The Role of White Matter Damage in the Risk of Periprocedural Diffusion-Weighted Lesions after Carotid Artery Stenting

Abstract

Background: White matter hyperintensities (WMH) are a common finding in aged individuals affected by carotid artery disease and are a risk factor for first-ever and recurrent stroke. We investigated if white matter damage increases the risk of brain microembolism during carotid artery stenting (CAS), as evaluated by the appearance of new areas of restricted diffusion on diffusion-weighted images (DWI). Methods: We evaluated 47 patients with severe internal carotid artery (ICA) stenosis undergoing CAS, comparing preprocedural clinical, ultrasound and radiological characteristics. WMH volume was computed on FLAIR images before CAS. After CAS, the DWI scan was looked over for areas of restricted diffusion (DWI lesions). A first univariate analysis was adopted to compare groups according to the occurrence of DWI lesions. Then, the variable DWI lesion was modelled by means of a logistic regression model. Results: Seventeen patients developed at least 1 DWI lesion after CAS. Compared with non-DWI, DWI patients were more commonly treated in the left ICA (p = 0.007) and had a more severe WMH damage (p = 0.027). Indeed, the risk of a DWI lesion was higher in left versus right stenosis (OR = 9.0, 95% CI 1.9-42.7, p = 0.005) and increased for each log-unit of WMH lesion load (OR = 7.05, 95% CI 1.07-46.49, p = 0.042). A WMH lesion load of at least 5.25 cm³ had a 50% probability of occurrence of a new DWI lesion. Conclusions: Treated side and preexisting white matter damage are risk conditions for brain microembolism during CAS. This should be taken into account to optimize severe carotid artery disease management.

Relationship between Deep White Matter Hyperintensities on Magnetic Resonance Imaging and Postoperative Cognitive Function Following Clipping of Unruptured Intracranial Aneurysm

“…48) Maggio et al concluded that the treated side and pre-existing white matter damage are risk conditions for brain micro-embolism during carotid artery stenting. 49) In the present study, 12 patients with IQ deterioration at 1 month postoperatively did not show worsening mRS score at 6 months. Because we evaluated cognitive function at 1 month after surgery, it could be inferred that some of these patients have long-term cognitive dysfunction.…”

“… 48) Maggio et al concluded that the treated side and pre-existing white matter damage are risk conditions for brain micro-embolism during carotid artery stenting. 49) …”

Risk factors for new ischaemic cerebral lesions after carotid artery stenting: protocol for a systematic review and meta-analysis

“…CAS is considered as a less invasive procedure with favourable successful rate for treatment of internal carotid artery stenosis 5. However, even with widespread use of embolic protection devices, new ischaemic cerebral lesions (NICL) after CAS detected by diffusion-weighted imaging MRI (DWI-MRI) are common, ranging from 18% to 57% 6–10. Although most are silent,11 NICL on DWI-MRI after CAS increased the risk of future cerebrovascular events reported by recent study 12.…”

“…For example, using embolic protection device is a risk factor for NICL in one study,15 but contradicts to many others 9 16–18. Other predictors such as age, symptomatic lesions, lesion side and so on are inconsistent in different literature 6 7 19. As most related researches are observational studies with low level of evidence, it is necessary to perform a systematic review and meta-analysis of English studies and databases for NICL occurrence determinants exploration.…”

WIRION™ Embolic Protection System for Carotid Artery Stenting and Lower Extremity Endovascular Intervention

“…plaque material [29,30]. Additionally, DE has been correlated with cognitive dysfunction [31] and postprocedural memory decline [32]. Thus, CAS should always be performed with adjunctive EPD in order to prevent the sequelae of DE.…”