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Jonathan Y. Streifler, MD; Michael Eliasziw, PhD; Oscar R. Benavente, MD; John W. Harbison, MD; Vladimir C. Hachinski, MD; Henry J. M. Barnett, MD; Denis Simard, MD; North American Symptomatic Carotid Endarterectomy Trial

Arch Neurol. 1995;52(3):246-249.

Abstract
Background
The prognosis of amaurosis fugax has been considered to be favorable compared with that of hemispheric transient ischemic attacks. However, this has remained uncertain for patients with significant carotid stenosis as the assessment of progression of the disease has been confounded when patients undergo carotid endarterectomy. In the North American Symptomatic Carotid Endarterectomy Trial, patients with high-grade (70% to 99%) carotid stenosis were randomized to receive either medical or surgical treatment, thus making an unconfounded analysis possible.

Method
We identified 129 medically treated patients with high-grade carotid stenosis who had their first-ever transient ischemic attack as the entry event into the trial. Fifty-nine patients with retinal transient ischemic attacks (RTIAs) were compared with 70 patients with hemispheric transient ischemic attacks (HTIAs).

Results
Patients with HTIAs were older, with a higher prevalence of most risk factors for stroke. Average time of delay from the onset of transient ischemic attacks to medical treatment was longer for patients with RTIAs than for patients with HTIAs (48.5 vs 15.2 days). Kaplan-Meier estimates of the risk of ipsilateral stroke at 2 years were 16.6%±5.6% for patients with RTIAs and 43.5%±6.7% for patients with HTIAs (P=.002 for the difference in risk between RTIAs and HTIAs). From corresponding Cox's proportional hazards regression analyses, the risk of ipsilateral stroke ranged from 11.2% to 28.9% for patients with RTIAs and from 37.4% to 96.3% for patients with HTIAs across stenoses, spanning 75% to 95%. Overall, the relative risk of ipsilateral stroke (HTIAs compared with RTIAs) was 3.23 (95% confidence interval, 1.47 to 7.12), regardless of the degree of high-grade stenosis.

Conclusion
To our knowledge, this study is the first report on the expected outcome for medically treated patients with high-grade (70% to 99%) carotid stenosis in whom the first-ever event was either an RTIA or HTIA. The presence of RTIAs carries a considerable risk of ipsilateral strokes, particularly at higher degrees of stenosis. However, in comparison with HTIAs, patients with RTIAs still have a better prognosis.

Author Affiliations
From the Departments of Clinical Neurological Sciences (Drs Streifler, Benavente, Hachinski, and Barnett) and Epidemiology and Biostatistics (Dr Eliasziw), University of Western Ontario, and The John P. Robarts Research Institute (Dr Eliasziw), London, Ontario; the Division of Neuro-Ophthalmology, Department of Neurology, Medical College of Virginia, Richmond (Dr Harbison); and the Department of Neurosciences, Hôpital de L'Enfant-Jésus, Quebec city, Quebec (Dr Simard). Dr Streifler is now with the Department of Neurology, Golda Medical Center, Hasharon Hospital, Petah Tiqwa, Israel.

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