Sex-dependent outcomes of recanalization-treated acute ischemic stroke patients at Shamir (Assaf Harofeh) medical center, Israel, 2011-2020.

BACKGROUND/OBJECTIVES: Sex-based differences in incidence, etiologies, severity and recanalization treatment outcomes of patients with acute ischemic stroke (AIS) have been studied extensively. We set out to determine if there were sex-based differences in outcomes among AIS patients who received recanalization treatments at Shamir (Assaf Harofeh) Medical Center (SMC), Israel, between 2011 and 2020. METHODS: This was a single-center, retrospective chart review. The primary analysis compared outcomes for men and women, overall and stratifying by disease severity. We compared also demographics, risk factors and workflow data. RESULTS: Eight hundred and eleven patients received recanalization treatment between 2011 and 2020: 472 (58.1%) men and 339 (41.8%) women. Mean age, NIHSS score and proportion with an NIHSS score ≥ 6 were higher for women. Cerebrovascular risk factors were more prevalent in women, particularly atrial fibrillation, except that current smoking was more prevalent in men. Six hundred and twenty patients (78.1%) were treated with TPA alone, 89 (11.2%) with TPA and endovascular treatment (EVT), and 85 (10.7%) with EVT alone. Fifty percent of patients were discharged home, 41% to a rehabilitation hospital or nursing home, and 9% did not survive. Twenty-four patients (3%) sustained symptomatic bleeds. Outcomes were worse in patients with NIHSS score ≥ 6. Outcomes did not differ by sex. CONCLUSIONS: While treated women presented with more severe AIS and more risk factors, we did not find significant sex-related differences in outcomes. Meticulous adherence to risk factor modification remains the best strategy to reduce stroke incidence, morbidity, and mortality in women and in men.

Reasons for delayed treatment initiation in Guillain-Barre syndrome.

OBJECTIVE: The goal of this study was to analyze the reasons for delayed diagnosis of Guillain-Barre syndrome (GBS). METHODS: We retrospectively reviewed the records of all adult patients with GBS treated at Shamir Medical Center (SMC) from 2006 to 2018. We divided the patients into two groups: those with early initiation of treatment (within 24 h of arrival to ED), and those with later initiation of treatment (>24 h after arrival). We extracted epidemiological and clinical data regarding those groups, and compared them. RESULTS: 100 patients with GBS were treated between 2006 and 2018 at SMC. 50 patients were treated within 24 h of arrival, and in 50 - treatment was initiated later. Of those with delayed treatment, 9 had mild disease, but did receive a working diagnosis of GBS. 41 patients were not diagnosed initially as a clear-cut GBS, and alternative diagnoses were considered, the most common were orthopedic (11/41), vascular (7/41) or nutritional deficiency (6\41). Findings that increased the likelihood for alternative diagnoses to be considered first were severe limb or back pain (26/41); intact or brisk reflexes (17/41); and an atypical pattern of weakness (7\41). CONCLUSIONS: GBS is a challenging diagnosis. Acknowledging the heterogeneity of its presentation and knowing its pitfalls is crucial for the prompt and accurate diagnosis of the disease.

Electrophysiological features and prognosis of Guillain-Barré syndrome in Israel: A single-center's 20 years' experience.

INTRODUCTION: We previously reported on 40 patients with Guillain-Barré syndrome (GBS) identified 1999-2005 at our center, and showed that a higher proportion had an axonal pattern, compared to Europe and North America. METHODS: Retrospective chart review of 100 adult patients with GBS between 2006 and 2018 at Shamir Medical Center. RESULTS: 46.8% of those with an abnormal EMG had an axonal pattern. Of the 60 patients who presented with mild disease (defined as Hughes score 1-2), walking deteriorated in 35 (58%, considering any worsening of Hughes score). 20 patients (33%) lost the ability to walk independently (Hughes score 3), 8 reached a point they could not walk (Hughes 4), and 2 needed mechanical ventilation. Ninety-four of 100 patients (94%) were treated with intravenous immunoglobulins (IVIg). Using ECG monitoring and DVT prophylaxis, IVIg-related adverse reactions were rare. CONCLUSIONS: This study demonstrated a higher proportion of axonal GBS patients in Israel, compared to European and North American patients, replicating the findings in the 1999-2005 patients. Due to the progressive nature of the disease, with more than half of patients presenting with mild disease deteriorating and needing inpatient rehabilitation - we advocate initiation of treatment once a clinical diagnosis of GBS is made.

