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In the ECIC Bypass Study, the stroke price at 2 years was 20 but at 4 years the stroke rate had only elevated by an further 6 .11 Inside the carotid endarterectomy trials, the stroke rate at two years for 70?9 stenosis was 20 but increased only by an added four by year 4.32 Information reported by Persoon and colleagues from 117 individuals with symptomatic internal carotid artery occlusion show a recurrent ischemic stroke rate of 12 at two years, rising to only 14 by four years.33 Continuing COSS for an further three years with a 1? /year price of stroke in the non-surgical group would not have resulted inside a statistically significant benefit for surgery, even if no extra strokes occurred inside the surgical group. A subsequent subgroup evaluation of 36 subjects in St. Louis Carotid Occlusion Study who met the clinical eligibility criteria for COSS confirmed the superiority on the count-based ratio OEF approach to ascertain eligibility. The threat of ipsilateral stroke in patients who met the COSS ratio criteria (7/18, 39 ) was practically identical to those with quantitative OEF threshold of 50 (4/10, 40 ) but the COSS ratio method identified much more individuals (7/9) who would go on to create a stroke than the absolute OEF criteria (4/9). 34 In the COSS surgical group, 30-day graft patency was 98 and patency at last follow-up was 96 . Mean OEF ratio improved from 1.258 to 1.109. Of 20 strokes within the surgical group, 14 occurred inside the 30 day post-operative period. This peri-operative stroke rate of 15 was not substantially distinctive from the international EC-IC Bypass Trial.11 Twelve of these post-operative strokes occurred within two days of surgery. Eliminating these 12 strokes, the subsequent stroke price inside the remainder with the surgical group was .09, drastically much less than the non-surgical group (p=.02).(Figure 3B) COSS demonstrated the significance of cerebral hemodynamics within the treatment of carotid occlusion. The pathophysiological hypothesis was right. Surgical improvement of hemodynamics by EC-IC bypass decreased stroke threat. On the other hand, the remedy was as undesirable as the disease. The peri-operative stoke rate was sufficiently high to nullify any advantage. Substantial post-hoc analyses failed to define any patient, procedural or surgeon characteristic that predicted who would have a peri-operative stroke.35 COSS demonstrated that EC-IC bypass supplies no advantage over medical management for stroke prevention in individuals with symptomatic carotid artery occlusion, even on these with improved OEF. Nonetheless, disagreement existed irrespective of whether strict blood pressure control was the most beneficial for these individuals or if larger blood pressures had been required to preserve cerebral perfusion and prevent subsequent stroke.1,36 To address this situation, we analyzed information in the non-surgical group of COSS.37 Of 98 non-surgical participants, 91 were included within the evaluation: three had no postrandomization blood pressures recorded, and four had ipsilateral ischemic strokes before the very first blood stress recording in the 30?5 day follow-up visit. We compared the occurrence of ipsilateral ischemic stroke throughout follow-up inside the 41 subjects with imply blood pressures throughout follow-up who met the COSS target 130/85 mm Hg to the remaining 50 with larger blood pressures. We utilized only the blood pressures recorded prior to the strokeNIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptStroke.