Carotid endarterectomy, siphon stenosis, collateral hemispheric pressure, and perioperative cerebral infarction

Lord, Reginald S. A.; Raj, T B; Graham, Antony R.

doi:10.1016/0741-5214(87)90011-5

Cited by 25 publications

(7 citation statements)

References 19 publications

(5 reference statements)

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“…The authors attributed their disappointing findings to the fact that the study involved a selected population of patients for whom surgery was already contraindicated due to a high surgical risk and multiple comorbidities, and they recommended a careful assessment of the risk/benefit ratio for endovascular procedures in patients with CTL [23]. The low perioperative risk of ipsilateral ischemic events and the 5-year 99 % freedom from late ipsilateral stroke in our group I patients suggest that the presence of severe ICS is not a sufficient reason to deny patients with severe symptomatic or asymptomatic carotid stenosis a CEA, supporting the assumption that ICS is a marker of systemic vascular disease rather than a specific cause of complications [10,11,17,18].…”

Section: Discussionmentioning

confidence: 78%

“…The beneficial effects of the surgical procedure remain uncertain, however, in cases with both extracranial lesion and concomitant intracranial carotid stenosis (ICS), because of the variable results reported in previous studies. Most of these studies were conducted before the publication of the results of multicenter randomized controlled trials' (RCTs), which proved inconclusive regarding the role of CEA in such patients [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Carotid tandem lesions (CTLs) are defined as a stenosis at the origin of the carotid artery at the bifurcation associated with any lesion of the intracranial portion of the internal carotid artery or the main trunk of the anterior cerebral artery (ACA) or middle cerebral artery (MCA) [18].…”

Section: Introductionmentioning

confidence: 99%

“…They are not uncommon, given the prevalence of ICS, which ranges from 10 to 84 %, depending on how it is defined [13]. In all earlier studies, the degree of ICS was assessed using traditional or digital intra-arterial subtraction angiography [6][7][8][9][10][11][12][13][14][15][16][17]19] and, more recently, duplex ultrasonography scan combined with noninvasive brain imaging studies [20]. Both extracranial lesion and ICS are independent risk factors for stroke and, although thromboembolism is the most recognized pathogenic mechanism for stroke in both settings, there may be coexisting hemodynamic factors that can sometimes exacerbate the effect of distal embolization, or represent the principal pathophysiological cause [21,22].…”

Section: Introductionmentioning

confidence: 99%

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Clinical Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Patients with Ipsilateral Intracranial Stenosis

et al. 2015

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Section: Discussionmentioning

confidence: 78%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Clinical Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Patients with Ipsilateral Intracranial Stenosis

et al. 2015

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“…[2][3][4] However, angiographic studies in patients with extracranial carotid atherosclerosis have shown that the prevalence of IAD can vary between 20% and 50%. [5][6][7][8][9][10][11] Overall, IAD is considered to account for 5% to 10% of ischemic strokes 3,12 and is associated with a risk of recurrent stroke as high as 15% per year. [13][14][15][16][17] The severity of IAD warrants an accurate knowledge of the natural history of the disease and the development of diagnostic tools.…”

mentioning

confidence: 99%

Autopsy Prevalence of Intracranial Atherosclerosis in Patients With Fatal Stroke

Mazighi

Labreuche²,

Góngora‐Rivera³

et al. 2008

Stroke

206

159

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Background and Purpose-The objective of this study was to determine the prevalence of intracranial plaques and stenoses and their causal role in patients with fatal stroke. Intracranial atherosclerosis is considered to be a rare condition with a severe prognosis. However, disease prevalence may be underestimated due to lack of appropriate diagnostic procedures. Methods-We performed a systematic analysis of intra-and extracranial arteries, the aortic arch, and the heart in 339 consecutive autopsies of patients with stroke. Clinical history, risk factors, imaging data, and general autopsy reports were analyzed. Patients with brain hemorrhage (nϭ80) were used as control subjects. Results-Intracranial plaques and stenoses occurred in 62.2% (95% CI, 56.3 to 68.1) and 43.2% (95% CI, 37.2 to 49.3) of patients with brain infarction, respectively, compared with 48.8% (PϽ0.05) and 17.5% (PϽ0.001) of patients with brain hemorrhage, respectively. In the 43% of patients with brain infarction with at least one intracranial plaqueinducing luminal stenosis graded Ͼ30%, the stenosis was considered to be causal in 5.8% of cases (nϭ15) because of superimposed clot on ulcerated plaques; 27% of these patients had stenoses graded 30% to 75%. In multivariate analyses, diabetes and male sex were significantly associated with intracranial plaques and stenosis. History of myocardial infarction was significantly associated with intracranial plaques and previous stroke was associated with intracranial stenosis. Conclusions-Intracranial plaques and stenoses are highly prevalent in fatal stroke, and stenoses graded 30% to 75% may be causal. New arterial wall imaging techniques should be used to reevaluate the frequency and role of intracranial artery plaques in living patients with stroke.

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“…3 Results often show tandem intracranial lesions (TILs), which raise concerns over the safety of CEA. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Some components of TILs may develop flow dependently, and they would be reversible as intracranial blood flow is increased by carotid revascularization. 19,20 These hemodynamic components in intracranial arteries may be best detected by 3-dimensional time-of-flight (TOF) MRA, which uses a flowrelated enhancement phenomenon to visualize vessels.…”

mentioning

confidence: 99%

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

Lee

Cho

Lee

et al. 2016

JAHA

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BackgroundHemodynamic tandem intracranial lesions (TILs) on intracranial magnetic resonance angiography, which develop flow dependently, have been overlooked clinically in patients undergoing carotid endarterectomy. As they represent severe baseline hemodynamic compromise at the segment, they may be associated with distinctive clinical outcomes.Methods and ResultsWe assessed 304 consecutive carotid endarterectomy cases treated over 3 years. Included cases had both preoperative and postoperative intracranial 3‐dimensional time‐of‐flight magnetic resonance angiography, of which signal intensities are flow dependent, and postoperative diffusion‐weighted imaging (≤3 days following carotid endarterectomy). Preoperative TILs in the ipsilateral intracranial arteries were evaluated by the presence of nonexclusive components: focal stenosis (>50%), diffuse stenosis (>50%), and decreased signal intensities (>50%). The components showing postoperative normalization were considered hemodynamic. TILs with hemodynamic components were defined as hemodynamic TILs, while others as consistent TILs. Baseline characteristics and postoperative outcomes were analyzed among 3 groups: no TILs, consistent TILs, and hemodynamic TILs. Preoperative TILs were identified in 104 (34.2%) cases; 54 (17.8%) had hemodynamic components. Diffuse stenosis and decreased signal intensities were usually reversed postoperatively. Patients with hemodynamic TILs tended to have severe proximal carotid stenosis and recent strokes (≤14 days). For the outcome, hemodynamic TILs were independently associated with the advent of postoperative ischemic lesions on diffusion‐weighted imaging (odds ratio: 2.50; 95% CI, 1.20–5.20).ConclusionsIn patients undergoing carotid endarterectomy, a significant number of preoperative TILs demonstrated hemodynamic components, which were reversed postoperatively. The presence of such components was distinctively associated with the postoperative incidence of new ischemic lesions.

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Carotid endarterectomy, siphon stenosis, collateral hemispheric pressure, and perioperative cerebral infarction

Cited by 25 publications

References 19 publications

Clinical Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Patients with Ipsilateral Intracranial Stenosis

Clinical Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Patients with Ipsilateral Intracranial Stenosis

Autopsy Prevalence of Intracranial Atherosclerosis in Patients With Fatal Stroke

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

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