CT-guided thrombolytic treatment of patients with wake-up strokes.

BACKGROUND: Observational studies of thrombolysis outcomes in wake-up acute ischemic stroke patients selected based on non-contrast brain CT criteria suggested that treated patients did as well as or better than those not treated, after adjustment for baseline characteristics. We began offering thrombolytic treatment (IVTPA) to patients presenting with wake-up strokes and normal non-contrast brain CTs, who could be treated within 4.5 h of being found. DESIGN/METHODS: A retrospective chart review was performed in patients presenting with AIS between November 2014 and December 2017 who received IVTPA. A planned subgroup analysis compared patients with wake-up strokes and normal non-contrast brain CTs to patients with witnessed stroke treated within 4.5 h of being found, or of witnessed onset, respectively. RESULTS: Three hundred and six patients were treated, 279 with witnessed-onset and 27 with wake-up strokes. The latter were not candidates for endovascular intervention. Efficacy and safety were similar in both groups. Discharges home, respectively, were 143(53%) and 13(48%); facility discharges were 112(40.1%) and 11(40.7%) and in-hospital mortality was 19 (6.8%) and 3 (11%). Treatment-related symptomatic bleeds were: 5(1.8%) and 1 (3.7%), respectively. CONCLUSIONS: The findings affirm, in a new clinical series reflecting routine practice, that it is safe to treat with IVTPA patients with wake-up strokes and a normal brain CT scan, who are not candidates for endovascular intervention. We hypothesize, that when the non-contrast brain CT scan is normal, it may be safe to extend beyond 4.5 h the IVTPA treatment eligibility window in similar patients with witnessed-onset stroke.

Pre-admission CHA2DS2-VASc score and outcome of patients with acute cerebrovascular events.

BACKGROUND: The CHA2DS2-VASc score has been recommended for the assessment of thromboembolic risk in patients with atrial fibrillation. Data regarding the association between the pre-admission CHA2DS2-VASc score and the outcome of patients with stroke and TIA are scarce. We aimed to assess the predictive value of pre-admission CHA2DS2-VASc score for early risk stratification of patients with acute cerebrovascular event. METHODS: The study group consisted of 8309 patients (53% males, mean age of 70±13.3years) with acute stroke and TIA included in the prospective National Acute Stroke Israeli (NASIS) registry. The two-primary end-points were in-hospital mortality and severe disability at discharge. We divided the study population into 4 groups according to their pre-admission CHA2DS2-VASc score (0-1, 2-3, 4-5, >5). RESULTS: Following a multivariate analysis odds ratios (OR) for all-cause mortality increased for CHA2DS2-VASc score >1 (OR=2.1 95% CI=1.2-3.6, OR=1.8 95% CI=1.1-3.2, OR=1.8 95% CI 1.1-3.3, for patients with CHA2DS2-VASc score of 2-3, 4-5 and >5, respectively, p<0.001). OR for severe disability (mRS 4-5) at discharge increased significantly in direct association with the CHA2DS2-VASc score (OR=1.55 95% CI=1.14-2.12, OR=2.42 95% CI=1.8-3.3, OR=3 95% CI 2.19-4.27, for patients with CHA2DS2-VASc score of 2-3, 4-5 and >5, respectively as compared with 0-1, p<0.001). Each 1-point increase in the CHA2DS2-VASc score was associated with a 21% increase in the risk for severe disability. CONCLUSIONS: High-risk pre-admission CHA2DS2-VASc score among patients with acute cerebrovascular events is associated with higher in-hospital mortality and severe disability at discharge.

Diagnostic value of neuro-ophthalmological signs in cases of Chiari I malformation.

INTRODUCTION: Our purpose was to evaluate the diagnostic value of measuring diameters of optic nerve sheath (ONSD), presence/absence of papilledema, tortuosity of the optic nerve, flattening of the posterior sclera, and intraocular protrusion of the prelaminar optic nerve for intracranial pressure assessment in cases of Chiari I malformation. METHODS: In a retrospective study, MRI data of 37 consecutive pediatric patients with Chiari malformation and data of 400 patients without intracranial pathology were compared and analyzed. ONSDs were measured at the point where the ophthalmic artery crosses the optic nerve (anatomical landmark). The correlation analysis was performed with clinical findings, gender, age, papilledema, and other neuro-ophthalmological findings. RESULTS: ONSD was enlarged in 38 % of cases of Chiari malformation. The enlargement was bilateral, no correlation with age or gender was found (p = 0.67 and p = 0.76, respectively). The presence of papilledema was detected in 19 % of cases presenting less valuable diagnostic sign if compared with ONSD. The tortuosity of the optic nerve was found in 22 % of cases, but in three patients, it was unilateral. All patients with enlarged ONSD and other neuro-ophthalmological signs present were treated surgically, while most of the patients without these signs (20/23) were treated conservatively. CONCLUSION: In majority of pediatric cases of Chiari malformation, the ONSD is not enlarged and other neuro-ophthalmological signs are not present. Detecting the enlarged ONSD and other neuro-ophthalmological signs in cases of Chiari malformation may indicate the elevated intracranial pressure and necessity for urgent surgical intervention.

The quantitative evaluation of intracranial pressure by optic nerve sheath diameter/eye diameter CT measurement.

BACKGROUND: The changes of the optic nerve sheath diameter (ONSD) have been used to assess changes of the intracranial pressure for 20 years. The aim of this research was to further quantify the technique of measuring the ONSD for this purpose. METHODS: Retrospective study of computed tomographic (CT) data of 1766 adult patients with intracranial hypotension (n=134) or hypertension (n=1632) were analyzed. The eyeball transverse diameter (ETD) and ONSD were obtained bilaterally, and the ONSD/ETD ratio was calculated. The ratio was used to calculate the normal ONSD for patients and to estimate the intracranial pressure of the patients before and after the onset of the pathology. Correlation analysis was performed with invasively measured intracranial pressure, the presence or absence of papilledema, sex, and age. RESULTS: In hypotension cases, the ONSD by CT was 3.4±0.7 mm (P=.03 against normative 4.4±0.8 mm). In cases with hypertension, the diameter was 6.9±1.3 (P=.02, with a cutoff value ˃5.5 mm). The ONSD/ETD ratio was 0.29±0.04 against 0.19±0.02 in healthy adults (P=.01). CONCLUSION: The ONSD and the ONSD/ETD ratio can indicate low intracranial pressure, but quantification is impossible at intracranial pressure less than 13 mm Hg. In elevated intracranial pressure, the ONSD and the ratio provide readings that correspond to readings in millimeters of mercury. The ONSD method, reinforced with additional calculations, may help to indicate a raised intracranial pressure, evaluate its severity quantitatively, and establish quantitative goals for treatment of intracranial hypertension, but the limitations of the method are to be taken into account.

Effect of the 2013 AHA/ASA guidelines on TPA use in acute ischemic stroke at Assaf Harofeh Medical Center in Israel.

BACKGROUND: Use of TPA to treat patients with acute ischemic stroke was introduced in Assaf Harofeh Medical Center (AHMC) in Israel in November 2007 initially with strict adherence to the inclusion/exclusion criteria of the pivotal NINDS TPA studies published in 1995. The treatment window was expanded in 2010 to 4.5h following the results of ECASS-III. Application of the 2013 AHA/ASA Guidelines resulted in further expanded inclusion and relaxed exclusion criteria. DESIGN/METHODS: A retrospective chart review was conducted of patients who received TPA at AHMC to evaluate the additional impact of applying the 2013 guidelines. Number of patients treated, outcomes at discharge, and safety were compared between two periods: May 2011-January 2013 (the 21months preceding the 2013 Guidelines); and February 2013-October 2014 (the 21months after publication of the 2013 Guidelines). Statistical analysis was done using z-tests for differences between proportions, and t-tests to compare means. RESULTS: 63 patients were treated during the immediate pre-2013 Guideline period (36/year, or approximately 5% of patients with ischemic stroke), and 105 during the post-2013 Guidelines period (60/year, approximately 8.3% of patients with ischemic stroke) (p<0.001). During the two periods, respectively: discharges home were 22(34%) and 55(52%) (p<0.05); facility discharges were 29(46%) and 33(31%); and inter-hospital transfers were 6(9%), and 11(10% of treated patients). Most transfers were for endovascular treatment. Total treatment-related symptomatic bleeds in the two periods, respectively, was: 4(6%) and 4(4%), and the number of in-hospital deaths was 6 (9%) and 6 (6%) (unchanged). CONCLUSIONS: Application of the 2013 AHA/ASA Guidelines resulted in a 64% increase in the number of acute ischemic stroke patients treated with TPA at AHMC with no worsening of aggregate outcomes and no increase in bleeds or deaths.

