1
|
Musialek P, Rosenfield K, Siddiqui AH, Grunwald IQ. Carotid Stenosis and Stroke: Medicines, Stents, Surgery-"Wait-and-See" or Protect? Thromb Haemost 2024. [PMID: 36170885 DOI: 10.1055/a-1952-1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland
- John Paul II Hospital Stroke Thrombectomy-Capable Centre, Krakow, Poland
| | - Kenneth Rosenfield
- Division of Cardiology, Vascular Medicine and Intervention Section, Massachusetts General Hospital, Boston, United States
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, United States
- Jacobs Institute, Buffalo, New York, United States
- Department of Neurosurgery, Gates Vascular Institute Kaleida Health, Buffalo, New York, United States
| | - Iris Q Grunwald
- Department of Radiology, Ninewells Hospital, Chair of Neuroradiology, University of Dundee, Dundee, Scotland, United Kingdom
| |
Collapse
|
2
|
Loufopoulos G, Manaki V, Tasoudis P, Meintanopoulos AS, Kouvelos G, Ntaios G, Spanos K. New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 106:297-311. [PMID: 38825067 DOI: 10.1016/j.avsg.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
Collapse
Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Saint Imier Hospital, Saint Imier, Switzerland.
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - George Kouvelos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
3
|
Václavík D, Pakizer D, Hrbáč T, Roubec M, Procházka V, Jonszta T, Herzig R, Školoudík D. Changes in Cognitive Functions after Carotid Endarterectomy and Carotid Stenting: A Decade-Apart Comparison. Biomedicines 2023; 12:13. [PMID: 38275374 PMCID: PMC10813376 DOI: 10.3390/biomedicines12010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND This study investigates changes in cognitive function in patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) and carotid stenting (CAS) over two decades. METHODS We compared cognitive function within 30 days after the procedure in 267 patients (first 100 each for CEA and CAS in two periods: 2008-2012 and 2018-2022) in a single institution. Assessments used Adenbrooke's Cognitive Examination-Revised (ACE-R), the Mini-Mental State Examination (MMSE), Speech Fluency Test (SFT), and Clock Drawing Test (CDT), conducted before and 30 ± 2 days after surgery. RESULTS Patients (mean age 67.2 years, 70%+ carotid stenosis) exhibited different cognitive changes over periods. In 2008-2012, significant declines in MMSE (CEA, p = 0.049) and CDT (CAS, p = 0.015) were observed among asymptomatic patients. On the contrary, in 2018-2022, improvements were observed in ACE-R and MMSE for symptomatic and asymptomatic patients undergoing CEA and CAS. CONCLUSION Over a decade, advances in interventional techniques and patient management have reduced risks of cognitive decline in patients with asymptomatic carotid stenosis and also have improved cognitive functions in both symptomatic and asymptomatic individuals.
Collapse
Affiliation(s)
- Daniel Václavík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
- Stroke Centre, Department of Neurology, Hospital Agel Ostrava Vitkovice, 703 00 Ostrava, Czech Republic
| | - David Pakizer
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Tomáš Hrbáč
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic;
- Department of Neuroscience, Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Václav Procházka
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Tomáš Jonszta
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Roman Herzig
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
| | - David Školoudík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| |
Collapse
|
4
|
Mazurek A, Malinowski K, Sirignano P, Kolvenbach R, Capoccia L, DE Donato G, VAN Herzeele I, Siddiqui AH, Castrucci T, Tekieli L, Stefanini M, Wissgott C, Rosenfield K, Metzger DC, Snyder K, Karpenko A, Kuczmik W, Stabile E, Knapik M, Casana R, Pieniazek P, Podlasek A, Taurino M, Schofer J, Cremonesi A, Sievert H, Schmidt A, Grunwald IQ, Speziale F, Setacci C, Musialek P. Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:570-582. [PMID: 38385840 DOI: 10.23736/s0021-9509.24.12933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA). EVIDENCE ACQUISITION Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect. EVIDENCE SYNTHESIS Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery. CONCLUSIONS Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).
Collapse
Affiliation(s)
- Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- KCRI, Krakow, Poland
| | - Pasqualino Sirignano
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Ralf Kolvenbach
- Department of Vascular Surgery in Sana Kliniken, Düsseldorf Gerresheim, Germany
| | - Laura Capoccia
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | | | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Tomaso Castrucci
- Department of Vascular Surgery, Sant' Eugenio Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Christian Wissgott
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Imland Klinik Rendsburg, Rendsburg, Germany
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrey Karpenko
- Center of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
| | - Eugenio Stabile
- Dipartimento Cardiovascolare, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Magdalena Knapik
- Department of Radiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
| | - Renato Casana
- Vascular Surgery Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Piotr Pieniazek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Maurizio Taurino
- Department of Vascular and Endovascular Surgery, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Joachim Schofer
- MVZ-Department Structural Heart Disease, Asklepios Clinic St Georg, Hamburg, Germany
| | - Alberto Cremonesi
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Horst Sievert
- Department of Cardiology and Vascular Medicine, Cardiovascular Center, Frankfurt, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Department of Radiology Ninewells Hospital, University of Dundee, Dundee, UK
| | - Francesco Speziale
- Department of Vascular Surgery "Paride Stefanini", Policlinico Umberto I, La Sapienza University, Rome, Italy
| | - Carlo Setacci
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital Stroke Thrombectomy-Capable Center, Krakow, Poland
| |
Collapse
|
5
|
Musialek P, Langhoff R, Stefanini M, Gray WA. Carotid stent as cerebral protector: the arrival of Godot. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:555-560. [PMID: 38385839 DOI: 10.23736/s0021-9509.23.12956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, Krakow, Poland -
- St. John Paul II Hospital, Stroke Thrombectomy-Capable Center, Krakow, Poland -
| | - Ralf Langhoff
- Department of Angiology, Sankt-Gertrauden Hospital, Academic Teaching Hospital of Charité University, Berlin, Germany
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - William A Gray
- Main Line Health, Wynnewood, PA, USA
- Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
- Lankenau Heart Institute, Wynnewood, PA, USA
| |
Collapse
|
6
|
Döring K, Aburub A, Krauss JK, Lang JM, Al-Afif S, Polemikos M, Weissenborn K, Grosse G, Grieb D, Lanfermann H, Götz F, Abu-Fares O. Early clinical experience with the new generation Pipeline Vantage flow diverter in the treatment of unruptured saccular aneurysms using short-term dual antiplatelet therapy. Interv Neuroradiol 2023:15910199231205047. [PMID: 37796761 DOI: 10.1177/15910199231205047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
PURPOSE The Pipeline Vantage flow diverter with Shield technology (PV) used in this study is a 4th-generation flow diverter (FD) designed to reduce thrombogenicity, promote endothelialization of the implant and increase efficiency in achieving aneurysm closure. In this study, we report the aneurysm occlusion rate, complication rate and clinical outcome with short-term dual antiplatelet therapy (DAPT) in the treatment of unruptured intracranial saccular aneurysms using the PV. METHODS We retrospectively identified patients treated between September 2021 and January 2023 with the PV and subsequently underwent short-term DAPT for 3 months. Patient and aneurysm characteristics, peri- and post-procedural complications, clinical outcomes and the grade of aneurysm occlusion were documented. RESULTS Thirty patients with 32 aneurysms were treated. Successful FD implantation was achieved in all cases (100%). No periprocedural complications were documented. The overall symptomatic complication rate was 10% and the neurologic, treatment-related symptomatic complication rate was 6.6%. Only one symptomatic complication (3.3%) was device-related. Permanent clinical deterioration occurred in 2/30 patients (6.6%), leading to deterioration of the mRS within the first 3 months after treatment. No mortality was documented. The rate of complete aneurysm occlusion after 3 months and after a mean imaging follow-up of 9.9 months was 65.6% and 75%, respectively. CONCLUSION Implantation of the PV for the treatment of saccular intracranial aneurysms achieves a good aneurysm occlusion rate with a low rate of complications. In addition, the use of short-term DAPT after PV implantation appears to be safe.
Collapse
Affiliation(s)
- Katja Döring
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, Hannover, Germany
| | - Abdallah Aburub
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Shadi Al-Afif
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Manolis Polemikos
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology and Clinical Neurophysiology, Hannover Medical School, Hannover, Germany
| | - Gerrit Grosse
- Department of Neurology and Clinical Neurophysiology, Hannover Medical School, Hannover, Germany
| | - Dominik Grieb
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, Hannover, Germany
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
| | - Heinrich Lanfermann
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, Hannover, Germany
| | - Friedrich Götz
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, Hannover, Germany
| | - Omar Abu-Fares
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School Hannover, Hannover, Germany
| |
Collapse
|
7
|
Donners SJ, Rots ML, Toorop RJ, van der Lugt A, Bonati LH, de Borst GJ. Long-Term Stroke Risk in Patients With New Ischemic Brain Lesions on MRI After Carotid Revascularization. Stroke 2023; 54:2562-2568. [PMID: 37615093 PMCID: PMC10519293 DOI: 10.1161/strokeaha.123.043336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Carotid artery revascularization can result in new ischemic brain lesions on diffusion-weighted magnetic resonance imaging. This study aimed to investigate the relationship between periprocedural ischemic diffusion-weighted imaging (DWI) lesions after carotid artery revascularization and recurrent long-term cerebrovascular events. METHODS A secondary observational prospective cohort analysis of existing clinical trial data was performed on 162 patients with symptomatic carotid stenosis that were previously randomized to carotid artery stenting or carotid endarterectomy in the ICSS (International Carotid Stenting Study) and included in the magnetic resonance imaging substudy. Magnetic resonance imagings were performed 1 to 7 days before and 1 to 3 days after treatment. The primary composite clinical outcome was the time to any stroke or transient ischemic attack during follow-up. Patients with new diffusion-weighted imaging (DWI) lesions on posttreatment magnetic resonance imaging scan (DWI+) were compared with patients without new lesions (DWI-). RESULTS The median time of follow-up was 8.6 years (interquartile range, 5.0-12.5). Kaplan-Meier cumulative incidence for the primary outcome after 12.5-year follow-up was 35.3% (SE, 8.9%) in DWI+ patients and 31.1% (SE, 5.6%) in DWI- patients. Uni- and multivariable regression analyses did not show significant differences (hazard ratio, 1.50 [95% CI, 0.76-2.94] and hazard ratio, 1.30 [95% CI, 0.10-1.02], respectively). Higher event rate of the primary outcome in DWI+ patients in the overall cohort was mainly caused by events in the carotid artery stenting group. CONCLUSIONS Based on our outcome analysis within the ICSS magnetic resonance imaging substudy, DWI lesions following carotid revascularization did not seem to have a relationship with long-term stroke risk. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: ISRCTN 25337470.
Collapse
Affiliation(s)
- Simone J.A. Donners
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands (S.J.A.D., R.J.T., G.J.d.B.)
| | - Marjolijn L. Rots
- Department of General Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands (M.L.R.)
| | - Raechel J. Toorop
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands (S.J.A.D., R.J.T., G.J.d.B.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands (A.v.d.L.)
| | - Leo H. Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, Switzerland (L.H.B.)
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands (S.J.A.D., R.J.T., G.J.d.B.)
| |
Collapse
|
8
|
Mihály Z, Booth S, Nguyen DT, Vecsey-Nagy M, Vértes M, Czinege Z, Péter C, Sótonyi P, Varga A. A Propensity-Matched Comparison of Ischemic Brain Lesions on Postprocedural MRI in Endovascular versus Open Carotid Artery Reconstruction. J Cardiovasc Dev Dis 2023; 10:257. [PMID: 37367422 DOI: 10.3390/jcdd10060257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
(1) Study purpose: The aim of our prospective single-center, matched case-control study was to compare the number and volume of acute ischemic brain lesions following carotid endarterectomy (CEA) versus carotid artery stenting (CAS) using a propensity-matched design. (2) Methods: Carotid bifurcation plaques were analyzed by using VascuCAP software on CT angiography (CTA) images. The number and volume of acute and chronic ischemic brain lesions were assessed on MRI scans taken 12-48 h after the procedures. Propensity score-based matching was performed at a 1:1 ratio to compare the ischemic lesions on postinterventional MR. (3) Results: A total of 107 patients (CAS, N = 33; CEA, N = 74) were included in the study. There were significant differences in smoking (p = 0.003), total calcification plaque volume (p = 0.004), and lengths of the lesion (p = 0.045) between the CAS and CEA groups. Propensity score matching resulted in 21 matched pairs of patients. Acute ischemic brain lesions were detected in ten patients (47.6%) of the matched CAS group and in three patients (14.2%) in the matched CEA group (p = 0.02). The volume of acute ischemic brain lesions was significantly larger (p = 0.04) in the CAS group than in the CEA group. New ischemic brain lesions were not associated with neurological symptoms in either group. (4) Conclusions: Procedure-related new acute ischemic brain lesions occurred significantly more frequently in the propensity-matched CAS group.
Collapse
Affiliation(s)
- Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Samuel Booth
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Dat Tin Nguyen
- Department of Cardiology, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
- Hungarian Vascular Radiology Research Group, 1122 Budapest, Hungary
| | - Milán Vecsey-Nagy
- Department of Cardiology, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Miklós Vértes
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Zsófia Czinege
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Csongor Péter
- Department of Cardiology, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Andrea Varga
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| |
Collapse
|
9
|
Fuga M, Tanaka T, Tachi R, Tomoto K, Wachi R, Teshigawara A, Ishibashi T, Hasegawa Y, Murayama Y. Thromboelastography 6s for assessment of platelet function during coil embolization of unruptured intracranial aneurysms. J Stroke Cerebrovasc Dis 2023; 32:106924. [PMID: 36508756 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/18/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Methods for assessing platelet function in patients with neurovascular disease remain controversial and poorly studied. This study aimed to assess associations between thromboelastography 6s (TEG6s) measurements and postoperative ischemic complications in patients with unruptured intracranial aneurysms (UIAs) treated by coil embolization. METHODS Eighty-four patients with UIAs taking a combined aspirin and clopidogrel protocol were retrospectively reviewed from January 2021 to May 2022. Blood samples were obtained for TEG6s to assess platelet function on the day of coil embolization. To identify acute ischemic complications, diffusion-weighted imaging (DWI) was performed within 24 h after coil embolization. Multivariate logistic regression analysis was conducted to identify potential risk factors for postoperative positive DWI (DWI (+)) lesions. RESULTS Forty-three of the 84 patients (51%) with DWI (+) lesions were identified. Compared with patients without DWI (+) lesions, Adenosine diphosphate (ADP)-induced platelet-fibrin clot strength (MAADP) was significantly higher (53.6 mm [Interquartile range (IQR): 48.3-58.3 mm] vs 46.7 mm [IQR: 36.8-52.2 mm]; p=0.001) and ADP inhibition rate (ADP%) was significantly lower (19% [IQR: 11-31%] vs 31% [IQR: 21-44%]; p=0.001) in DWI (+) patients. Multivariate analysis identified MAADP, ADP%, and procedure time as significant independent predictors of subsequent DWI (+) lesions (odds ratios: 1.07, 0.96, and 1.02, respectively). Based on receiver operating characteristic curve analysis, MAADP >50.9 mm and ADP% <28.8% were associated with postoperative DWI (+) lesions in patients undergoing coil embolization for UIAs. CONCLUSIONS MAADP and ADP% as assessed by TEG6s can offer reliable parameters to predict postoperative ischemic complications after coil embolization of UIAs. Lower MAADP values and higher ADP% may decrease the risk of postoperative ischemic complications.
Collapse
Affiliation(s)
- Michiyasu Fuga
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan.
| | - Toshihide Tanaka
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Rintaro Tachi
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Kyoichi Tomoto
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Ryoto Wachi
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Akihiko Teshigawara
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuzuru Hasegawa
- Department of Neurosurgery, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
10
|
Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 184] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
|
11
|
Ganesh A, Goyal M, Wilson AT, Ospel JM, Demchuk AM, Mikulis D, Poublanc J, Krings T, Anderson R, Tymianski M, Hill MD. Association of Iatrogenic Infarcts With Clinical and Cognitive Outcomes in the Evaluating Neuroprotection in Aneurysm Coiling Therapy Trial. Neurology 2022; 98:e1446-e1458. [PMID: 35169007 DOI: 10.1212/wnl.0000000000200111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/11/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Small iatrogenic brain infarcts are often seen on diffusion-weighted MRI (DWI) following surgical or endovascular procedures, but there are few data on their clinical effects. We examined the association of iatrogenic infarcts with outcomes in the ENACT (Evaluating Neuroprotection in Aneurysm Coiling Therapy) randomized controlled trial of nerinetide in patients undergoing endovascular repair of intracranial aneurysms. METHODS In this post hoc analysis, we used multivariable models to evaluate the association of the presence and number of iatrogenic infarcts on DWI with neurologic impairment (NIH Stroke Scale [NIHSS]), functional status (modified Rankin Scale [mRS]), and cognitive and neuropsychiatric outcomes (30-minute test battery) at 1-4 days and 30 days postprocedure. We also related infarct number to a z score-derived composite outcome score using quantile regression. RESULTS Among 184 patients (median age 56 years [interquartile range (IQR) 50-64]), 124 (67.4%) had postprocedural DWI lesions (median 4, IQR 2-10.5). Nerinetide treatment was associated with fewer iatrogenic infarcts but no overall significant clinical treatment effects. Patients with infarcts had lower Mini-Mental State Examination (MMSE) scores at 2-4 days (median 28 vs 29, adjusted coefficient [acoef] -1.11, 95% CI -1.88 to -0.34, p = 0.005). Higher lesion counts were associated with worse day 1 NIHSS (adjusted odds ratio for NIHSS ≥1: 1.07, 1.02-1.12, p = 0.009), day 2-4 mRS (adjusted common odds ratio [acOR] 1.05, 1.01-1.09, p = 0.005), and day 2-4 MMSE (acoef -0.07, -0.13 to -0.003, p = 0.040) scores. At 30 days, infarct number remained associated with worse mRS (acOR 1.04, 1.01-1.07, p = 0.016) and Hopkins Verbal Learning Test (HVLT) delayed recall scores (acoef -0.21, -0.39 to -0.03, p = 0.020). Patients with infarcts trended towards lower 30-day Digit Symbol Substitution Test (DSST) scores (acoef -3.73, -7.36 to -0.10, p = 0.044). Higher lesion count was associated with worse composite outcome scores at both 1-4 days and 30 days (30-day acoef -0.12, 95% CI -0.21 to -0.03, p = 0.008). Among those with infarcts, day 1 NIHSS and day 2-4 mRS correlated with 30-day NIHSS, DSST, HVLT, and mRS scores, whereas day 2-4 MMSE correlated with 30-day NIHSS and DSST scores (Spearman ρ 0.47, p = 0.001). DISCUSSION Iatrogenic brain infarcts were associated with subtle differences in postprocedural (1-4 days) and 30-day outcomes on different measures in this middle-aged cohort, with earlier dysfunction correlating with later differences. TRIAL REGISTRATION INFORMATION Clinical trials registration NCT00728182.
