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Feng Y, Bai X, Zhang X, Wang T, Lu X, Yang K, Ling F, Ma Y, Jiao L. Risk factors for new ischemic cerebral lesions after carotid artery stenting: A systematic review and meta-analysis. Ann Vasc Surg 2021; 77:296-305. [PMID: 34437972 DOI: 10.1016/j.avsg.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/13/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND New ischemic cerebral lesions (NICL) are commonly occur after carotid artery stenting (CAS) with an incidence rate ranging from 18-58% and are detected by diffusion-weighted imaging-magnetic resonance imaging (DWI-MRI). Numerous studies have reported that NICL could increase the risk of future cerebrovascular events and cognitive impairment. This systematic review and meta-analysis aimed to identify risk factors for NICL after CAS. METHODS Relevant literature reporting risk factors for NICL after CAS were searched. Randomized controlled trials, case-control studies, or cohort studies were included in accordance with the pre-specified eligibility criteria. The risk of bias was assessed using the Cochrane Collaboration criteria and the quality of evidence was assessed with the corresponding scale. Data were analyzed using the RevMan V. 5.3 analysis software. RESULTS The final analyses included a total of 21 studies and 1907 participants, including 764 NICL-positives and 1143 NICL-negatives. Determinants for NICL-positivity were age (mean deviation (MD): 2.60; 95% confidence interval (CI): [1.53-3.68]), symptomatic carotid lesions (odds ratio (OR): 1.77; 95% CI: [1.39-2.25]) and smoking (OR: 0.74; 95% CI: [0.58-0.94]). For symptomatic patients, risk factors for NICL-positive included diabetes mellitus (OR: 1.76; 95% CI: [1.09-2.82]), but smoking (OR: 0.54; 95% CI: [0.31-0.93]) was a protective factor. Risk factors for centers with high NICL incidence were age (MD: 2.05; 95% CI: [0.93-3.17]) and symptomatic carotid lesions (OR: 1.77; 95% CI: [1.29-2.45]). CONCLUSIONS Older age and symptomatic carotid lesions are associated with an increased risk of post-CAS NICL whereas smoking is associated with a decreased risk. Risk factors for NICL in symptomatic patients is diabetes mellitus, while those for patients at centers with high incidence are age and symptomatic carotid lesions. Systematic review registration: CRD42019121129.
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Affiliation(s)
- Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Xia Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China; Department of Interventional Neuroradiology, Capital Medical University, Beijing, China.
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2
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Wang WX, Wang T, Ma L, Sun ZH, Wang GS. New-onset lesions on MRI-DWI and cerebral blood flow changes on 3D-pCASL after carotid artery stenting. Sci Rep 2021; 11:8005. [PMID: 33850199 PMCID: PMC8044121 DOI: 10.1038/s41598-021-87339-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/22/2021] [Indexed: 11/09/2022] Open
Abstract
This study aimed to investigate the relationship between the new-onset hyperintense lesions on diffusion-weighted images (DWI) and the changes of cerebral blood flow (CBF) before and after carotid artery stenting (CAS) in patients with symptomatic unilateral carotid artery stenosis. Twenty-four patients with symptomatic unilateral carotid stenosis (50-99%) were enrolled. Routine head magnetic resonance imaging and three-dimensional pseudo-continuous arterial spin labeling were taken 7 days before the surgery and for four consecutive days post CAS. While the incidence of new DWI lesions were high (17/24, 70.8%) and 176 lesions were observed among the 17 cases, there was only one subject showing the symptoms. The majority of the lesions were located at the cortex/subcortex of the ipsilateral frontal and parietal lobes (60.8%) with 92.6% of the lesions size being less than 3 mm. The CBFs in this area were significantly higher than that of the temporal lobe on the first 3 days post stenting (p < 0.05). No periprocedural CBF differences were observed between the two groups, however, the micro-embolism group presented decreased relative CBF in frontal and parietal lobes prior to stenting compared with the non-embolism group. The systolic blood pressure in the micro-embolism group at discharge was significantly lower than that at admission. The high incidence rate of micro-embolism in patients receiving CAS may not be the result of direct changes of hemodynamics in the brain but rather the loss of CBF regulation due to long-term hypoperfusion prior to the stenting.
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Affiliation(s)
- Wen-Xin Wang
- Department of Neurosurgery, Dongfang Hospital of Beijing University of Chinese Medicine, Fengtai District, Beijing, China
- Department of Radiology, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Ting Wang
- Department of Radiology, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Lin Ma
- Department of Radiology, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Zheng-Hui Sun
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Ge-Sheng Wang
- Department of Neurosurgery, Dongfang Hospital of Beijing University of Chinese Medicine, Fengtai District, Beijing, China.
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Xu X, Feng Y, Bai X, Ma Y, Wang Y, Chen Y, Yang B, Ling F, Zhang X, Jiao L. Risk factors for silent new ischemic cerebral lesions following carotid artery stenting. Neuroradiology 2020; 62:1177-1184. [DOI: 10.1007/s00234-020-02447-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
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4
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Feng Y, Li L, Bai X, Wang T, Chen Y, Zhang X, Ling F, Jiao L. Risk factors for new ischaemic cerebral lesions after carotid artery stenting: protocol for a systematic review and meta-analysis. BMJ Open 2019; 9:e030025. [PMID: 31446417 PMCID: PMC6719763 DOI: 10.1136/bmjopen-2019-030025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION New ischaemic cerebral lesions (NICL) detected by diffusion-weighted imaging MRI are common after carotid artery stenting (CAS), with an occurrence rate ranging from 18% to 57%. Many studies reported occurrence of NICL could increase risk of future cerebrovascular events and cognitive impairment. However, controversies about determinants for occurrence of NICL after CAS exist among studies, and one risk factor embodied in an article may not be in another. Aim of this study is to introduce a protocol for a systematic review and meta-analysis to identify risk factors associated with occurrence of NICL after CAS. METHODS AND ANALYSIS All relevant literature referring to risk factors for occurrence of NICL after CAS will be searched on the major databases, such as PubMed, Embase, Web of Science and the Cochrane Library until 31 December 2018. Literature, which must be randomised controlled trials, case-control studies or cohort studies, will be included in accordance with the prespecified eligibility criteria. The risk of bias will be assessed using the Cochrane Collaboration criteria and the quality of evidence will be assessed with the corresponding scale. Data will be extracted with a form prepared before and analysed using RevMan V.5.3 analyses software. Heterogeneity will be assessed using I2 statistic. Our systematic review will be performed according to the guidance from the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. ETHICS AND DISSEMINATION There is no need for ethical approval because primary data will not be attained. The systematic review will be presented at international conferences and published in peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42019121129.
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Affiliation(s)
- Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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5
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Traenka C, Engelter ST, Brown MM, Dobson J, Frost C, Bonati LH. Silent brain infarcts on diffusion-weighted imaging after carotid revascularisation: A surrogate outcome measure for procedural stroke? A systematic review and meta-analysis. Eur Stroke J 2019; 4:127-143. [PMID: 31259261 DOI: 10.1177/2396987318824491] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aim To investigate whether lesions on diffusion-weighted imaging (DWI+) after carotid artery stenting (CAS) or endarterectomy (CEA) might provide a surrogate outcome measure for procedural stroke. Materials and Methods Systematic MedLine® database search with selection of all studies published up to the end of 2016 in which DWI scans were obtained before and within seven days after CAS or CEA. The correlation between the underlying log odds of stroke and of DWI+ across all treatment groups (i.e. CAS or CEA groups) from included studies was estimated using a bivariate random effects logistic regression model. Relative risks of DWI+ and stroke in studies comparing CAS vs. CEA were estimated using fixed-effect Mantel-Haenszel models. Results We included data of 4871 CAS and 2099 CEA procedures (85 studies). Across all treatment groups (CAS and CEA), the log odds for DWI+ was significantly associated with the log odds for clinically manifest stroke (correlation coefficient 0.61 (95% CI 0.27 to 0.87), p = 0.0012). Across all carotid artery stenting groups, the correlation coefficient was 0.19 (p = 0.074). There were too few CEA groups to reliably estimate a correlation coefficient in this subset alone. In 19 studies comparing CAS vs. CEA, the relative risks (95% confidence intervals) of DWI+ and stroke were 3.83 (3.17-4.63, p < 0.00001) and 2.38 (1.44-3.94, p = 0.0007), respectively. Discussion This systematic meta-analysis demonstrates a correlation between the occurrence of silent brain infarcts on diffusion-weighted imaging and the risk of clinically manifest stroke in carotid revascularisation procedures. Conclusion Our findings strengthen the evidence base for the use of DWI as a surrogate outcome measure for procedural stroke in carotid revascularisation procedures. Further randomised studies comparing treatment effects on DWI lesions and clinical stroke are needed to fully establish surrogacy.
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Affiliation(s)
- Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Martin M Brown
- Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
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6
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Rosen AC, Soman S, Bhat J, Laird AR, Stephens J, Eickhoff SB, Fox PM, Long B, Dinishak D, Ortega M, Lane B, Wintermark M, Hitchner E, Zhou W. Convergence Analysis of Micro-Lesions (CAML): An approach to mapping of diffuse lesions from carotid revascularization. NEUROIMAGE-CLINICAL 2018; 18:553-559. [PMID: 29868451 PMCID: PMC5984594 DOI: 10.1016/j.nicl.2018.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/19/2017] [Accepted: 01/18/2018] [Indexed: 11/25/2022]
Abstract
Carotid revascularization (endarterectomy, stenting) prevents stroke; however, procedure-related embolization is common and results in small brain lesions easily identified by diffusion weighted magnetic resonance imaging (DWI). A crucial barrier to understanding the clinical significance of these lesions has been the lack of a statistical approach to identify vulnerable brain areas. The problem is that the lesions are small, numerous, and non-overlapping. Here we address this problem with a new method, the Convergence Analysis of Micro-Lesions (CAML) technique, an extension of the Anatomic Likelihood Analysis (ALE). The method combines manual lesion tracing, constraints based on known lesion patterns, and convergence analysis to represent regions vulnerable to lesions as probabilistic brain atlases. Two studies were conducted over the course of 12 years in an active, vascular surgery clinic. An analysis in an initial group of 126 patients at 1.5 T MRI was cross-validated in a second group of 80 patients at 3T MRI. In CAML, lesions were manually defined and center points identified. Brains were aligned according to side of surgery since this factor powerfully determines lesion distribution. A convergence based analysis, was performed on each of these groups. Results indicated the most consistent region of vulnerability was in motor and premotor cortex regions. Smaller regions common to both groups included the dorsolateral prefrontal cortex and medial parietal regions. Vulnerability of motor cortex is consistent with previous work showing changes in hand dexterity associated with these procedures. The consistency of CAML also demonstrates the feasibility of this new approach to characterize small, diffuse, non-overlapping lesions in patients with multifocal pathologies. Convergence Analysis of Micro-Lesions technique finds patterns in diffuse lesions. Lesions from carotid revascularization affect consistent brain targets. Motor cortex is the most vulnerable brain region to these lesions.
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Affiliation(s)
- Allyson C Rosen
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Psychiatry, Stanford University, Stanford, CA 94305, United States.
