Carotid Plaque Surface Irregularity Predicts Cerebral Embolism during Carotid Artery Stenting

Rosenkranz, Michael; Russjan, Arkadiusz; Goebell, Einar; Havemeister, Stefanie; Thomalla, Götz; Cheng, Bastian; Beck, Christoph; Krützelmann, Anna; Fiehler, Jens; Gerloff, Christian

doi:10.1159/000328883

Cited by 17 publications

(13 citation statements)

References 62 publications

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“…3, 27 Our current results also demonstrate that the length of the stent, which represents the atherosclerotic burden of the stented site, is associated with the occurrence of SECI. Therefore, the dislodgement of atheroma from the plaque seems to be one of the most important mechanisms involved in SECI occurrence.…”

Section: Discussionsupporting

confidence: 67%

“…7 Second, during the stent deployment, the plaque may be cracked and dislodged and may migrate to distal cere- bral vessels. 3,27 Finally, the inserted stent can cause embolism until stabilization. 18 Nearly half of the patients in our present study presented with SECI outside of the vascular territory of the stented vessel, and these lesions can be explained by the dislodgement of atheroma that arose during multiple switching and approaches of wires and stents through the more proximal sites (for example, the aortic arch).…”

Section: Discussionmentioning

confidence: 99%

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Association between silent embolic cerebral infarction and continuous increase of P2Y12 reaction units after neurovascular stenting

Kim¹,

Kwon

Jung

et al. 2014

JNS

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S tenting of intra-or extracranial arteries with severe stenosis is likely to be effective for preventing subsequent ischemic stroke by improving cerebral perfusion and reducing the risk of thromboembolism by removing the plaque and eliminating turbulent flow. However, a recent large clinical trial failed to show a beneficial effect of intracranial stenting on secondary stroke prevention. 9Despite a low incidence of periprocedural myocardial infarction after carotid artery stenting, the prevalence of periprocedural stroke was higher than that in patients treated with carotid endarterectomy.6 High periprocedural risk of embolic stroke in intravascular procedures may limit the benefit of stenting for ischemic stroke patients. Object. Endovascular procedures are one of the important treatment options for steno-occlusive arteries in ischemic stroke patients. However, embolic complications after such procedures are always a concern. The authors investigated the association between serial change of residual platelet reactivity and silent embolic cerebral infarction (SECI) after endovascular treatment.Methods. Ischemic stroke patients undergoing stenting of intra-or extracranial arteries were recruited prospectively. Residual platelet reactivity, represented by aspirin reaction units (ARUs) and P2Y12 reaction units (PRUs), was measured serially (6 hours before, immediately after, and 24 hours after the procedure). A loading dosage of aspirin (500 mg) and/or clopidogrel (300 mg) was given 24 hours before the procedure to patients naïve to antiplatelet agents, whereas the usual dosage (aspirin 100 mg and clopidogrel 75 mg) was continued for patients who had previously been taking these agents for more than a week. Diffusion-weighted MRI was performed before and 24 hours after the procedure to detect new SECIs. Clinical characteristics, baseline ARU and PRU values, and the change in ARU and PRU values after stenting were compared between patients with and without SECIs.Results. Among 69 consecutive patients who underwent neurovascular stent insertion, 41 patients (59.4%) had poststenting SECIs. The lesion was located only at the vascular territory of the stented vessel in 21 patients (51.2%), outside the stented vessel territory in 8 patients (19.5%), and both inside and outside in 12 patients (29.3%). The occurrence of SECIs was not associated with the baseline ARU or PRU value, but was associated with PRU increase after stenting (36 ± 73 vs -12 ± 59, p = 0.007), deployment of a longer stent (31.1 ± 16.5 mm vs 21.8 ± 9.9 mm, p = 0.01), and stent insertion in extracranial arteries (78.1% vs 45.2%, p = 0.008). Stent length (OR 1.066, p = 0.01) and PRU change (OR 1.009, p = 0.04) were independently associated with the occurrence of SECI.Conclusions. Residual platelet reactivity after dual antiplatelet treatment measured before stenting did not predict poststenting SECI. However, the longer stent and the serial increase of PRU values after stenting were related to SECI. Continuous increase of platelet activation after endova...

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Section: Discussionsupporting

confidence: 67%

Section: Discussionmentioning

confidence: 99%

Association between silent embolic cerebral infarction and continuous increase of P2Y12 reaction units after neurovascular stenting

Kim¹,

Kwon

Jung

et al. 2014

JNS

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“…However, there are only limited data on subgroup variables that might specifically affect the periprocedural risks of one procedure more than the other: the morphology of the target carotid lesion and aortic atherosclerosis have been shown to affect the risk of ischemic events in carotid stenting [13,14,15]. Recently, carotid plaque surface morphology and the length of stenosis have been suggested to add to this risk [16,17]. In the present study, we added these two additional morphological variables to an earlier analysis of data from an institutional carotid-stenting safety trial [15] and evaluated the relation between clinical and morphological patient variables and the occurrence of new brain lesions in diffusion-weighted MR imaging (DWI) after carotid stenting.…”