Collapse
Affiliation(s)
- Aravind Ganesh
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Mayank Goyal
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Alexis T Wilson
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Johanna Maria Ospel
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Andrew M Demchuk
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - David Mikulis
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Julien Poublanc
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Timo Krings
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Roberta Anderson
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Michael Tymianski
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Michael D Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | | |
Collapse
|
12
|
Flow-cytometry based platelet reactivity testing to predict the occurrence of peroperative solid microemboli during carotid endarterectomy. Eur J Vasc Endovasc Surg 2022; 63:800-806. [DOI: 10.1016/j.ejvs.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 01/15/2022] [Accepted: 03/05/2022] [Indexed: 11/20/2022]
|
13
|
Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022; 21:273-283. [DOI: 10.1016/s1474-4422(21)00359-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
|
14
|
Miyake S, Suzuki R, Akimoto T, Iida Y, Shimohigoshi W, Nakai Y, Manaka H, Shimizu N, Yamamoto T. Renal Dysfunction is the Strongest Prognostic Factor After Carotid Artery Stenting According to Real-World Data. J Stroke Cerebrovasc Dis 2021; 31:106269. [PMID: 34963079 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/17/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Through the progression of devices, the adaptation of carotid artery stenting (CAS) has been expanded according to the non-inferiority of CAS for carotid endarterectomy reported by several randomized control trials. To maintain favorable outcomes, identifying prognostic factors is essential for optimizing treatment indications and periprocedural management. This study focused on the prognostic factors of CAS using real-world data. METHODS This retrospective multicenter cohort study aimed to identify the prognostic factors after CAS using real-world data from the stroke registry of Yokohama (STrOke Registry of Yokohama; STORY) from January 1, 2018 to May 31, 2021. Patient characteristics, procedural factors, complications, and prognoses were collected using medical records. RESULTS Data from 107 patients were enrolled in this study after excluding those with insufficient data (2 cases). The mean participant age was 74.9±8.2 years, and 66 patients (61.7%) were symptomatic. Symptomatic lesions were a significant prognostic factor in the overall analysis (p=0.003). A multivariate analysis showed that the estimated glomerular filtration rate (eGFR) (odds ratio: 1.11, p=0.003) and staged CAS (odds ratio: 38.9, p=0.04) were independent prognostic factors. The odds ratio and relative risk of mRS deterioration when eGFR was under 49 mL/min/1.73 m2 compared with when eGFR was above 49 mL/min/1.73 m2 were 5.2 and 3.74, respectively. CONCLUSIONS In this real-world multicenter study, we established independent prognostic factors for CAS using high totality data. For patients with symptomatic lesions and low eGFR (≤49 mL/min/1.73 m2), indication for treatment should be considered strictly.
Collapse
Affiliation(s)
- Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa, 2350012, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama, 2320024, Japan.
| | - Yu Iida
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama, 2320024, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa, 2350012, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama, 2320024, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, 2360004, Japan
| |
Collapse
|
15
|
Karpenko A, Bugurov S, Ignatenko P, Starodubtsev V, Popova I, Malinowski K, Musialek P. Randomized Controlled Trial of Conventional Versus MicroNet-Covered Stent in Carotid Artery Revascularization. JACC Cardiovasc Interv 2021; 14:2377-2387. [PMID: 34736737 DOI: 10.1016/j.jcin.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to compare procedure-related ipsilateral cerebral embolism with a conventional (Acculink, Abbott Vascular) versus a MicroNet-covered (CGuard, InspireMD) stent in carotid artery stenting (CAS). BACKGROUND The MicroNet-covered stent may reduce periprocedural cerebral embolism in CAS, but level 1 evidence is lacking. METHODS A total of 100 consecutive patients were randomized 1:1 to filter-protected CAS using the Acculink or the CGuard device. The study was powered for its primary endpoint of at least 50% reduction in ipsilateral diffusion-weighted magnetic resonance imaging lesion average volume 48 hours postprocedure (blinded external core laboratory analysis). RESULTS The baseline characteristics of the study groups were similar. Eighty-two (total volume = 18,212 mm3) diffusion-weighted magnetic resonance imaging postprocedural cerebral lesions occurred in 26 Acculink-treated patients and 45 lesions (total volume = 3,930 mm3; 78.4% reduction) in 25 CGuard-treated patients. New cerebral lesion average volume was 171 mm3 vs 73 mm3 (P = 0.017) per affected patient and 222 mm3 vs 84 mm3 (P = 0.038) per lesion (Acculink vs CGuard). In lesion-affected patients, the average sum of lesion volumes was 701 mm3 vs 157 mm3 (P = 0.007). The Acculink significantly increased the risk for multiple (≥5) cerebral lesions (relative risk: 7.8; 95% CI: 1.3-14.9; P = 0.021). At 30 days, new permanent (fluid-attenuated inversion recovery) lesion prevalence was 3:1 (P < 0.001), with total permanent lesion volume 7,474 mm3 vs 574 mm3 (92.3% reduction with the CGuard). There were 6 vs 0 new ipsilateral lesions (P = 0.030) and 2 versus 0 strokes. CONCLUSIONS The MicroNet-covered stent significantly reduced periprocedural and abolished postprocedural cerebral embolism in relation to a conventional carotid stent. This is consistent with the MicroNet-covered stent's sustained embolism prevention, translating into cerebral protection not only during but also after CAS. The present findings may influence decision making in carotid revascularization. (The SIBERIA Trial [Acculink™ Versus CGuard™]; NCT03488199).
Collapse
Affiliation(s)
- Andrey Karpenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia.
| | - Savr Bugurov
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Pavel Ignatenko
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir Starodubtsev
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Irina Popova
- Centre of Vascular and Hybrid Surgery, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | | | - Piotr Musialek
- Jagiellonian University, Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland.
| |
Collapse
|
16
|
Nakagawa I, Kotsugi M, Park H, Furuta T, Sato F, Myochin K, Nishimura F, Yamada S, Motoyama Y, Nakase H. Near-infrared spectroscopy carotid plaque characteristics and cerebral embolism in carotid artery stenting. EUROINTERVENTION 2021; 17:599-606. [PMID: 33283761 PMCID: PMC9725057 DOI: 10.4244/eij-d-20-01050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Perioperative thromboembolism is the main consideration in carotid artery stenting (CAS). Precise evaluation of carotid plaque components is clinically important to reduce ischaemic complications since CAS mechanically pushes plaque outwards, which releases plaque debris into the bloodstream. AIMS This study aimed to determine whether high lipid core plaque (LCP) assessed by catheter-based near-infrared spectroscopy (NIRS) is associated with ipsilateral cerebral embolism by diffusion-weighted magnetic resonance imaging during CAS using a first-generation stent. METHODS Carotid stenosis magnetic resonance (MR) T1-weighted plaque signal intensity ratio (T1W-SIR) followed by NIRS assessment at the time of CAS (using the carotid artery Wallstent) was performed in 117 consecutive patients. RESULTS The maximum lipid core burden index (max-LCBI) at minimal luminal areas (MLA; max-LCBIMLA) and the max-LCBI for any 4 mm segment in a target lesion defined as max-LCBIarea were significantly higher for the post-procedural new ipsilateral diffusion-weighted magnetic resonance imaging (DWI)-positive than negative patients (p<0.001 for all). There was a significant linear correlation between max-LCBIarea and the number of new emboli (r=0.544, p<0.0001). We also found that the second quantile (Q2) of T1W-SIRMLA had a significantly higher max-LCBIMLA and a higher incidence of DWI positivity than Q1 and Q3 (p<0.001 for all). Furthermore, max-LCBIMLA appeared to distinguish between patients with and without postoperative new ipsilateral DWI positivity (AUC 0.91, 95% CI: 0.86-0.96; p<0.0001). CONCLUSIONS High LCP assessed by NIRS is associated with cerebral embolism by diffusion-weighted imaging in CAS using a first-generation stent.