| | - Salil Soman
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Radiology, Boston, MA 00215, United States
| | - Jyoti Bhat
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Palo Alto Veterans Institute for Research, Palo Alto, CA 94304, United States
| | - Angela R Laird
- Department of Physics, School of Integrated Science and Humanity, Florida International University, Miami, FL 33199, United States
| | - Jeffrey Stephens
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States
| | - Simon B Eickhoff
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany
| | - P Mickle Fox
- Research Imaging Institute, The University of Texas Health Science Center at San Antonio, TX 78229, United States
| | - Becky Long
- Department of Surgery, Stanford University, Stanford, CA 94305, United States; Department of Surgery, Texas Tech University Health Science Center El Paso, TX 79905, United States
| | - David Dinishak
- Palo Alto University, Redwood City, CA 94063, United States
| | - Mario Ortega
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Barton Lane
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Radiology, Stanford University, Stanford, CA 94305, United States
| | - Max Wintermark
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Radiology, Stanford University, Stanford, CA 94305, United States
| | - Elizabeth Hitchner
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Vascular Surgery, Stanford University, Stanford, CA 94305, United States
| | - Wei Zhou
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Vascular Surgery, Stanford University, Stanford, CA 94305, United States; Department of Surgery, Tucson, AZ 85724-5066, United States
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7
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Zhou W, Baughman BD, Soman S, Wintermark M, Lazzeroni LC, Hitchner E, Bhat J, Rosen A. Volume of subclinical embolic infarct correlates to long-term cognitive changes after carotid revascularization. J Vasc Surg 2016; 65:686-694. [PMID: 28024850 DOI: 10.1016/j.jvs.2016.09.057] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/22/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Carotid intervention is safe and effective in stroke prevention in appropriately selected patients. Despite minimal neurologic complications, procedure-related subclinical microemboli are common and their cognitive effects are largely unknown. In this prospective longitudinal study, we sought to determine long-term cognitive effects of embolic infarcts. METHODS The study recruited 119 patients including 46% symptomatic patients who underwent carotid revascularization. Neuropsychological testing was administered preoperatively and at 1 month, 6 months, and 12 months postoperatively. Rey Auditory Verbal Learning Test (RAVLT) was the primary cognitive measure with parallel forms to avoid practice effect. All patients also received 3T brain magnetic resonance imaging with a diffusion-weighted imaging (DWI) sequence preoperatively and within 48 hours postoperatively to identify procedure-related new embolic lesions. Each DWI lesion was manually traced and input into a neuroimaging program to define volume. Embolic infarct volumes were correlated with cognitive measures. Regression models were used to identify relationships between infarct volumes and cognitive measures. RESULTS A total of 587 DWI lesions were identified on 3T magnetic resonance imaging in 81.7% of carotid artery stenting (CAS) and 36.4% of carotid endarterectomy patients with a total volume of 29,327 mm3. Among them, 54 DWI lesions were found in carotid endarterectomy patients and 533 in the CAS patients. Four patients had transient postoperative neurologic symptoms and one had a stroke. CAS was an independent predictor of embolic infarction (odds ratio, 6.6 [2.1-20.4]; P < .01) and infarct volume (P = .004). Diabetes and contralateral carotid severe stenosis or occlusion had a trend of positive association with infarct volume, whereas systolic blood pressure ≥140 mm Hg had a negative association (P = .1, .09, and .1, respectively). There was a trend of improved RAVLT scores overall after carotid revascularization. Significantly higher infarct volumes were observed among those with RAVLT decline. Within the CAS cohort, infarct volume was negatively correlated with short- and long-term RAVLT changes (P < .05). CONCLUSIONS Cognitive assessment of procedure-related subclinical microemboli is challenging. Volumes of embolic infarct correlate with long-term cognitive changes, suggesting that microembolization should be considered a surrogate measure for carotid disease management.
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Affiliation(s)
- Wei Zhou
- Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif; Department of Surgery, Stanford University, Stanford, Calif.
| | | | - Salil Soman
- Department of Radiology, Harvard Medical School, Cambridge, Mass
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, Calif
| | - Laura C Lazzeroni
- Department of Psychiatry and Behavior Science, Stanford University, Stanford, Calif
| | | | - Jyoti Bhat
- Department of Psychiatry, VA Palo Alto Health Care System, Palo Alto, Calif
| | - Allyson Rosen
- Department of Psychiatry and Behavior Science, Stanford University, Stanford, Calif; Department of Psychiatry, VA Palo Alto Health Care System, Palo Alto, Calif
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8
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Gensicke H, Zumbrunn T, Jongen LM, Nederkoorn PJ, Macdonald S, Gaines PA, Lyrer PA, Wetzel SG, van der Lugt A, Mali WPTM, Brown MM, van der Worp HB, Engelter ST, Bonati LH. Characteristics of Ischemic Brain Lesions After Stenting or Endarterectomy for Symptomatic Carotid Artery Stenosis. Stroke 2013; 44:80-6. [DOI: 10.1161/strokeaha.112.673152] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In a substudy of the International Carotid Stenting Study (ICSS), more patients had new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (MRI) after stenting (CAS) than after endarterectomy (CEA). In the present analysis, we compared characteristics of diffusion-weighted MRI lesions.
