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Cerebral microembolization after protected carotid artery stenting in surgical high-risk patients: results of a
Frank D Hammer1, Valerie Lacroix, Thierry Duprez
1Department of Radiology, University Hospital St Luc, Brussels, Belgium. hammer@rdgn.ucl.ac.be
Insights
Carotid artery stenting with filter devices caused new brain lesions in 40% of high-risk patients. Most lesions were small and clinically silent, but the high rate warrants further investigation into cognitive effects.
Area of Science:
- Neurology
- Vascular Surgery
- Medical Imaging
Background:
- Carotid artery stenting (CAS) is an alternative for patients unsuitable for endarterectomy.
- Neuroprotective filter devices are used during CAS to minimize cerebral embolization.
- Assessing the incidence and characteristics of microembolization during CAS is crucial.
Purpose of the Study:
- To evaluate cerebral embolization during CAS using neuroprotective filters in high-risk patients.
- To analyze the incidence and extent of new ischemic brain lesions post-CAS.
- To identify potential predictors of microembolization during the procedure.
Main Methods:
- Prospective single-center study of 53 high-risk patients undergoing CAS with Spider or FilterWire devices.
- Diffusion-weighted magnetic resonance imaging (DWI) performed pre- and post-procedure to detect ischemic lesions.
- Inclusion criteria: symptomatic (≥70%) or asymptomatic (≥80%) internal carotid artery stenosis.
Main Results:
- Two minor strokes (4%) occurred.
- Post-CAS DWI revealed new ischemic lesions in 40% of patients (21/53).
- Most lesions (90%) were small (≤1 mL) and clinically silent; average number of lesions was 5.9 per patient.
- Microembolization risk was not predictable by clinical or lesion characteristics.
- Difficult carotid arch implantations were associated with increased ipsilateral hemispheric embolization (P = .04).
Conclusions:
- The incidence of new ischemic lesions detected by DWI after CAS with filters is higher than previously reported.
- Embolization likely originates from the aortic arch or common carotid arteries in high-risk patients.
- While mostly silent, the high rate of microembolization necessitates further research into potential long-term cognitive consequences.
Background:
This was a prospective single-center study to assess and analyze cerebral embolization resulting from carotid artery stenting with neuroprotective filter devices in patients considered as poor surgical candidates for surgical carotid endarterectomy.
Methods:
Fifty-three consecutive patients with an internal carotid artery stenosis were treated by placement of carotid Wallstents with two different types of temporary distal filter protection devices: the Spider filter and the FilterWire. Diffusion-weighted magnetic resonance imaging (DWI) of the brain was obtained 24 hours before the procedure and within 5 to 30 hours after the procedure to detect ischemic brain lesions resulting from the procedure. Inclusion criteria were symptomatic (> or =70%) or asymptomatic (> or =80%) stenoses in surgical high-risk patients.
Results:
Two (4%) regressive minor strokes occurred. Postprocedural DWI detected new focal ischemic lesions in 21 patients (40%). The average number of lesions was 5.9 per patient, and the mean lesion volume was 1 mL or less in 19 patients (90%). Small differences were found in the lesion distribution: homolateral anterior circulation in eight cases (15.1%), other vascular territories in seven cases (13.2%), and homolateral anterior circulation plus other vascular territories in six cases (11.3%). The microembolization risk seemed nonpredictable on the basis of clinical parameters and internal carotid artery lesion characteristics. An increased risk in the rate of ipsilateral hemispheric embolization has been observed in difficult carotid arch implantations (P = .04).
Conclusions:
The incidence of new focal ischemic lesions detected by DWI is higher than expected on the basis of previous reports. Embolization from the aortic arch or common carotid arteries could account for most of those events in patients considered as surgical high-risk patients. Although 90% of the events were clinically silent, this high rate of microembolization raises questions about the possible consequences on cerebral cognitive functions.
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