Collapse
Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hun Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Fumiya Sato
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Kaoru Myochin
- Department of Radiology, Nara Medical University, Nara, Japan
| | | | - Syuichi Yamada
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| |
Collapse
|
17
|
Donners SJA, Toorop RJ, de Kleijn DPV, de Borst GJ. A narrative review of plaque and brain imaging biomarkers for stroke risk stratification in patients with atherosclerotic carotid artery disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1260. [PMID: 34532397 PMCID: PMC8421959 DOI: 10.21037/atm-21-1166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
Objective In this narrative review, we aim to review imaging biomarkers that carry the potential to non-invasively guide stroke risk stratification for treatment optimization. Background Carotid atherosclerosis plays a fundamental part in the occurrence of ischemic stroke. International guidelines select the optimal treatment strategy still mainly based on the presence of clinical symptoms and the degree of stenosis for stroke prevention in patients with atherosclerotic carotid plaques. These guidelines, based on randomized controlled trials that were conducted three decades ago, recommend carotid revascularization in symptomatic patients with high degree of stenosis versus a conservative approach for most asymptomatic patients. Due to optimization of best medical therapy and risk factor control, it is suggested that a subgroup of symptomatic patients is at lower risk of stroke and may not benefit from revascularization, whereas a selective subgroup of high-risk asymptomatic patients would benefit from this procedure. Methods A literature search was performed for articles published up to December 2020 using PubMed, EMBASE and Scopus. Based on the literature found, change in stenosis degree and volume, plaque echolucency, plaque surface, intraplaque haemorrhage, lipid-rich necrotic core, thin fibrous cap, inflammation, neovascularization, microembolic signals, cerebrovascular reserve, intracranial collaterals, silent brain infarcts, diffusion weighted imaging lesions and white matters lesions have the potential to predict stroke risk. Conclusions The applicability of imaging biomarkers needs to be further improved before the potential synergistic prognostic ability of imaging biomarkers can be verified on top of the clinical biomarkers. In the future, the routine and combined assessment of both plaque and brain imaging biomarkers might help to improve optimization of treatment strategies in individual patients with atherosclerotic carotid artery disease.
Collapse
Affiliation(s)
- Simone J A Donners
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Raechel J Toorop
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
18
|
Engelter ST, Lyrer P, Traenka C. Cervical and intracranial artery dissections. Ther Adv Neurol Disord 2021; 14:17562864211037238. [PMID: 34408787 PMCID: PMC8366117 DOI: 10.1177/17562864211037238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022] Open
Abstract
This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.
Collapse
Affiliation(s)
- Stefan T Engelter
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Petersgraben 4, Basel 4031, Switzerland
| |
Collapse
|
19
|
In Silico Hemodynamics and Filtering Evaluation of a Commercial Embolic Protection Device. Ann Biomed Eng 2021; 49:2659-2670. [PMID: 34405319 DOI: 10.1007/s10439-021-02846-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
During the last years, several kinds of Embolic Protection Devices (EPD) have been developed, with the aim of minimizing complication caused by thrombi generated during Carotid Artery Stenting (CAS). These devices are capable of capturing small particles generated during the intervention, avoiding cerebral stroke and improving the outcomes of the surgery. However, they have associated complications, like the increase on flow resistance associated by their use or the lack of knowledge on their actual filtration efficiency for thrombi of low size. Current work proposes a validated computational methodology in order to predict the hemodynamic features and filtering efficiency of a commercial EPD. It will be observed how Computational Fluid Dynamics predicts pressure drop with fair agreement with the experimental measurements. Finally, this work analyzes the filtration efficiency and the influence of the distribution of injected particles on this parameter. The capabilities of the filter for retaining particles of diameter below the pore size is, additionally, discussed.
Collapse
|
20
|
Yuan X, Guo L, Wang J, Wang D, Yang S, Guo F. Serum glial fibrillary acidic protein and S100 calcium-binding protein B correlates cerebral vessel reactivity following carotid artery stenting. Sci Rep 2021; 11:16366. [PMID: 34381130 PMCID: PMC8358004 DOI: 10.1038/s41598-021-95867-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
Using detection markers in serum has the advantages of simplicity, repeatability and the capability. This study combined the use of serum glial fibrillary acidic protein (GFAP) and S100B protein (S100B) with imaging tools to confirm the role of serum biomarkers in evaluating the cerebral vessel reactivity after carotid artery stenting (CAS). After CAS, the serum concentrations of GFAP and S100B increased to the peak at 24 h after operation, and then gradually decreased. The mean flow velocity (MFV) (pre-operation, post-operation, 30 days follow-up: 47.65 ± 17.24 cm/s, 62.37 ± 18.25 cm/s, 70.29 ± 16.89 cm/s; P < 0.05) and pulsatility index (PI) (pre-operation, post-operation, 30 days follow-up: 0.78 ± 0.21, 0.98 ± 0.19, 1.02 ± 0.20; P < 0.05) increased significantly in the ipsilateral middle cerebral artery after CAS. At the 30-day follow-up, the cerebrovascular reserve (CVR) (post-operation, 30 days follow-up: 27.47 ± 12.13 cm/s, 31.92 ± 10.94 cm/s; P < 0.05) improved significantly. In patients with different degrees of stenosis, the more severe the stenosis in the carotid artery, the more obvious the improvement of CVR at the 30 days of follow-up (CVR changes: 11.08 ± 7.95 cm/s, Kendall’s tau-b = 0.645, P < 0.001). And the serum concentrations of GFAP (r = − 0.629, P < 0.0001) and S100B (r = − 0.604, P < 0.0001) correlated negatively with CVR at 30 days after CAS. Therefore, we recommend using the biomarkers GFAP and S100B associated with imaging tools such as transcranial Doppler (TCD) and Magnetic resonance imaging (MRI) to evaluate the cerebral vessel reactivity following CAS.