Methods—
Number, individual and total volumes, and location of new diffusion-weighted MRI lesions were compared in patients with symptomatic carotid stenosis randomized to CAS (n=124) or CEA (n=107) in the ICSS-MRI substudy.
Results—
CAS patients had higher lesion numbers than CEA patients (1 lesion, 15% vs 8%; 2–5 lesions, 19% vs 5%; >5 lesions, 16% vs 4%). The overall risk ratio for the expected lesion count with CAS versus CEA was 8.8 (95% confidence interval, 4.4–17.5;
P
<0.0001) and significantly increased among patients with lower blood pressure at randomization, diabetes mellitus, stroke as the qualifying event, left-side stenosis, and if patients were treated at centers routinely using filter-type protection devices during CAS. Individual lesions were smaller in the CAS group than in the CEA group (
P
<0.0001). Total lesion volume per patient did not differ significantly. Lesions in the CAS group were more likely to occur in cortical areas and subjacent white matter supplied by leptomeningeal arteries than lesions in the CEA group (odds ratio, 4.2; 95% confidence interval, 1.7–10.2;
P
=0.002).
Conclusions—
Compared with patients undergoing CEA, patients treated with CAS had higher numbers of periprocedural ischemic brain lesions, and lesions were smaller and more likely to occur in cortical areas and subjacent white matter. These findings may reflect differences in underlying mechanisms of cerebral ischemia.
Clinical Trial Registration—
URL:
http://www.isrctn.org
. Unique identifier: ISRCTN25337470.
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Affiliation(s)
- Henrik Gensicke
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Thomas Zumbrunn
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Lisa M. Jongen
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Paul J. Nederkoorn
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Sumaira Macdonald
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Peter A. Gaines
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Philippe A. Lyrer
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Stephan G. Wetzel
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Aad van der Lugt
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Willem P. Th. M. Mali
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Martin M. Brown
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - H. Bart van der Worp
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Stefan T. Engelter
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
| | - Leo H. Bonati
- From the Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (H.G., P.A.L., S.T.E., L.H.B.); Clinical Trial Unit, University Hospital Basel, Basel, Switzerland (T.Z.); Department of Radiology (L.M.J., W.P.T.M.M.) and Department of Neurology, Rudolf Magnus Institute of Neuroscience (H.B.v.d.W.), University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neurology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands (P.J.N.); Department of
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Zhou W, Zareie R, Tedesco M, Gholibeikian S, Lane B, Hernandez-Boussard T, Rosen A. Risk factors predictive of carotid artery stenting-associated subclinical microemboli. Int J Angiol 2012; 20:25-32. [PMID: 22532767 DOI: 10.1055/s-0031-1272546] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Subclinical microemboli documented on diffusion-weighted magnetic resonance imaging (DWI) are common following carotid artery stenting (CAS) procedures despite absence of neurological symptoms. This study was to evaluate risk factors predictive of microemboli in patients undergoing protected CAS with a distal embolic protection device. All CAS patients who received pre- and postprocedural magnetic resonance imaging (MRI) evaluations for carotid interventions at a single academic institution from July 2004 to December 2008 were examined. Microemboli were defined by new hyperintensities on postoperative DWI with corresponding decreased diffusion. Risk factors including patient demographics, medical comorbidities, clinical symptoms, lesion morphologies, and perioperative information were examined, and logistic regression analyses were utilized to determine predictors of CAS-related microemboli. A total of 204 patients underwent carotid interventions (76 CAS and 128 carotid endarterectomies) during the study period; 167 of them, including 67 CAS patients, received both preoperative and postoperative MRIs. Among those who underwent protected CAS, the incidence of microemboli was 46.3% despite a relative low incidence of associated neurological symptoms (2.9%). Univariate and multivariate regression analyses showed that date of procedure (odds ratio [OR] 30.6 and p = 0.019) and preoperative transient ischemic attack symptoms (OR 9.24 and p = 0.009) were independent predictors of developing postoperative changes on DWI in the ipsilateral hemisphere, and age >76 years was predictive of having new lesions on DWI in the contralateral hemisphere (OR 6.11 and p = 0.026). Our study underscores that certain risk factors are significantly associated with CAS-related microemboli and that physician experience and patient selection are essential in improving outcome of CAS procedures.
