The majority of microemboli do not have long-term radiographic sequelae. Size and hyperintensity on postoperative FLAIR are predictive of residual brain structure abnormality, and further neurocognitive evaluations are warranted.
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.
Results: Overall, 10,546 patients underwent CEAs. The percentage of patients in each glucose range were as follows: 80-120mg/dl (38.6%), Ͼ120-160mg/dl (37.8%), Ͼ160-200mg/dl (13.9%), Ͼ200mg/dl (9.7%). Univariate analysis of the data revealed that hyperglycemia greater than 120mg/dl was associated with increased risk of MI, CVA, respiratory complication, and the likelihood of having two or more complications. Multivariate analysis confirmed that serum glucose greater than 120mg/dl was associated with an increase in OR for MI 2.01 (1.23-3.27), CVA 2.20 (1.48-3.29), respiratory complication 1.81 (1.28-2.54), and incidence of two or more complications 1.82 (1.05-3.14). Also, odds ratio of complications increased with each increase in glucose range, as shown in Table 1.Conlusion: Postoperative hyperglycemia above 120mg/dl is associated with an increased risk of complications following CEA. The magnitude of increased risk is directly proportional to the level of hyperglycemia, indicating that hyperglycemia-associated morbidity may be mitigated even if glucose cannot be strictly controlled to normoglycemic levels. Table 1. Adjusted odds ratio of complications by glucose range Glucose MI CVA Respiratory Ն 2 Complications OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
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