Stroke Outcomes and System Review Health-Related Quality of Life After Transient Ischemic Attack and Minor Stroke: Is Medical or Surgical Treatment Influential? Peter J. Martin, MD, MRCP,Maria Fotopoulou, MA, Gus A. Baker, PhD, and Peter R.D. Humphrey, DM, FRCP Although randomized trials have proven the benefit of carotid endarterectomy (CEA) for appropriate patients, health care purchasers increasingly look beyond clinical outcome toward measures of cost effectiveness and health-related quality of life (HRQoL) in apportioning limited resources. We used a generic HRQoL outcome scale, the Short Form 36 (SF-36), to assess the differences in patient-perceived HRQoL in two cohorts of patients who had suffered minor cerebral ischemic events. One group (n = 100) had undergone CEA, whereas members of the second cohort (n = 100) were not appropriate candidates for surgery and were therefore treated with best medical therapy. The overall response rate was 83%. No significant difference in health profile between the CEA and medical cohorts was detected for the eight SF-36 domains. However, the CEA cohort rated a significantly improved change in general health over the previous year compared with the group managed medically (P (.01). A greater proportion of the former group than of the medical group thought their treatment had been successful and that their health had been improved by treatment (P (.01). Both groups shared the same anxieties over future cerebral ischemic events (P = .3). Patients' perception of HRQoL measured by the SF-36 domains was almost identical between the CEA and medical cohorts apart from a small but significant improvement in self-reported overall health in the CEA cohort. HRQoL outcome measures may be of value in future clinical trials of cerebral revascularization. Key Words: TIA--Stroke--Quality of life---Carotid end- arterectomy. Changes in health care provision have prompted the justification of different treatments according to defined measures, and it is increasingly apparent that services will only be purchased if their costs are justified by improved outcome. Historically, new therapies have been validated on the basis of improved medical outcome, that is accord- From the Department of Neurology and Neuropsychology,Walton Center for Neurology and Neurosurgery,Liverpool England. ReceivedJanuary 29,1997;accepted August 1, 1997. Address reprint requests to P.J. Martin, MD, MRCP,Department of Neurology, Walton Centre for Neurology and Neurosurgery, Rice Lane, LiverpoolL9 1AE,England. Copyright 9 1998by National Stroke Association 1052-3057/98/0701-001153.00/0 ing to the physician's perspective. The patient's views of the success or otherwise of their treatment has been relatively neglected. Recently, outcome according to the patient's perspective has been increasingly appreciated, heralding the development of scales designed to show health-related quality of life (HRQoL). 1 There is no doubt that carotid endarterectomy (CEA) reduces the risk of stroke in patients with severe, symptom- atic internal carotid artery stenosis (ICA).2,3 Patients with severe asymptomatic disease might also benefit.4 How- ever, health care purchasers may argue that more cost- effective ways of preventing stroke occurrence exist at the primary care level, thereby jeopardizing the provision of a proven intervention for the at-risk individual.~ Further- more, they may argue that to benefit from CEA the patient 70 Journal of Stroke and Cerebrovascular Diseases, Vol. 7, No. 1 (January-February), 1998: pp 70-75