Operative Factors Associated with the Development of New Brain Lesions During Awake Carotid Endarterectomy

Abstract

One in every eight CEA patients developed new DWI lesions (rate doubled in symptomatic patients). Shunt dependence in conscious CEA patients is highly associated with the development of new DWI lesions compared with non-shunted patients. For non-shunted patients the new lesion risk is low, and in those patients the risk in the eversion group is lower than in the patched group.

Hemodynamic Tandem Intracranial Lesions on Magnetic Resonance Angiography in Patients Undergoing Carotid Endarterectomy

“…The involvement of other factors related to new ischemic lesions is also plausible. Severe carotid stenosis may enhance the low perfusion state and slow blood flow, and intraoperative shunt use has been associated with new ischemic lesions . Inflammation, as indicated by high levels of C‐reactive protein, may trigger plaque instability or enhance procoagulant activity .…”

“…Severe carotid stenosis may enhance the low perfusion state and slow blood flow, and intraoperative shunt use has been associated with new ischemic lesions. 38,43 Inflammation, as indicated by high levels of C-reactive protein, may trigger plaque instability or enhance procoagulant activity. 44 Finally, a recent stroke can promote the 45 Then, what are the clinical implications of hemodynamic TILs on TOF-MRA?…”

Commentary on ‘Operative Factors Associated with the Development of New Brain Lesions During Awake Carotid Endarterectomy’

“…There are two main causes of stroke or new DWI lesions in shunt dependent patients: technical usage, as well as surgeon experience (shunt used in 19 patients only in a 6 year period), and brain ischemia due to reduced cerebral reserve. 5 In this regard, it is important to note that 20% (five of 27) of patients had new DWI lesions in the contralateral hemisphere (see Table 1 4 ). In assessing the pathofysiological mechanism, the majority of strokes develops after a symptom free interval due to hemodynamic disturbance or thromboembolism of the artery that was operated on.…”

“…Bourke et al studied operative factors associated with the development of new DWI-lesions following CEA under local anesthesia, 4 revealing that (1) shunted patients were more prone to new lesions; (2) vein patched non-shunted patients and patients undergoing eversion CEA (ECEA) were less prone for new lesions; (3) compared with longitudinal endarterectomy (LCEA), patients with ECEA without a shunt showed fewer DWI changes. Of importance, the authors did not randomize the patients but assessed two separate heterogeneous cohorts over time: 1) LCEA with vein patch versus cohort; 2) all patients underwent ECEA except when a shunt was neededdthese cases still underwent LCEA with vein patch.…”

“…Therefore, the findings by Bourke et al strictly relate to their specifically applied APT protocol. 4 Bourke et al applied 3T MRI 2 days prior to and 5 days after surgery. 4 ICSS obtained MRI at 1.5 or 3 T at a median of 1 day after intervention.…”