Late Evaluation of Silent Cerebral Ischemia Detected by Diffusion-Weighted MR Imaging after Filter-Protected Carotid Artery Stenting

Palombo, Giovanni; Faraglia, V.; Stella, Nazzareno; Giugni, Elisabetta; Bozzao, Alessandro; Taurino, Maurizio

doi:10.3174/ajnr.a1102

Cited by 42 publications

(48 citation statements)

References 22 publications

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“…This result compares favorably with previous reports that reveal a number of silent ischemic lesions after neuroprotected CAS, ranging from 15.3% to 50%. 32,33 This finding supports the idea that less device manipulation, including CPDs, across the lesion minimized emboli dislodgment.…”

Section: Discussionsupporting

confidence: 76%

Carotid Artery Stenting without Angioplasty and Cerebral Protection: A Single-Center Experience with up to 7 Years' Follow-Up

Baldi¹,

Zander²,

Rabellino³

et al. 2011

AJNR Am J Neuroradiol

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Section: Discussionsupporting

confidence: 76%

Carotid Artery Stenting without Angioplasty and Cerebral Protection: A Single-Center Experience with up to 7 Years' Follow-Up

Baldi¹,

Zander²,

Rabellino³

et al. 2011

AJNR Am J Neuroradiol

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“…2 In line with previous studies, acute lesion volume was the only predictor for lesion persistence. 7,[9][10][11] This finding is in line with the clinical observation that in ICSS, most periprocedural clinical strokes associated with stenting recovered quickly and there was no difference in the proportion of patients with disabling symptoms after 1 month. 12 The most important limitation of our study was the lack of power to perform interaction tests investigating whether risk factors for lesions differed significantly between treatment groups.…”

Section: Discussionsupporting

confidence: 76%

“…White matter disease might be considered an indicator for increased vulnerability of the brain toward periprocedural embolism. 6 In previous reports, the proportion of brain lesions persisting on follow-up FLAIR imaging ranged from 3% to 40% after stenting [7][8][9][10] and was 33% after endarterectomy. 10 In contrast to these studies, we were able to compare the rate of conversion from acute to persisting lesions between patients randomized to stenting or endarterectomy.…”

Section: Discussionmentioning

confidence: 99%

Predictors of Acute and Persisting Ischemic Brain Lesions in Patients Randomized to Carotid Stenting or Endarterectomy

Rostamzadeh

Zumbrunn

Jongen

et al. 2014

Stroke

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In the MRI substudy of the International Carotid Stenting Study (ICSS), acute ischemic brain lesions on diffusion-weighted imaging (DWI) were found more often after stenting than after endarterectomy.1,2 We investigated risk factors for acute periprocedural brain lesions and lesions persisting on follow-up imaging. MethodsMRI was performed 1 to 7 days before (pretreatment scan), 1 to 3 days after (early post-treatment scan), and 27 to 33 days after treatment (follow-up scan, performed in 6 of 7 centers) among patients with symptomatic carotid stenosis randomized to stenting or endarterectomy. Acute ischemic brain lesions were defined as new hyperintense DWI lesions on the early post-treatment scan and persisting lesions as hyperintense signal on fluid-attenuated inversion recovery (FLAIR) imaging on the follow-up scan at the site of previous acute lesions.Negative binomial regression models were used to compare the number of acute and persisting lesions (lesion count) between treatment groups. Negative binomial regression models with persisting lesion count as the dependent variable, which included an offset for acute lesion count, were used to compare the rate of conversion from acute to persisting lesions between treatment groups. The association between location (superficial versus deep and border-zone versus non border-zone) 2 and volume (A×B×C/2 converted to cubic root) of ResultsAt 7 centers taking part in the ICSS-MRI substudy, the numbers of patients randomized in ICSS and participating in the substudy were 189 and 124, respectively, in the stenting group and 190 and 107, respectively, in the endarterectomy group. Characteristics of patients participating and not participating in the substudy did not differ ( Table). 2 In the stenting group, acute lesion count was higher in older patients by trend (≥71 years; RR, 2.1; 95% CI, 1.0-4.6; P=0.067), men (RR, 2.4; 95% CI, 1.00-5.8; P=0.042), and patients with stroke as the qualifying event (RR, 2.5; 95% CI, 1.2-5.5; P=0.021; Figure). Higher systolic blood pressure (≥158.5 mm Hg) was associated with an increased acute lesion count in the endarterectomy group (RR, 4.2; 95% CI, 1.00-16.7; P=0.044). More severe white matter disease (age-related white matter changes 3 sum score, ≥5) increased the number of acute lesions both in the stenting (RR, 2.4; 95% CI, 1.1-5.3; P=0.028) and in the endarterectomy group (RR, 4.1; 95% CI, 1.1-15.4; P=0.035).Follow-up FLAIR was obtained at 6 centers, in 86 stenting and in 75 endarterectomy patients and showed signal-hyperintensity in 89 (27%) of 537 acute DWI lesions in the stenting group and 18 (53%) of acute DWI lesions in the endarterectomy group. Patients in the stenting group had more persisting lesions than patients in the endarterectomy group (RR, 4.2; 95% CI, 1.6-11.1; P=0.005; Table). However, the probability of conversion from acute to persisting lesions was lower in the stenting group (RR, 0.4; 95% CI, 0.2-0.8; P=0.007). None of the analyzed variables at patient level in both treatment groups combined predicted lesio...