Collapse
Affiliation(s)
- Xiaofan Yuan
- Neurology Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Lei Guo
- Neurology Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Jianhong Wang
- Neurology Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Duozi Wang
- Neurology Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Shu Yang
- Neurology Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Fuqiang Guo
- Neurology Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, China.
| |
Collapse
|
21
|
Matsuo K, Fujita A, Hosoda K, Tanaka J, Imahori T, Ishii T, Kohta M, Tanaka K, Uozumi Y, Kimura H, Sasayama T, Kohmura E. Potential of machine learning to predict early ischemic events after carotid endarterectomy or stenting: a comparison with surgeon predictions. Neurosurg Rev 2021; 45:607-616. [PMID: 34080079 DOI: 10.1007/s10143-021-01573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/26/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022]
Abstract
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended for high stroke-risk patients with carotid artery stenosis to reduce ischemic events. However, we often face difficulty in determining the best treatment strategy. We aimed to develop an accurate post-CEA/CAS outcome prediction model using machine learning that will serve as a basis for a new decision support tool for patient-specific treatment planning. Retrospectively collected data from 165 consecutive patients with carotid stenosis underwent CEA or CAS and were divided into training and test samples. The following five machine learning algorithms were tuned, and their predictive performance was evaluated by comparison with surgeon predictions: an artificial neural network, logistic regression, support vector machine, random forest, and extreme gradient boosting (XGBoost). Seventeen clinical factors were introduced into the models. Outcome was defined as any ischemic stroke within 30 days after treatment including asymptomatic diffusion-weighted imaging abnormalities. The XGBoost model performed the best in the evaluation; its sensitivity, specificity, positive predictive value, and accuracy were 31.9%, 94.6%, 47.2%, and 86.2%, respectively. These statistical measures were comparable to those of surgeons. Internal carotid artery peak systolic velocity, low-density lipoprotein cholesterol, and procedure (CEA or CAS) were the most contributing factors according to the XGBoost algorithm. We were able to develop a post-procedural outcome prediction model comparable to surgeons in performance. The accurate outcome prediction model will make it possible to make a more appropriate patient-specific selection of CEA or CAS for the treatment of carotid artery stenosis.
Collapse
Affiliation(s)
- Kazuya Matsuo
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kohkichi Hosoda
- Department of Neurosurgery, Kobe City Nishi-Kobe Medical Center, Kobe, Hyogo, Japan
| | - Jun Tanaka
- Department of Neurosurgery, Konan Hospital, Kobe, Hyogo, Japan
| | - Taichiro Imahori
- Department of Neurosurgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Taiji Ishii
- Department of Neurosurgery, Toyooka Hospital, Toyooka, Hyogo, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| |
Collapse
|
22
|
Engelter ST, Traenka C, Gensicke H, Schaedelin SA, Luft AR, Simonetti BG, Fischer U, Michel P, Sirimarco G, Kägi G, Vehoff J, Nedeltchev K, Kahles T, Kellert L, Rosenbaum S, von Rennenberg R, Sztajzel R, Leib SL, Jung S, Gralla J, Bruni N, Seiffge D, Feil K, Polymeris AA, Steiner L, Hamann J, Bonati LH, Brehm A, De Marchis GM, Peters N, Stippich C, Nolte CH, Christensen H, Wegener S, Psychogios MN, Arnold M, Lyrer P. Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial. Lancet Neurol 2021; 20:341-350. [PMID: 33765420 DOI: 10.1016/s1474-4422(21)00044-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines-based on available evidence from mostly observational studies-suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. METHODS We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0-3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. FINDINGS Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI -4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. INTERPRETATION Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.
Collapse
Affiliation(s)
- Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland.
| | - Christopher Traenka
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Sabine A Schaedelin
- Department of Clinical Research and Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas R Luft
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland; Cereneo, Centre for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Barbara Goeggel Simonetti
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland; Department of Neuropaediatrics, Institute of Paediatrics of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gaia Sirimarco
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georg Kägi
- Department of Neurology and Stroke Centre, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology and Stroke Centre, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology and Stroke Centre, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology and Stroke Centre, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany; Institute for Stroke and Dementia Research, University Hospital LMU Munich, Munich, Germany
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Regina von Rennenberg
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Roman Sztajzel
- Department of Neurology and Stroke Centre, University Hospital Geneva and Medical School, Geneva, Switzerland
| | - Stephen L Leib
- Institute for Infectious Diseases, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Nicole Bruni
- Department of Clinical Research and Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Seiffge
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Levke Steiner
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Janne Hamann
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Christoph Stippich
- Department of Neuroradiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Susanne Wegener
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | | |
Collapse
|
23
|
Petrov A, Rentsenkhuu G, Nota B, Ganzorig E, Regzengombo B, Jagusch S, Henkes E, Henkes H. Initial experience with the novel p64MW HPC flow diverter from a cohort study in unruptured anterior circulation aneurysms under dual antiplatelet medication. Interv Neuroradiol 2021; 27:42-50. [PMID: 32640858 PMCID: PMC7874381 DOI: 10.1177/1591019920939845] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE p64MW HPC is a new low-profile flow diverter with reduced thrombogenicity due to hydrophilic coating. The purpose of this study was to evaluate its safety and efficacy in Mongolian patients under dual antiplatelet therapy. METHODS Consecutive patients with unruptured anterior circulation aneurysms were prospectively enrolled. All patients received aspirin and clopidogrel before and six months after the procedure, followed by lifelong aspirin medication. High platelet reactivity (VerifyNow) did not trigger further action. The safety and efficacy endpoints were clinical outcome and aneurysm occlusion. RESULTS In 29 patients (26 female, median age 57 years), 46 aneurysms (neck width 3.3 mm, fundus diameter 3.7 mm, median) were treated. Dual platelet function inhibition was confirmed in eight patients (28%). The response to Clopidogrel was between 100 and 239 P2Y12 reaction units (VerifyNow) in 13 patients (45%). Non-response to at least one drug was found in 8 of 29 patients (28%). One collapsed p64MW HPC required balloon angioplasty. No other periprocedural thrombus formation occurred. Postprocedural MRI revealed lesions with diffusion restriction in 3 of 29 patients. Digital subtraction angiography after three months for 42 of 46 (91%) aneurysms showed an adequate aneurysm occlusion in 25 (60%). Distal p64MW HPC migration of 3 implants was retreated with another p64MW HPC. Follow-up digital subtraction angiography of 26 of 46 (57%) aneurysms after six months showed adequate aneurysm occlusion in 22 (85%). Significant in-stent stenosis or thrombosis, morbidity or mortality was not encountered. CONCLUSION p64MW HPC implantation in patients under dual antiplatelet therapy with or without dual platelet function inhibition has a low procedural complication rate. The early aneurysm occlusion rate is high.
