Hemodynamic Instability Increases New Ischemic Brain Lesions on Diffusion-Weighted Imaging After Carotid Artery Stenting

Abstract

Hemodynamic instability (HI) may impair the washout of debris during distal intracranial circulation and increase the risk of clinically evident cerebral ischemia. However, the interaction between HI and new ischemic brain lesions detected on diffusion-weighted imaging (DWI) has not been examined. This study evaluated whether HI was significantly associated with the incidence of new ischemic brain lesions on DWI. Data on 128 patients who underwent carotid artery stenting (CAS) with the same devices and procedures between January 2005 and May 2010 were retrospectively analyzed. HI was noted in 31 (24.2%) patients. New ischemic brain lesions were detected on DWI in 25 (19.5%) patients. Ten of 31 (32.2%) patients with HI showed new ischemic brain lesions on DWI. Fifteen of 97 (15.5%) patients without HI showed new lesions. Univariate analysis showed that patients with HI had a significantly higher incidence of new ischemic brain lesions than patients without HI (p ＝ 0.04). A multivariable model showed that age and HI were significantly associated with the incidence of new ischemic brain lesions. In patients with carotid artery stenosis, decreased blood pressure produced no active vascular response, but reduced the cerebral blood volume and velocity due to impaired dynamic cerebral autoregulation. The results of this study suggest that HI with CAS induces impaired clearance of microembolisms and causes an increased number of new ischemic brain lesions detected on DWI.

Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

“… 14) In addition, some reports mentioned that plaque volumes, severe aortic valve stenosis, approach route, intraoperative hemodynamic instability, were associated with the treatment outcomes of CAS. 9 , 22 – 24) For these findings, it is reasonable to evaluate treatment risks and select the treatment. 7 , 16) Recently, CEA and CAS appear to be complementary treatments for ICAS with various risk factors.…”

Anatomical Risk Factors for Ischemic Lesions Associated with Carotid Artery Stenting

“…In this article, both the CCA and ECA were continuously occluded using balloons before the insertion of a guidewire through the stenotic lesion until the end of the procedure. The rate of appearance of new ischemic lesions detected by DWI was not sig-sinus reflex 18,19 , performing an arch aortogram prior to CAS 6 , advanced age 20 , the presence of ulcerated stenosis 20 and a lesion length more than 1 cm 20 were all described as risk factors. However, it remains unclear which factor is the most important, and few clinical studies have addressed the anatomical risk factors for ischemic lesions associated with CAS 21 .…”

Endovascular Treatment of Carotid Atherosclerosis: Concerns and Perspectives

“…Риск развития эмболических осложнений также увеличивается при развитии пери-и послеоперационной гипотензии, что позволяет об-суждать роль гипоперфузии в увеличении восприим-чивости мозга к эмболии и гемодинамическое про-исхождение ишемических очагов, особенно при их ло-кализации в зонах смежного кровообращения [69]. Ишемические изменения на МРТ в режиме DWI вы-являются у 15% пациентов со стабильной и у 32% боль-ных с нестабильной гемодинамикой, что требует рас-смотрения вопроса о тактике гипотензивной и инфу-зионной терапии в периоперационный период [70].…”