Noninvasive assessment of the intracranial pressure in non-traumatic intracranial hemorrhage.

The article describes the modified technique of measuring the diameters of the optic nerve sheath (ONSD) for assessment of the intracranial pressure (ICP) in patients with intracerebral or subarachnoid hemorrhage (SAH). The CT scans of 443 patients were analyzed retrospectively. The ONSDs were measured at 3mm behind the globe and at the point where the ophthalmic artery crosses the optic nerve. The ONSD/eyeball transverse diameter (ETD) ratio was calculated. The correlation analysis was performed with the Glasgow Coma Scale score, Hemispheric Stroke Scale score, Glasgow Outcome Score, and invasive ICP readings. ONSD was enlarged in 95% of patients with intracerebral hemorrhage or SAH. Pathological ONSDs were 6.6±0.8mm (cut-off value >5.5mm; p<0.05). ONSD/ETD ratio was 0.29±0.05 against normative 0.19±0.02 (p<0.01) with no correlation with initial Glasgow Coma Scale score or Hemispheric Stroke Scale score. There was an inverse correlation between ONSD/ETD ratio and Glasgow Outcome Score (r=-0.7) and direct correlation with invasive ICP readings. This study provides further evidence that in patients with intracranial hemorrhage and SAH, the presence of ONSD greater than a threshold of 5.5mm is significantly predictive of invasively measured elevated ICP. The prediction of raised ICP can be further refined by measuring ONSD at the point where the optic nerve and the ophthalmic artery cross, and by determining the ratio between the ONSD and ETD.

Initial evaluation of the intracranial pressure in cases of traumatic brain injury without hemorrhage.

Our objective was to apply the technique of measuring diameters of optic nerve sheath (ONSD) for the intracranial pressure assessment for the cases with traumatic head injury without hemorrhage. In a retrospective study, CT data of 720 adult patients were collected and analyzed. ONSDs were measured at the point where the ophthalmic artery crosses the optic nerve (anatomical landmark) together with the eyeball transverse diameter (ETD). The ONSD/ETD index was calculated. The correlation analysis was performed with gender, age, the Glasgow Coma Scale score, and the Glasgow Outcome Score. ONSD was enlarged in 82% cases (n=591). Enlarged right/left ONSDs were 6.7±1.0/6.7±0.9mm (cut-off value˃5.5mm). ONSD/ETD ratio was 0.28±0.05 against 0.19±0.02 in healthy adults (p=0.02). We did not find correlation between ONSD/ETD ratio with initial Glasgow Coma Scale score but there was an inverse correlation between ONSD/ETD ratio and the Glasgow Outcome Score (r=-0.64). We conclude that in majority of cases with traumatic head injury without hemorrhage the ONSD is significantly enlarged indicating elevated intracranial pressure even if CT scans are negative.

Diagnostic value of the optic nerve sheath diameter in pseudotumor cerebri.

If persistent severe headache remains the only complaint of a patient, then the diagnosis of pseudotumor cerebri (PTC) can be delayed because in such cases practitioners are hesitant to immediately apply invasive intracranial pressure (ICP) measurement. Our purpose was to apply the technique of measuring diameters of the optic nerve sheath (ONSD) as a diagnostic tool in cases of PTC. Our aim was to provide practitioners with an additional sign to speed up their decision making about implementation of the lumbar puncture. In a retrospective study, CT scan data of 35 consecutive adult patients with PTC were collected and analyzed. ONSD were measured at the point where the ophthalmic artery crosses the optic nerve (anatomical landmark). The correlation analysis was performed with sex, age, and neuro-ophthalmological findings. We found that the ONSD was enlarged in 94.3% of patients with PTC. The enlarged ONSD were 6.2±1.2mm for the right and 6.3±0.9mm for the left (cut-off value >5.5mm). The enlargement was bilateral, and no correlation with age or sex was found (p=0.67 and p=0.76, respectively). Presence of papilledema was detected in 91.4% of patients (32/35) presenting as a slightly less valuable diagnostic sign compared with ONSD. We conclude that in the majority of cases of PTC the ONSD is significantly enlarged, indicating elevated ICP even if CT scans are negative. Implementing this ONSD method as a diagnostic tool in cases of suspected PTC may help in early accurate diagnosis, avoiding misdiagnosis, and providing appropriate early treatment.