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Zhou W, Hitchner E, Gillis K, Sun L, Floyd R, Lane B, Rosen A. Prospective neurocognitive evaluation of patients undergoing carotid interventions. J Vasc Surg 2012; 56:1571-8. [PMID: 22889720 DOI: 10.1016/j.jvs.2012.05.092] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 05/25/2012] [Accepted: 05/26/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Distal cerebral embolization is a known complication of carotid interventions. We prospectively investigated whether subclinical microembolization seen on postoperative magnetic resonance imaging (MRI) leads to cognitive deficits in patients undergoing carotid revascularization procedures. METHODS Patients undergoing carotid interventions and eligible for MRI scanning were recruited. Among 247 patients who received preoperative and postoperative MRI evaluations, 51 also completed neuropsychologic testing before and at 1 month after their procedure. Cognitive evaluation included the Rey Auditory Verbal Learning Test (RAVLT) for memory evaluation and the Mini-Mental State Examination (MMSE) for general cognitive impairment screening. RESULTS The 51 patients (all men), comprising 16 with carotid artery stenting (CAS) and 35 with carotid endarterectomy (CEA), were a mean age of 71 years (range, 54-89 years). Among them, 27 patients (53%) were symptomatic preoperatively, including 11 who had prior stroke and 16 who had prior preoperative transient ischemic attack symptoms. Most patients had significant medical comorbidities, including hypertension (96%), diabetes (31.3%), coronary artery disease (47%), and chronic obstructive pulmonary disease (15.7%). Two patients (4%) had prior ipsilateral CEA and eight had contralateral carotid occlusion (15.7%). Memory decline evident on RAVLT was identified in eight CAS patients and 13 CEA patients. Eleven patients had evidence of procedure-related microemboli. Although there was no significant difference in baseline cognitive function or memory change between the CEA and CAS cohorts, the CAS cohort had a significantly higher incidence of microembolic lesions. Multivariate regression analysis showed that procedure-related microembolization was associated with memory decline (P = .016) as evident by change in RAVLT. A history of neurologic symptoms was significantly associated with poor baseline cognitive function (MMSE; P = .03) and overall cognitive deterioration (change in MMSE; P = .026), as determined by Wilcoxon rank sum test and linear regression analysis, respectively. CONCLUSIONS Although CEA and CAS are effective in stroke prevention, with minimal neurologic complication, neurocognitive effects remain uncertain. Procedure-associated microembolization and pre-existing neurologic symptoms are associated with poor baseline cognitive function and memory decline after the procedures. Further comprehensive cognitive evaluation to determine the benefit of carotid interventions is warranted.
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Affiliation(s)
- Wei Zhou
- Department of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA.
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New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9:353-62. [PMID: 20189458 DOI: 10.1016/s1474-4422(10)70057-0] [Citation(s) in RCA: 404] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Zhou W, Dinishak D, Lane B, Hernandez-Boussard T, Bech F, Rosen A. Long-term radiographic outcomes of microemboli following carotid interventions. J Vasc Surg 2009; 50:1314-9. [DOI: 10.1016/j.jvs.2009.07.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 07/23/2009] [Accepted: 07/25/2009] [Indexed: 10/20/2022]
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Garg N, Karagiorgos N, Pisimisis GT, Sohal DPS, Longo GM, Johanning JM, Lynch TG, Pipinos II. Cerebral Protection Devices Reduce Periprocedural Strokes During Carotid Angioplasty and Stenting:A Systematic Review of the Current Literature. J Endovasc Ther 2009; 16:412-27. [PMID: 19702342 DOI: 10.1583/09-2713.1] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Schofer J, Arendt M, Tübler T, Sandstede J, Schlüter M. Late Cerebral Embolization After Emboli-Protected Carotid Artery Stenting Assessed by Sequential Diffusion-Weighted Magnetic Resonance Imaging. JACC Cardiovasc Interv 2008; 1:571-7. [PMID: 19463360 DOI: 10.1016/j.jcin.2008.06.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 05/20/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022]
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Abstract
Stroke is the second most frequent cause of death worldwide and the most frequent cause of permanent disability. Patients with diabetes are at 1.5 to three times the risk of stroke compared with the general population. Cerebrovascular disease causes 20% of deaths in diabetic patients. Interestingly, there are some striking differences of stroke patterns between diabetic and non-diabetic subjects suffering a stroke. Even more important is the fact that diabetes dramatically increases the risk of stroke in younger subjects as well as women. These data highlight the need for detection and treatment of diabetes particularly in these patient groups. This review summarises several aspects of stroke in type 2 diabetes, focusing on differences from non-diabetic stroke.