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“…In general, smaller DWI lesions are more likely to be reversible and more often remain clinically silent compared with larger lesions. 20,21 The impact of silent DWI lesions on cognition is the subject of current research. In line with 2 other studies, 22,23 a single-center substudy in ICSS revealed a small but statistically significant decrease in global cognitive performance 6 months after CAS compared with baseline values, an effect that was not present in the CEA arm.…”

Section: Strokementioning

confidence: 99%

Characteristics of Ischemic Brain Lesions After Stenting or Endarterectomy for Symptomatic Carotid Artery Stenosis

Gensicke

Zumbrunn

Jongen

et al. 2013

Stroke

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Background and Purpose-In a substudy of the International Carotid Stenting Study (ICSS), more patients had new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (MRI) after stenting (CAS) than after endarterectomy (CEA). In the present analysis, we compared characteristics of diffusion-weighted MRI lesions. Methods-Number, individual and total volumes, and location of new diffusion-weighted MRI lesions were compared in patients with symptomatic carotid stenosis randomized to CAS (n=124) or CEA (n=107) in the ICSS-MRI substudy. Results-CAS patients had higher lesion numbers than CEA patients (1 lesion, 15% vs 8%; 2-5 lesions, 19% vs 5%; >5 lesions, 16% vs 4%). The overall risk ratio for the expected lesion count with CAS versus CEA was 8.8 (95% confidence interval, 4.4-17.5; P<0.0001) and significantly increased among patients with lower blood pressure at randomization, diabetes mellitus, stroke as the qualifying event, left-side stenosis, and if patients were treated at centers routinely using filter-type protection devices during CAS. Individual lesions were smaller in the CAS group than in the CEA group (P<0.0001). Total lesion volume per patient did not differ significantly. Lesions in the CAS group were more likely to occur in cortical areas and subjacent white matter supplied by leptomeningeal arteries than lesions in the CEA group (odds ratio, 4.2; 95% confidence interval, 1.7-10.2; P=0.002). Conclusions-Compared with patients undergoing CEA, patients treated with CAS had higher numbers of periprocedural ischemic brain lesions, and lesions were smaller and more likely to occur in cortical areas and subjacent white matter. These findings may reflect differences in underlying mechanisms of cerebral ischemia. Clinical Trial Registration-URL: http://www.isrctn.org. Unique identifier: ISRCTN25337470. (Stroke. 2013;44:80-86.)

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Late Evaluation of Silent Cerebral Ischemia Detected by Diffusion-Weighted MR Imaging after Filter-Protected Carotid Artery Stenting

Abstract: BACKGROUND AND PURPOSE:Postoperative diffusion-weighted MR imaging (DWI) often discloses new lesions after carotid artery stent placement (CAS), most of them asymptomatic. Our aim was to investigate the fate of these silent ischemic lesions.

Cited by 42 publications

References 22 publications

Carotid Artery Stenting without Angioplasty and Cerebral Protection: A Single-Center Experience with up to 7 Years' Follow-Up

Carotid Artery Stenting without Angioplasty and Cerebral Protection: A Single-Center Experience with up to 7 Years' Follow-Up

Predictors of Acute and Persisting Ischemic Brain Lesions in Patients Randomized to Carotid Stenting or Endarterectomy

Characteristics of Ischemic Brain Lesions After Stenting or Endarterectomy for Symptomatic Carotid Artery Stenosis

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