Intracranial Pressure Assessment in Traumatic Head Injury with Hemorrhage Via Optic Nerve Sheath Diameter.

Our purpose was to improve the technique of measuring optic nerve sheath diameter (ONSD) for intracranial pressure (ICP) monitoring in cases of traumatic head injury with hemorrhage. In a retrospective study, computed tomography (CT) data of 312 adult patients were collected and analyzed. ONSDs were measured at 3 mm and 8-10 mm distance from the globe together with the eyeball transverse diameter (ETD). The ONSD/ETD ratio was calculated. The correlation analysis was performed with gender, age, Glasgow Coma Scale score, and Glasgow Outcome Score. ONSD was enlarged in all cases when CT scans indicated hematoma. Enlarged right/left ONSDs were 6.5 ± 1.5/6.4 ± 1.3 mm at 3 mm and 6.6 ± 0.8/6.6 ± 0.6 mm at 8-10 mm from the globe (cut-off value > 5.5 mm). ONSD/ETD ratio was 0.29 ± 0.05, compared with 0.19 ± 0.02 in healthy adults (p < 0.01). We did not find a correlation between ONSD/ETD ratio and initial Glasgow Coma Scale score, but there was an inverse correlation between ONSD/ETD ratio and Glasgow Outcome Score (r = -0.83). We conclude that in cases with a traumatic head injury with hemorrhage, the ONSD is significantly enlarged, indicating elevated ICP. In ICP assessment, the most accurate results can be obtained if the ONSD is measured 8-10 mm from the globe and the ONSD/ETD ratio is calculated.

Monitoring of Intracranial Pressure by CT-Defined Optic Nerve Sheath Diameter.

BACKGROUND AND PURPOSE: Intracranial pressure (ICP) can be monitored by the optic nerve sheath diameter (ONSD) technique. We hypothesized that diameter of the optic canal (OC) can be a limiting factor for this technique. METHODS: In the prospective cohort study, we analyzed CT scans of 600 OCs of healthy adults and 54 canals of patients with ICP monitoring. The diameters were measured through its length and the narrowest one was chosen for further analysis. ONSD was measured at 3 and 10 mm from the anterior opening of the canal. The correlation analysis was performed between invasive and ONSD methods of ICP monitoring and OC diameters in pathological cases. RESULTS: The narrowest cross-sectional area of the normal OC was 13.85±2.89 mm² and varied from 25.5 to 6.6 mm². Apparently 9.17% OCs were narrow (˂10.9 mm²). Correlations exist between the optic nerve sheath area at the 3-mm distance from the anterior opening of the canal and the area of the anterior opening itself (P = .012), and the sheath area 10 mm from the anterior opening and the narrowest part of the canal (P = .015). Cases with narrow canals provided false-negative readings via ONSD method if compared with invasive monitoring. CONCLUSION: In its narrowest part, the average OC is 11 to 16.75 mm² wide. We suggest measuring this area simultaneously with the ONSD during ICP monitoring. If the area of the narrowest lumen of the canal is less than 10 mm², ONSD technique for ICP monitoring should not be used.

Gender differences in characteristics, management and outcome at discharge and three months after stroke in a national acute stroke registry.

BACKGROUND: The importance of gender as an independent risk factor for poor outcome is not clear. We examined gender differences in patients' characteristic, management and outcome at discharge and 3-months after acute stroke in a national hospital-based registry. METHODS: Data were derived from the triennial two-month national Acute Stroke Israeli Registry (Feb-March 2004, March-April 2007, April-May 2010). Unselected patients in all Israeli hospitals (n = 28) were included. Outcome at 3-month was assessed in a sub-sample. Logistic regression models were used in the study of gender as an independent risk factor for poor outcome. RESULTS: In total, 5034 patients (88.5% ischemic stroke, 9.6% ICH and 1.9% undetermined stroke) were included, of them 2285 (45.4%) women. Follow-up at 3-month was completed for 1040 patients, 41.9% women. Women showed higher rates of cardiovascular risk factors in-hospital death (p = 0.007) and poor functional outcome (p < 0.0001). Following adjustment for age, prior disability, NIHSS, prior stroke and risk factors, risk estimates (ORs, 95%CI) for women compared to men were 0.72 (0.55-0.96) for in-hospital death, 1.03 (0.83-1.29) for discharge to a nursing home or death, and 1.01 (0.86-1.20) for disability. Poor outcomes at 3-month were significantly more common in women; however, adjusted risk estimates were not significantly increased: OR 0.95 (95%CI 0.50-1.81) for death at 3-months, 1.41 (0.99-2.01) for Barthel Index ≤ 60, 1.24 (0.90-1.72) for dependency and 0.88 (0.55-1.39) for living in a nursing home or death. CONCLUSION: Gender-differences in risk of death and poor functional outcome after stroke are mainly explained by dissimilarities in patients' characteristics and stroke severity.

