2. Professor Jean – Baptiste Ricco Hospital Jean Bernard, Poitiers, France Hospital Jean Bernard, Poitiers, France

3. Professor Peter R F Bell

4. Patients with contralateral occlusion who had immediate surgery had a benefit compared to those with deferred surgery Stroke rate:1.5% (1/147) vs. 10/1 % (10/128), OR :[1.9-15.4%]

5. Patients with silent infarcts on CT scan have a threefold excess risk (3.6 % vs. 1%, p=0.02) of late ipsilateral stroke ACSRS study

6.  Low Gray scale median score are associated with echolucent plaques which were also shown to be associated with infarction on CT-Scan  Combination of TCD microemboli and plaque echolucency could identified a high-risk group

7. Embolization and late ipsilateral stroke in ACS STUDYNSTROKE TCD+ STROKE TCD- OR [95% CI] ACES*4675/77 (6.5%)5/390 (1.3%)5.3 [1.5-18.9] ABBOTT2312/60 (3.3%)4/171 (2.3%)1.4 [0.3 - 8.0] SPENCE3195/32 (15.6%)3/287 (1.1%)17.5 [3.9 - 77.4]

8.  3D Ultrasonography can reliably detect ulceration in the carotid artery  The 3-year risk of stroke in patients with ACS increases with the number of carotid ulcers Ulcer on 3D UltrasoundStroke at 3-year 01.9% 14.4% 27.1% ≥318.2%

9.  A univariate cox regression analysis showed that in a group of patients with ACS, intraplaque hemorrhage on MRI was associated with a threefold increased risk of ipsilateral stroke SOURCECONDITIONOR TakayaIntraplaque hemorrhage5.2 Thin or ruptured fibrous cap17 Large lipid necrotic core1.6

10.  Fluoro-deoxyglucose-PET has been used to visualize inflamed high-risk carotid plaques.  FDG uptake has been used in clinical research as a biomarker of carotid plaque inflammation

11. A small, but significant benefit, for CEA was observed in ACAS and ACST. 1. A small, but significant benefit, for CEA was observed in ACAS and ACST. 2. Mass interventions in asymptomatic patients prevent very few strokes and more than 90% of these patients will undergo an unnecessary intervention costing enormous sums of money. 3. We have the responsibility to identify who really does benefit from intervention 3. We have the responsibility to identify who really does benefit from intervention.

12. 1.Contralateral symptoms or occlusion 2.Silent infarct 3.Plaque echolucency 4.TCD microemboli detection 5.Ulceration on 3D ultrasonography 6.MRI for intra-plaque haemorrhage 7.PET scan for plaque inflammation

13. Professor A Ross Naylor. University of Leicester, UK

16. early risk of stroke after TIA is low + AHA=treatment<6 months acceptable + procedural risk lower if CEA is delayed + how can I learn CAS if I have to intervene early = NO real incentive to intervene early

17.  The benefit conferred by CEA (CAS) declines rapidly as delays to treatment occur  The natural history risk of stroke after TIA is very much higher than previously thought

21. 48 h 72 h 7d 14d Fairhead Neurology 2005 20% OIS Stroke 2009 17% 22% 25% Johansson Int J Stroke 2012 5,2% 7,9% 11,2%

22. CEA <4 weeks 66% have overlying thrombus CEA >4 weeks 21% have overlying thrombus

23. who performs CEA within 2 weeks with a 10% risk of death/stroke who waits 4 weeks but when operates with a 0% procedural risk

25. If you suffered a TIA and were found to have a 50-99% stenosis, would you want your CEA or CAS deferred or would you seek an urgent intervention?

27. Thank you for attention!