Collapse
Affiliation(s)
- Andrey Petrov
- Vascular Neurosurgery Department,
Russian Polenov Neurosurgical Institute, Branch of National Medical Research
Center “Almazov”, St. Petersburg, Russia
| | | | - Baatarjan Nota
- Department of Angiography, Shastin
Central Hospital, Ulaanbaatar, Mongolia
| | - Erdenebat Ganzorig
- Department of Angiography, Shastin
Central Hospital, Ulaanbaatar, Mongolia
| | | | | | - Elina Henkes
- Neuroradiological Clinic, Klinikum
Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum
Stuttgart, Stuttgart, Germany
- University Duisburg-Essen,
Medizinische Fakultät, Essen, Germany
| |
Collapse
|
24
|
Transient flow reversal combined with sustained embolic prevention in transcervical revascularization of symptomatic and highly-emboligenic carotid stenoses for optimized endovascular lumen reconstruction and improved peri- and post-procedural outcomes. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:495-506. [PMID: 33598027 PMCID: PMC7863838 DOI: 10.5114/aic.2020.102134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/20/2020] [Indexed: 11/24/2022] Open
|
25
|
Fujioka H, Urasaki E, Soejima Y, Harada H, Yamashita K. Combination of Single- and Paired-Pulse Somatosensory Evoked Potentials in Ischemic Monitoring: Preliminary Investigation in Carotid Endarterectomy. Cureus 2020; 12:e12206. [PMID: 33489615 PMCID: PMC7815265 DOI: 10.7759/cureus.12206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Severe ischemia induces cerebral excitability imbalance before completion of infarct. To investigate the clinical availability of this imbalance with ischemic monitoring, paired-pulse somatosensory evoked potentials (SEPs) were performed in conjunction with conventional SEPs during carotid endarterectomy. Methods For carotid endarterectomy patients with hemodynamic deficits of the middle cerebral artery area (n = 34), the excitability imbalances (Q) were measured by paired-pulse SEPs, wherein the second response (A2) was divided by the first (A1; Q = A2/A1). Regional cerebral saturation (rSO2) was also measured. Occlusion was performed twice using shunting. Results Each carotid occlusion induced a significant decrease in mean A1 and rSO2, and an increase in mean Q values (p < 0.001), which returned to the baseline level after occlusion. While neuronal imbalances were mostly transient, persistently increased Q values were observed in four cases (11.8%), all indicating postoperative abnormalities in diffusion-weighted magnetic resonance imaging (100%). Meanwhile, A1 detected the postoperative abnormality in only one case (25%). Preoperative Q values at the time of surgery were significantly higher in symptomatic patients having the upper limb deficits than those without (p < 0.01), indicating persistent or permanent imbalances. Conclusion Paired-pulse SEPs reliably identified transient, persistent or permanent neuronal imbalances, depending on the ischemic severity. These preliminary results indicated that paired-pulse SEPs, in combination with conventional SEPs (A1), may offer better ischemic monitoring.
Collapse
Affiliation(s)
- Hiroshi Fujioka
- Neurosurgery, Nagasaki Yurino Hospital, Nagasaki, JPN.,Neurosurgery, Kanmon Medical Center, National Hospital Organization (NHO), Shimonoseki, JPN.,Neurosurgery, Cognitive and Molecular Research Institute of Brain Diseases, Kurume University, Fukuoka, JPN
| | | | - Yoshiteru Soejima
- Neurosurgery, Kanmon Medical Center, National Hospital Organization (NHO), Shimonoseki, JPN
| | - Hideki Harada
- Anaesthesiology, Cognitive and Molecular Research Institute of Brain Diseases, Kurume University, Fukuoka, JPN
| | - Katsuhiro Yamashita
- Neurosurgery, Kanmon Medical Center, National Hospital Organization (NHO), Shimonoseki, JPN
| |
Collapse
|
26
|
Dakour-Aridi H, Cui CL, Barleben A, Schermerhorn ML, Eldrup-Jorgensen J, Malas MB. Poststent ballooning during transcarotid artery revascularization. J Vasc Surg 2020; 73:2041-2049.e1. [PMID: 33253868 DOI: 10.1016/j.jvs.2020.10.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/18/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Poststent ballooning/angioplasty (post-SB) have been shown to increase the risk of stroke risk after transfemoral carotid artery stenting. With the advancement of transcarotid artery revascularization (TCAR) with dynamic cerebral blood flow reversal, we aimed to study the impact of post-SB during TCAR. METHODS Patients undergoing TCAR in the Vascular Quality Initiative between September 2016 and May 2019 were included and were divided into three groups: those who received prestent deployment angioplasty only (pre-SB, reference group), those who received poststent deployment ballooning only (post-SB), and those who received both prestent and poststent deployment ballooning (prepost-SB). Patients who did not receive any angioplasty during their procedure (n = 367 [6.7%]) were excluded because these represent a different group of patients with less complex lesions than those requiring angioplasty. Primary outcome was in-hospital stroke or death. Analysis was performed using univariable and multivariable logistic regression models. RESULTS Of 5161 patients undergoing TCAR, 34.7% had pre-SB only, 25% had post-SB only, and 40.3% had both (prepost-SB). No differences in the rates of in-hospital and 30-day stroke, death, and stroke/death were observed among the three groups; in-hospital stroke/death in the pre-SB group was 1.4% (n = 25), post-SB 1.2% (n = 16), and prepost-SB 1.4% (n = 29; P = .92). However, patients undergoing post-SB and prepost-SB had higher rates of in-hospital transient ischemic attacks (TIA) (post-SB, 0.9%; prepost-SB, 1% vs pre-SB, 0.2%, P < .01) and postprocedural hypotension (16.6% and 16.8% vs 13.1%, respectively; P < .001). Post-SB also had longer operative times, as well as flow reversal and fluoroscopy times. On multivariable analysis, no association was seen between post-SB and the primary outcome of in-hospital stroke/death (post-SB odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44-1.73; prepost-SB OR, 0.98; 95% CI, 0.57-1.70). Similarly, no significant differences were noted in terms of postprocedural hemodynamic instability and 30-day outcomes. However, post-SB and prepost-SB were associated with four times the odds of in-hospital TIA compared with pre-SB alone (post-SB OR, 4.24 [95% CI, 1.51-11.8]; prepost-SB OR, 4.76 [95% CI, 1.53-14.79]; P = .01). Symptomatic patients had higher rates of in-hospital stroke/death compared with their asymptomatic counterparts; however, there was no significant interaction between symptomatic status and ballooning in predicting the primary outcome. CONCLUSIONS Post-SB was used in 65.3% of TCAR patients. This maneuver seems to be safe without an increase in the odds of postoperative in-hospital stroke/death. However, the increased rates of TIA associated with post-SB requires further investigation.