Section: Introductionmentioning

confidence: 99%

Predictors of Periprocedural Brain Lesions Associated with Carotid Stenting

et al. 2011

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Background: Carotid stenting carries a risk of periprocedural stroke. We aimed at determining predictors of cerebral ischemic events associated with stenting for symptomatic carotid stenosis. Methods: 127 patients who had been studied by diffusion-weighted MR imaging (DWI) before and on the day after carotid stenting were included. Six clinical variables and 5 variables characterizing the target carotid artery and aortic atherosclerosis were analyzed as potential risk factors for new ipsilateral DWI lesions after stenting. Results: Among all variables assessed, only age, length of stenosis and carotid intima-media thickness (IMT) significantly modified the risk of new lesions after stenting. Age ≧68 years, stenosis ≧15 mm and IMT ≧1.3 mm were identified as the best thresholds to predict new lesions. In the subgroup of patients ≧68 years with carotid stenosis ≧15 mm in length and IMT ≧1.3 mm, the risk of new lesions was markedly higher than in patients to whom no more than two of these factors applied (odds ratio 7.250, 95% CI 1.612–34.513, p = 0.005). The use of this simple predictive model correctly identified patients who had new lesions after stenting with high specificity (0.96) and a negative predictive value (0.83), while the positive predictive value was moderate (0.60) and sensitivity was low (0.23). Conclusions: The risk of stenting for symptomatic carotid stenosis may vary with clinical and morphological patient characteristics. Further research is needed to validate these results and to evaluate the safety of stenting versus endarterectomy in specific patient subgroups.

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“…7 In the case of carotid stenting, plaque composition has been associated with risk of periprocedural embolic events and early ipsilateral stroke. [21][22][23] In the case of endarterectomy, MRI-detected ulcerated, irregular plaque surface has been reported to be associated with increased rates of periprocedural embolization. 24 We do not have detailed plaque imaging (echo-Doppler or MRI) for the majority of patients in this study.…”

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Histological Features of Carotid Plaque in Patients With Ocular Ischemia Versus Cerebral Events

Howard

Lammeren

Redgrave

et al. 2013

Stroke

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T he risk of ipsilateral ischemic stroke in patients with recent ocular ischemic events is less than half that of otherwise similar patients with recent cerebral ischemic events, [1][2][3] and in those with carotid stenosis, their prognosis is similar to that in patients with asymptomatic stenosis. 4,5 Consequently, in patients with ≥70% carotid artery stenosis in the European Carotid Surgery Trial and North American Symptomatic Carotid Endarterectomy Trial (NASCET), the absolute reduction in 5-year risk of ipsilateral ischemic stroke with surgery was ≈5% for patients with recent ocular events and 17% for those with cerebral events, 4,5 despite a lower procedural risk in the patients with ocular events only. 4,5 Across all carotid endarterectomy trials and case-series, the 30-day risk of stroke in patients with ocular ischemic events is less than half that in patients with cerebral events independent of degree of carotid artery stenosis, 6 and the same difference has been observed in the procedural risk of carotid stenting. 7The reasons for the relatively low risk of ipsilateral ischemic stroke in patients with carotid stenosis and ocular ischemic events are not fully understood. However, the fact that these patient groups have the same prevalence of previous coronary heart disease and peripheral vascular disease and the same risk of future coronary events 5,[8][9][10] suggests that the lower stroke risk in patients with ocular events only may reflect differences in local carotid plaque pathology. The only previous study comparing histological plaque features from patients with ocular versus cerebral ischemic events suggested that patients with ocular events may have more stable plaques, 11 but the number of cases was too small to allow reliable adjustment for differences in other risk factors. We aimed to study carotid plaque composition in a larger number of consecutive patients undergoing carotid endarterectomy for symptomatic stenosis to compare features in those who had cerebral events within the last 6 months versus those with ocular events only.Background and Purpose-Patients with carotid artery stenosis and ocular ischemic events have a much lower risk of future ipsilateral ischemic stroke on medical treatment and lower procedural risks for endarterectomy and stenting than patients with cerebral ischemic events, and are closer in risk to patients with asymptomatic stenosis. The reasons for this difference in prognosis are not fully understood, but may reflect differences in carotid plaque pathology. Methods-In consecutive patients undergoing carotid endarterectomy for recently symptomatic stenosis (Oxford Plaque Study, Athero-Express Study), we compared carotid plaque histology (using validated semiquantitative scales) in those who had cerebral events within the last 6 months (n=1317) versus those with ocular events only (n=323 All patients (and their relevant imaging) were reviewed by a neurologist before carotid endarterectomy. Patients were categorized as having only ocular ischemic events or cerebral...

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Carotid Plaque Surface Irregularity Predicts Cerebral Embolism during Carotid Artery Stenting

Cited by 17 publications

References 62 publications

Association between silent embolic cerebral infarction and continuous increase of P2Y12 reaction units after neurovascular stenting

Association between silent embolic cerebral infarction and continuous increase of P2Y12 reaction units after neurovascular stenting

Predictors of Periprocedural Brain Lesions Associated with Carotid Stenting

Histological Features of Carotid Plaque in Patients With Ocular Ischemia Versus Cerebral Events

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