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Published on: January 23, 2019
Late cerebral embolization after emboli-protected carotid artery stenting assessed by sequential diffusion-weighted
Joachim Schofer1, Melanie Arendt, Thilo Tübler
1Medical Care Center Prof. Mathey, Prof. Schofer and Hamburg University Cardiovascular Center, Germany.
Insights
Late cerebral ischemia occurs in 17% of patients after emboli-protected carotid artery stenting (CAS), potentially affecting either hemisphere. Monitoring and delayed diffusion-weighted MRI (DWMRI) are recommended post-procedure.
Area of Science:
- Neurology
- Vascular Surgery
- Radiology
Background:
- Cerebral ischemia is a known complication of emboli-protected carotid artery stenting (CAS).
- The precise timing and location of ischemia remain incompletely understood.
- Up to 50% of patients undergoing CAS experience clinically silent cerebral ischemia.
Purpose of the Study:
- To determine the timing of cerebral ischemia after emboli-protected CAS.
- To elucidate the location and incidence of ischemic events.
- To inform preventive strategies and patient monitoring protocols.
Main Methods:
- Diffusion-weighted magnetic resonance imaging (DWMRI) was used to assess cerebral ischemia.
- 59 CAS procedures in 58 patients were evaluated.
- DWMRI scans were performed pre-intervention and at two time points post-intervention (approx. 3.5h and 18h).
Main Results:
- No pre-procedural cerebral injury was detected.
- Early ischemia (3.5h post-CAS) was observed in 20.3% of patients, exclusively in the ipsilateral hemisphere.
- Late ischemia (18h post-CAS) occurred in 17% of patients, with foci in either hemisphere, and was not associated with neurological deficits within 30 days.
Conclusions:
- A significant incidence of late cerebral ischemia (17%) occurs between 3.5 and 18 hours after emboli-protected CAS.
- Ischemic events can occur in either cerebral hemisphere.
- Preventive strategies should address both target lesions and access vasculature, with delayed DWMRI recommended for monitoring.
Objectives:
This study sought to assess the timing of cerebral ischemia after emboli-protected carotid artery stenting (CAS).
Background:
Predominantly clinically silent cerebral ischemia has been observed in up to 50% of patients undergoing emboli-protected CAS. The timing and location of cerebral ischemia has not been sufficiently elucidated.
Methods:
In 58 patients (69.6 +/- 8.3 years) who underwent 59 procedures, diffusion-weighted magnetic resonance imaging (DWMRI) was performed before the intervention and at 2 time points (t(1) and t(2)) after the intervention.
Results:
No patient showed recent cerebral injury before CAS. At t(1) = 3.5 +/- 1.8 h, new ischemic foci, all located in the ipsilateral hemisphere, were observed in 12 of 59 DWMRI studies (20.3%, 95% confidence interval: 11.0% to 32.8%). At t(2) = 18.0 +/- 3.1 h, 7 more DWMRI scans showed recent ischemic foci, and 3 scans in patients with positive scans at t(1) showed additional foci, for a total of 10 scans (17.0%, 95% confidence interval: 8.4% to 29.0%) documenting late cerebral ischemia. In 4 of these (40%), ischemic foci were located contralaterally. Cerebral ischemia was not associated with overt neurological sequelae out to 30 days in any patient.
Conclusions:
The incidence of late cerebral ischemia occurring between 3.5 and 18 h after emboli-protected CAS was 17%. It may occur with equal likelihood in either hemisphere. Preventive measures to possibly reduce the incidence of cerebral embolization should focus not only on the target lesion, but also on the access vasculature. Patients should be monitored and DWMRI delayed for at least 18 h after the intervention.