Collapse
Affiliation(s)
- Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif
| | - Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif
| | - Andrew Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, Calif.
| |
Collapse
|
27
|
Risk Factors of Cerebellar Microembolic Infarctions After Carotid Artery Stenting. World Neurosurg 2020; 142:e290-e296. [DOI: 10.1016/j.wneu.2020.06.207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/28/2022]
|
28
|
Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology (L.R.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| |
Collapse
|
29
|
Schönfeld MH, Kabiri R, Kniep HC, Meyer L, McDonough R, Sedlacik J, Ernst M, Broocks G, Faizy T, Schön G, Cheng B, Thomalla G, Fiehler J, Hanning U. Effect of Balloon Guide Catheter Utilization on the Incidence of Sub-angiographic Peripheral Emboli on High-Resolution DWI After Thrombectomy: A Prospective Observational Study. Front Neurol 2020; 11:386. [PMID: 32457694 PMCID: PMC7221024 DOI: 10.3389/fneur.2020.00386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/17/2020] [Indexed: 01/19/2023] Open
Abstract
Background: Thrombus fragmentation causing distal emboli is a feared complication during mechanical thrombectomy (MT). We aimed to investigate the impact of procedural parameters and thrombus properties on the incidence of peripheral emboli after MT for large vessel occlusions (LVO). Methods: We performed a prospective analysis of patients with LVO stroke successfully treated with MT, defined as a score of 2b, 2c, or 3 on the thrombolysis in cerebral infarction (TICI) scale. A follow-up MRI including high-resolution diffusion-weighted imaging (DWI) was performed within 24 h following MT. The primary endpoint was the number and volume of peripheral emboli, classified as punctuate DWI lesions distant to the diffusion-restricted core lesion. Further analysis included the influence of baseline characteristics, procedural and outcome parameters, and thrombus properties on peripheral emboli. Results: Thirty-seven patients with successful MT met the inclusion criteria. Use of a balloon guide catheter (BGC) and TICI were the only independent predictors for a reduced number of peripheral emboli. The use of a BGC led to a significant reduction in the number and volume of peripheral emboli, with a median number/volume of peripheral emboli of 4.5/287 μl (IQR 1.25–8.25/76–569 μl) vs. 12/938 μl (IQR 4–19/242–1,836 μl). In cases where BGC was not employed, the number of peripheral emboli increased with decreasing TICI scores. Conclusions: BGC-aided MT reduces the number of peripheral emboli in successful but incomplete reperfusion (TICI 2b and 2c). The effectiveness of this strategy therefore goes above and beyond that which can be demonstrated by the TICI score alone.
Collapse
Affiliation(s)
- Michael H Schönfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Sedlacik
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Biomedical Engineering Department, Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
30
|
Rots ML, Fassaert LM, Kappelle LJ, de Groot MC, Haitjema S, Bonati LH, van Klei WA, de Borst GJ. Intra-Operative Hypotension is a Risk Factor for Post-operative Silent Brain Ischaemia in Patients With Pre-operative Hypertension Undergoing Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2020; 59:526-534. [DOI: 10.1016/j.ejvs.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/28/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
|
31
|
Magnetic Resonance Imaging Identified Brain Ischaemia in Symptomatic Patients Undergoing Carotid Endarterectomy Is Related to Histologically Apparent Intraplaque Haemorrhage. Eur J Vasc Endovasc Surg 2019; 58:796-804. [PMID: 31631008 DOI: 10.1016/j.ejvs.2019.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/11/2019] [Accepted: 07/14/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Intraplaque haemorrhage (IPH) has been independently associated with a higher risk of future ipsilateral stroke in patients with carotid artery stenosis. Evaluation of plaque characteristics may contribute to risk assessment of recurrent (silent) cerebrovascular events in order to prioritise patients for timing of treatment. It is unknown if patients showing histologically apparent IPH also have increased risk of silent ischaemic brain lesions in the waiting period between index event and revascularisation. METHODS A retrospective analysis was performed based on prospectively collected data of patients included simultaneously in the magnetic resonance imaging (MRI) substudy of the International Carotid Stenting Study and Athero-Express biobank. Patients randomised for carotid endarterectomy (CEA) underwent surgery between 2003 and 2008. Brain MRI was performed one to seven days prior to CEA. Plaques were histologically examined for presence of IPH. The primary outcome parameter was presence of silent ipsilateral brain ischaemia on magnetic resonance diffusion weighted imaging (MR-DWI) appearing hypo or isointense on apparent diffusion coefficient. RESULTS Fifty-three patients with symptomatic carotid stenosis meeting the study criteria were identified, of which 13 showed one or more recent ipsilateral DWI lesion on pre-operative scan. The median time between latest ipsilateral neurological event and revascularisation was 45 days (range 6-200) in DWI negative patients vs. 34 days (range 6-74, p = .16) in DWI positive patients. IPH was present in 24/40 (60.0%) DWI negative patients vs. 12/13 (92.3%) DWI positive patients (OR 8.00; 95% CI 0.95-67.7, p = .06). Multivariable logistic regression analysis correcting for age and type of index event revealed that IPH was independently associated with DWI lesions in the waiting period till surgery (OR 10.8; 95% CI 1.17-99.9, p = .04). CONCLUSION Symptomatic patients with ipsilateral carotid stenosis and silent brain ischaemia on pre-operative MR-DWI, more often showed pathological evidence of IPH compared with those without ischaemic lesions. This identifies carotid IPH as a marker for patients at risk of silent brain ischaemia and possibly for future stroke and other arterial disease complications. Such patients may be more likely to benefit from CEA than those without evidence of ipsilateral carotid IPH.
Collapse
|
32
|
Surrogate Markers and Reporting Standards for Outcome After Carotid Intervention. Eur J Vasc Endovasc Surg 2019; 58:794-795. [PMID: 31585695 DOI: 10.1016/j.ejvs.2019.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/14/2019] [Accepted: 08/18/2019] [Indexed: 11/22/2022]
|