The detrimental impact of silent cerebral infarcts on asymptomatic carotid endarterectomy outcome

Pini, Rodolfo; Faggioli, Gianluca; Longhi, Matteo; Gallitto, Enrico; Freyrie, Antonio; Gargiulo, Mauro; Stella, Andréa

doi:10.1016/j.jvs.2015.12.049

Cited by 17 publications

(21 citation statements)

References 42 publications

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“…29 Such studies should also focus on the relationship between WML and other promising imaging markers such as (silent) ischaemic brain lesions, which have been associated with poor outcome and WMLs. 30,31 Studies should report predictive value of both ipsi-and contralateral cerebral lesions, should investigate methods for easy identification and quantification of lesions, and should stratify symptomatic from asymptomatic patients in their analysis.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Timmerman

Rots

Koeverden

et al. 2020

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDSThis study investigated the clinical relevance of reported cerebral small vessel disease (SVD, including white matter lesions and lacunar infarcts) for post-operative stroke and death risk in symptomatic patients undergoing carotid endarterectomy (CEA). The study highlights that the presence of SVD in standard routine pre-operative brain imaging reports identifies patients at high risk of cardiovascular death. Yet, reported SVD is not associated with procedural or long term post-operative stroke risk and therefore this should not influence the decision whether CEA should be performed in symptomatic patients with high degree carotid artery stenosis.Objective: Cerebral white matter lesions (WMLs) and lacunar infarcts are surrogates of cerebral small vessel disease (SVD). WML severity as determined by trained radiologists predicts post-operative stroke or death in patients undergoing carotid endarterectomy (CEA). It is unknown whether routine pre-operative brain imaging reports as part of standard clinical practice also predict short and long term risk of stroke and death after CEA. Methods: Consecutive patients from the Athero-Express biobank study that underwent CEA for symptomatic high degree stenosis between March 2002 and November 2014 were included. Pre-operative brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) reports were reviewed for reporting of SVD, defined as WMLs or any lacunar infarcts. The primary outcome was defined as any stroke or any cardiovascular death over three year follow up. The secondary outcome was defined as the 30 day perioperative risk of stroke or cardiovascular death. Results: A total of 1038 patients were included (34% women), of whom 659 (63.5%) had CT images and 379 (36.5%) MRI images available. Of all patients, 697 (67%) had SVD reported by radiologists. Patients with SVD had a higher three year risk of cardiovascular death than those without (6.5% vs. 2.1%, adjusted HR 2.52 [95% CI 1.12e5.67]; p ¼ .026) but no association was observed for the three year risk of stroke (9.0% vs. 6.7%, for patients with SVD vs. those without, adjusted HR 1.24 [95% CI 0.76e2.02]; p ¼ .395). No differences in 30 day peri-operative risk were observed for stroke (4.4% vs. 2.9%, for patients with vs. those without SVD; adjusted HR 1.49 [95% CI 0.73e3.05]; p ¼ .28), and for the combined stroke/cardiovascular death risk (4.4% vs. 3.5%, adjusted HR 1.20 [95% CI 0.61e2.35]; p ¼ .59). Conclusion: Presence of SVD in pre-operative brain imaging reports can serve as a predictor for the three year risk of cardiovascular death in symptomatic patients undergoing CEA but does not predict peri-operative or long term risk of stroke.

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Section: Strengths and Limitationsmentioning

confidence: 99%

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Timmerman

Rots

Koeverden

et al. 2020

European Journal of Vascular and Endovascular Surgery

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“…1 Clinical characteristics, technical aspects and perioperative (30-day) outcome were prospectively entered into a dedicated database in each of the two tertiary hospitals. As previously presorted, 13,14 the clinical characteristics included the following: age; sex; hypertension (presence of systolic blood pressure >140 or/and diastolic >90 mmHg, or specific therapy); dyslipidemia (total cholesterol >200 mg/dl or low density lipoprotein >120 mg/dl or specific therapy); diabetes mellitus (pre-diagnosed in therapy with oral hypoglycemic drugs or with insulin); current smoking; coronary artery disease (defined as a history of angina pectoris, myocardial infarction or coronary revascularization); chronic obstructive pulmonary disease (defined as chronic bronchitis or emphysema); chronic renal failure (glomerular filtration rate <60 ml/min); contralateral carotid occlusion and atrial fibrillation (paroxysmal or permanent). Perioperative medical therapy was also considered: specifically, single or double antiplatelet therapy, statins and oral anticoagulant therapy.…”

Section: Patient Selectionmentioning

confidence: 59%

The different scenarios of urgent carotid revascularization for crescendo and single transient ischemic attack

et al. 2018

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Objective Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. Methods Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. Results On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02). Conclusions cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

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“…29 and Pini et al. 30 recognize SBIs as a significant independent risk factor for stroke. Kakkos et al.…”

Section: Resultsmentioning

confidence: 99%

“…From Table 3, it is seen that the five studies all found that SBI significantly increased the risk of a future stroke. Inzitari et al 29 and Pini et al 30 recognize SBIs as a significant independent risk factor for stroke. Kakkos et al 31 found a doubling in stroke events over eight years of follow-up in patients with SBIs compared to those without, with an annual event rate of 4.6% among patients with SBI as compared to 2.4% in patients with no evidence of SBIs.…”

Section: Stroke Risk In Asymptomatic Carotid Stenosis With Sbimentioning

confidence: 99%

Asymptomatic carotid stenosis and concomitant silent brain infarctions

Rudolph

Eldrup

2019

Vascular

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Objectives This review aims to clarify (1) the definition of silent brain infarct (SBI), (2) the diagnostic criteria of SBI using magnetic resonance imaging (MRI), (3) the prevalence of patients with asymptomatic carotid stenosis and SBI based on MRI assessment, (4) the association of SBI and asymptomatic carotid stenosis and the risk of stroke compared to patients without SBI, (5) the association between development of dementia/cognitive impairment in people with asymptomatic carotid stenosis and SBI, and (6) the evidence for treating patients with carotid stenosis and SBI. Methods A systematic search of PubMed and Scopus including all studies published from 2000 to 2018 and written in English. Results No consensus of the definition and diagnostic criteria for SBI was found. The prevalence of SBI in asymptomatic carotid patients is 17–33.3%. SBI is a significant risk factor for future stroke, OR 4.6 (95% CI: 3.0–7.2; p < 0.0001). One substudy showed that immediate CEA is beneficial compared to delayed CEA in these patients, showing a 45% reduction in annual stroke rate from 1.5%/year to 0.7%/year. Conclusion This review emphasizes the need to standardize the definition and diagnostic criteria of SBI on MRI. Current evidence suggests an increased risk and a small potential benefit of offering carotid endarterectomy to patient with silent brain infarct. Prospective studies are warranted to elucidate these issues further.

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The detrimental impact of silent cerebral infarcts on asymptomatic carotid endarterectomy outcome

Cited by 17 publications

References 42 publications

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

The different scenarios of urgent carotid revascularization for crescendo and single transient ischemic attack

Asymptomatic carotid stenosis and concomitant silent brain infarctions

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