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Affiliation(s)
- Dirk Sander
- Department of Neurology, Medical Park Hospital, Bischofswiesen Germany, , Department of Neurology, University of Technology, Munich, Germany
| | - Kerstin Sander
- Department of Neurology, Medical Park Hospital, Bischofswiesen Germany, Department of Neurology, University of Technology, Munich, Germany
| | - Holger Poppert
- Department of Neurology, University of Technology, Munich, Germany
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Tedesco MM, Lee JT, Dalman RL, Lane B, Loh C, Haukoos JS, Rapp JH, Coogan SM. Postprocedural microembolic events following carotid surgery and carotid angioplasty and stenting. J Vasc Surg 2007; 46:244-50. [PMID: 17600657 DOI: 10.1016/j.jvs.2007.04.049] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Accepted: 04/18/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The relative safety of percutaneous carotid interventions remains controversial. Few studies have used diffusion-weighted magnetic resonance imaging (DW-MRI) to evaluate the safety of these interventions. We compared the incidence and distribution of cerebral microembolic events after carotid angioplasty and stenting (CAS) with distal protection to standard open carotid endarterectomy (CEA) using DW-MRI. METHODS From November 2004 through August 2006, 69 carotid interventions (27 CAS, and 42 CEA) were performed in 68 males at a single institution. Pre- and postprocedure DW-MRI exams were obtained on each patient undergoing CAS and the 20 most recent CEA operations. These 46 patients (47 procedures as one patient underwent bilateral CEAs in a staged fashion) constitute our study sample, and the hospital records of these patients (27 CAS and 20 CEA) were retrospectively reviewed. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs and assessed independently by two neuroradiologists without knowledge of the subjects' specific procedure. RESULTS Nineteen CAS patients (70%, 95% confidence interval [CI]: 42%-81%) demonstrated evidence of postoperative, acute, cerebral microemboli by DW-MRI vs none of the CEA patients (0%, 95% CI: 0%-17%) (P < .0001). Of the 19 CAS patients with postoperative emboli, nine (47%) were ipsilateral to the index carotid lesion, three (16%) contralateral, and seven (36%) bilateral. The median number of ipsilateral microemboli identified in the CAS group was 1 (interquartile ranges [IQR]: 0-2, range 0-21). The median number of contralateral microemboli identified in the CAS group was 0 (IQR: 0-1, range 0-5). Three (11%) CAS patients experienced temporary neurologic sequelae lasting less than 36 hours. These patients suffered 12 (six ipsilateral and six contralateral), 20 (19 ipsilateral and one contralateral), and zero microemboli, respectively. By univariate analysis, performing an arch angiogram prior to CAS was associated with a higher risk of microemboli (median microemboli 5 vs none, P =.04) CONCLUSIONS Although our early experience suggests that CAS may be performed safely (no permanent neurologic deficits following 27 consecutive procedures), cerebral microembolic events occurred in over two-thirds of the procedures despite the uniform use of distal protection. Open carotid surgery in this series seems to offer a lower risk of periprocedural microembolic events detected by DW-MRI.
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Affiliation(s)
- Maureen M Tedesco
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA 94305, USA
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