artery occlusion apparently have a benign prognosis. Key messages Key messages Young adults with a history of transient ischaemic attack and stroke have a low prevalence of high grade symptomatic carotid artery stenosis and occlusion The five year prognosis is apparently benign in patients aged 15-44 with internal carotid artery occlusion but poor (in terms of fatal and non-fatal events) in the presence of high grade carotid stenosis Primary and secondary medical prevention of cerebral ischaemia based on routine Doppler examinations should be initiated early in subjects at risk Endarterectomy should be considered even in young adults with ipsilateral carotid artery stenosis of 70-99% to halt the progression of arterial lesions and improve prognosis