Long-term follow-up of patients after carotid stenting with or without distal protective device in a single tertiary medical center.

OBJECTIVE: To evaluate the immediate and long-term clinical outcomes after carotid artery stenting (CAS) with and without protection devices (PDs), compared with carotid endarterectomy (CEA). METHODS: A total of 116 patients with symptomatic carotid stenosis underwent CAS; 56 patients (48.3%) underwent CAS-PD; and 137 patients underwent CEA. RESULTS: There were more ipsilateral transient ischemic attacks (TIAs) in the CEA group than in CAS-PD and CAS + PD (4 [3%] vs 1 [1.6%] and 0 respectively, P = 0.02). In the CAS-PD group there were more vertebrobasilar TIAs, ipsi- and contralateral strokes, myocardial infarctions, and death rates in the 30-day postprocedural period. After 8-year follow-up, there were 18 (30%) death cases in the CAS-PD group, 10 death cases (17%) in the CAS + PD patients, and 15 death cases (11%) in the CEA group of patients (P = .02). CONCLUSION: Our data show that CAS + PD was associated with lower rate of vascular complications and mortality compared with CAS-PD and CEA.

Rapid improvement of tardive dyskinesia with tetrabenazine, clonazepam and clozapine combined: a naturalistic long-term follow-up study.

Tardive dyskinesia (TD) is a complex involuntary movement disorder affecting about 23% of neuroleptic-treated patients. Our objective was to retrospectively analyze a combination of tetrabenazine (TBZ), clonazepam (CLONAZ) and clozapine (CLOZ) used simultaneously for TD in psychotic patients. Six patients with severe, unsuccessfully controlled TD were referred for treatment (mean age 51.5 years; three male; four schizophrenics; one bipolar disease; one borderline personality disorder). They were being treated with neuroleptics (classic, three; risperidone, two; olanzapine, one) and developed severe neck and buccolingual dyskinesias. At our clinic, all of them were treated simultaneously with TBZ (mean dose 141.6 mg); CLONAZ (mean dose 4.3 mg); and CLOZ (mean dose 125 mg). In parallel, we stopped the offending medication. With 1 week, we observed a very impressive improvement in symptoms and within 1 month all the patients were free of symptoms. The mean observation period was 4 years. The combination of TBZ, CLONAZ and CLOZ is a rapid and beneficial option for the management of TD. An augmentation effect probably played a role in the rapid alleviation of symptomatology.

Carotid artery stenting in high risk patients with carotid artery stenosis not eligible for endarterectomy: clinical outcome after 5 years.

BACKGROUND: Carotid artery stenting is used as an alternative to surgical endarterectomy. OBJECTIVES: To determine the outcome of CAS in a retrospective cohort of patients. METHODS: Between July 1999 and March 2003, 56 consecutive patients with carotid artery stenosis who were considered ineligible for surgery were treated (45 males, 11 females, mean age 69). All underwent the procedure prior to the introduction of distal protective devices in Israel. RESULTS: Intraprocedural complications included transient neurological findings in 5 patients (8%), cerebrovascular accident in 2 (3%), hemodynamic changes in 11 (18%), and 4 procedural failures. Post-procedural complications included transient ischemic attack in 3 patients and cardiovascular accident in 6 (10%). At 30 days follow-up, three patients (5%) remained with signs of CVA. Two patients (3%) died during the post-procedural period and 16 (28%) during the 5 year follow-up, one due to recurrent CVA and the remainder to non-neurological causes. Five-year carotid Doppler follow-up was performed in 25 patients (45%), which revealed normal stent flow in 21 (84%), 50-60% restenosis in 3 (12%) and > 70% restenosis in one patient (4%). CONCLUSIONS: This study confirms that stent procedures are beneficial for symptomatic carotid stenosis in patients not eligible for surgery.