Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk

Henrik Gensicke, H Bart van der Worp, Paul J Nederkoorn, Sumaira Macdonald, Peter A Gaines, Aad van der Lugt, Willem P Th M Mali, Philippe A Lyrer, Nils Peters, Roland L Featherstone, Gert J de Borst, Stefan T Engelter, Martin M Brown, Leo H Bonati, ICSS-MRI Substudy Investigators, G J de Borst, G A P de Kort, L M Jongen, L J Kappelle, T H Lo, W P Th M Mali, F L Moll, H B van der Worp, L H Bonati, S T Engelter, F Fluri, S Haller, A L Jacob, E Kirsch, P A Lyrer, E-W Radue, P Stierli, M Wasner, S G Wetzel, H Z Flach, J M Hendriks, P J Koudstaal, P M T Pattynama, L C van Dijk, M R H M van Sambeek, A van der Lugt, H van Urk, H J M Verhagen, M Clarke, M Davis, A K Dixit, P Dorman, A Dyker, G Ford, A Golkar, R Jackson, V Jayakrishnan, D Lambert, T Lees, S Louw, S Macdonald, D Mendelow, H Rodgers, J Rose, G Stansby, M Wyatt, M J W Koelemaij, C B L M Majoie, P J Nederkoorn, J A A Reekers, Y B W E M Roos, M Adiseshiah, C Bishop, S Brew, J Brookes, M M Brown, H R Jäger, N Kitchen, J Beard, T Cleveland, D Dodd, P A Gaines, R Lonsdale, R Nair, A Nassef, S Nawaz, G Venables, Henrik Gensicke, H Bart van der Worp, Paul J Nederkoorn, Sumaira Macdonald, Peter A Gaines, Aad van der Lugt, Willem P Th M Mali, Philippe A Lyrer, Nils Peters, Roland L Featherstone, Gert J de Borst, Stefan T Engelter, Martin M Brown, Leo H Bonati, ICSS-MRI Substudy Investigators, G J de Borst, G A P de Kort, L M Jongen, L J Kappelle, T H Lo, W P Th M Mali, F L Moll, H B van der Worp, L H Bonati, S T Engelter, F Fluri, S Haller, A L Jacob, E Kirsch, P A Lyrer, E-W Radue, P Stierli, M Wasner, S G Wetzel, H Z Flach, J M Hendriks, P J Koudstaal, P M T Pattynama, L C van Dijk, M R H M van Sambeek, A van der Lugt, H van Urk, H J M Verhagen, M Clarke, M Davis, A K Dixit, P Dorman, A Dyker, G Ford, A Golkar, R Jackson, V Jayakrishnan, D Lambert, T Lees, S Louw, S Macdonald, D Mendelow, H Rodgers, J Rose, G Stansby, M Wyatt, M J W Koelemaij, C B L M Majoie, P J Nederkoorn, J A A Reekers, Y B W E M Roos, M Adiseshiah, C Bishop, S Brew, J Brookes, M M Brown, H R Jäger, N Kitchen, J Beard, T Cleveland, D Dodd, P A Gaines, R Lonsdale, R Nair, A Nassef, S Nawaz, G Venables

Abstract

Background: Brain lesions on diffusion-weighted imaging (DWI) are frequently found after carotid artery stenting (CAS), but their clinical relevance remains unclear.

Objectives: This study sought to investigate whether periprocedural ischemic DWI lesions after CAS or carotid endarterectomy (CEA) are associated with an increased risk of recurrent cerebrovascular events.

Methods: In the magnetic resonance imaging (MRI) substudy of ICSS (International Carotid Stenting Study), 231 patients with symptomatic carotid stenosis were randomized to undergo CAS (n=124) or CEA (n=107). MRIs were performed 1 to 7 days before and 1 to 3 days after treatment. The primary outcome event was stroke or transient ischemic attack in any territory occurring between the post-treatment MRI and the end of follow-up. Time to occurrence of the primary outcome event was compared between patients with (DWI+) and without (DWI-) new DWI lesions on the post-treatment scan in the CAS and CEA groups separately.

Results: Median time of follow-up was 4.1 years (interquartile range: 3.0 to 5.2). In the CAS group, recurrent stroke or transient ischemic attack occurred more often among DWI+ patients (12 of 62) than among DWI- patients (6 of 62), with a cumulative 5-year incidence of 22.8% (standard error [SE]: 7.1%) and 8.8% (SE: 3.8%), respectively (unadjusted hazard ratio: 2.85; 95% confidence interval: 1.05 to 7.72; p=0.04). In DWI+ and DWI- patients, 8 and 2 events, respectively, occurred within 6 months after treatment. In the CEA group, there was no difference in recurrent cerebrovascular events between DWI+ and DWI- patients.

Conclusions: Ischemic brain lesions discovered on DWI after CAS seem to be a marker of increased risk for recurrent cerebrovascular events. Patients with periprocedural DWI lesions might benefit from more aggressive and prolonged antiplatelet therapy after CAS. (A Randomised Comparison of the Risks, Benefits and Cost Effectiveness of Primary Carotid Stenting With Carotid Endarterectomy: International Carotid Stenting Study; ISRCTN25337470).

Keywords: DWI lesions; carotid stenosis; endarterectomy; long-term outcome; stenting.

Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Study Flow Diagram Diagram outlining the 2 arms of the study, including events that precluded patients from analysis. Scans are magnetic resonance imaging (MRI). BMT = best medical treatment; CAS = carotid artery stenting; CEA = carotid endarterectomy; DWI = diffusion-weighted imaging; MI = myocardial infarction.
Figure 2
Figure 2
Cumulative Incidence Rates of Outcome Events During Follow-Up Comparison of any stroke or transient ischemic attack (TIA), ipsilateral stroke or TIA, and any stroke between patients with periprocedural DWI lesions (red curve) and without periprocedural DWI lesions (blue curve) with either carotid artery stenting (CAS) or carotid endarterectomy (CEA). Percentages are point estimates of cumulative incidences after 1 and 5 years of follow-up. CI = confidence interval; HR = hazard ratio.
Central Illustration
Central Illustration
Significance of Brain Lesions After Carotid Artery Stenting: Kaplan-Meier Cumulative Incidence Curves of Recurrent Stroke or TIA During Follow-Up Unadjusted Cox regression hazard ratio (HR) for any stroke or TIA in patients with and without new ischemic diffusion-weighted imaging (DWI) lesions on post-treatment magnetic resonance imaging. Percentages are point estimates of cumulative incidences after 1 and 5 years of follow-up. CI = confidence interval.

References

    1. Schnaudigel S., Groschel K., Pilgram S.M., Kastrup A. New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature. Stroke. 2008;39:1911–1919.
    1. Bonati L.H., Dobson J., Featherstone R.L., et al. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet. 2014 Oct 14 [E-pub ahead of print]
    1. Bonati L.H., Jongen L.M., Haller S., et al. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS) Lancet Neurol. 2010;9:353–362.
    1. Hauth E.A., Jansen C., Drescher R., et al. MR and clinical follow-up of diffusion-weighted cerebral lesions after carotid artery stenting. Am J Neuroradiol. 2005;26:2336–2341.
    1. Palombo G., Faraglia V., Stella N., Giugni E., Bozzao A., Taurino M. Late evaluation of silent cerebral ischemia detected by diffusion-weighted MR imaging after filter-protected carotid artery stenting. Am J Neuroradiol. 2008;29:1340–1343.
    1. Zhou W., Dinishak D., Lane B., Hernandez-Boussard T., Bech F., Rosen A. Long-term radiographic outcomes of microemboli following carotid interventions. J Vasc Surg. 2009;50:1314–1319.
    1. Rostamzadeh A., Zumbrunn T., Jongen L.M., et al. Predictors of acute and persisting ischemic brain lesions in patients randomized to carotid stenting or endarterectomy. Stroke. 2014;45:591–594.
    1. Altinbas A., van Zandvoort M.J., van den B.E., et al. Cognition after carotid endarterectomy or stenting: a randomized comparison. Neurology. 2011;77:1084–1090.
    1. Lal B.K., Younes M., Cruz G., Kapadia I., Jamil Z., Pappas P.J. Cognitive changes after surgery vs stenting for carotid artery stenosis. J Vasc Surg. 2011;54:691–698.
    1. Wasser K., Pilgram-Pastor S.M., Schnaudigel S., et al. New brain lesions after carotid revascularization are not associated with cognitive performance. J Vasc Surg. 2011;53:61–70.
    1. Ederle J., Dobson J., Featherstone R.L., et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985–997.
    1. North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke. 1991;22:711–720.
    1. Wahlund L.O., Barkhof F., Fazekas F., et al. A new rating scale for age-related white matter changes applicable to MRI and CT. Stroke. 2001;32:1318–1322.
    1. van Swieten J.C., Koudstaal P.J., Visser M.C., Schouten H.J., van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19:604–607.
    1. Bijuklic K., Wandler A., Hazizi F., Schofer J. The PROFI study (Prevention of Cerebral Embolization by Proximal Balloon Occlusion Compared to Filter Protection During Carotid Artery Stenting): a prospective randomized trial. J Am Coll Cardiol. 2012;59:1383–1389.
    1. Yamada K., Yoshimura S., Kawasaki M., et al. Embolic complications after carotid artery stenting or carotid endarterectomy are associated with tissue characteristics of carotid plaques evaluated by magnetic resonance imaging. Atherosclerosis. 2011;215:399–404.
    1. Tanemura H., Maeda M., Ichikawa N., et al. High-risk plaque for carotid artery stenting evaluated with 3-dimensional T1-weighted gradient echo sequence. Stroke. 2013;44:105–110.
    1. Burow A., Lyrer P.A., Nederkoorn P.J., et al. Echographic risk index and cerebral ischemic brain lesions in patients randomized to stenting versus endarterectomy for symptomatic carotid artery stenosis. Ultraschall Med. 2014;35:267–272.
    1. Spagnoli L.G., Mauriello A., Sangiorgi G., et al. Extracranial thrombotically active carotid plaque as a risk factor for ischemic stroke. JAMA. 2004;292:1845–1852.
    1. Faggioli G., Ferri M., Rapezzi C., Tonon C., Manzoli L., Stella A. Atherosclerotic aortic lesions increase the risk of cerebral embolism during carotid stenting in patients with complex aortic arch anatomy. J Vasc Surg. 2009;49:80–85.
    1. Kastrup A., Groschel K., Schnaudigel S., Nagele T., Schmidt F., Ernemann U. Target lesion ulceration and arch calcification are associated with increased incidence of carotid stenting-associated ischemic lesions in octogenarians. J Vasc Surg. 2008;47:88–95.
    1. Patti G., Tomai F., Melfi R., et al. Strategies of clopidogrel load and atorvastatin reload to prevent ischemic cerebral events in patients undergoing protected carotid stenting. Results of the randomized ARMYDA-9 CAROTID (Clopidogrel and Atorvastatin Treatment During Carotid Artery Stenting) study. J Am Coll Cardiol. 2013;61:1379–1387.
    1. Gensicke H., Zumbrunn T., Jongen L.M., et al. Characteristics of ischemic brain lesions after stenting or endarterectomy for symptomatic carotid artery stenosis: results from the International Carotid Stenting Study-Magnetic Resonance Imaging substudy. Stroke. 2013;44:80–86.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner