Haemodynamic depression associated with a higher number of new ischaemic brain lesions after carotid artery stenting

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In patients treated with carotid artery stenting, periprocedural haemodynamic depression is associated with an excess of new ischaemic lesions on diffusion-weighted imaging, the randomised International Carotid Stenting Study (ICSS)-MRI substudy has concluded. The findings were published in the January 2014 issue of Stroke.

Aysun Altinbas,from the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands, and colleagues write that carotid artery stenting “is associated with a higher risk of both haemodynamic depression and new ischaemic brain lesions on diffusion-weighted imaging than carotid endarterectomy.” In this substudy, they assessed whether the occurrence of haemodynamic depression was associated with these lesions in patients with symptomatic carotid stenosis treated by stenting or endarterectomy.

The number and total volume of new ischaemic lesions on diffusion-weighted imaging one to three days after carotid stenting or endarterectomy was measured in the ICSS-MRI substudy. Haemodynamic depression was defined as periprocedural bradycardia, asystole, or hypotension requiring treatment. The number of new ischaemic lesions was the primary outcome measure. The investigators calculated risk ratios and 95% confidence intervals per treatment with Poisson regression comparing the number of lesions in patients with or without hemodynamic depression.

A total of 229 patients were included (122 allocated to carotid stenting and 107 to endarterectomy). Fifteen patients (12%) treated with stenting and nine (8%) treated with endarterectomy had haemodynamic depression requiring treatment.

In both patient groups, there was no difference in the proportion of patients with ≥1 new DWI lesion between patients who had haemodynamic depression compared with those without haemodynamic depression.

After stenting, patients with haemodynamic depression had a mean of 13 new diffusion-weighted imaging lesions, compared with a mean of four in those without haemodynamic depression (risk ratio, 3.36; 95% confidence interval, 1.73–6.50). The occurrence of haemodynamic depression had no effect on lesion count after endarterectomy.

“We found that in patients who were treated by carotid artery stenting, the occurrence of periprocedural haemodynamic depression was associated with a >3 times higher number of new ischaemic brain lesions on DWI compared with patients without this complication. This effect was not observed in patients who had haemodynamic depression after endarterectomy,” the authors write. They add that “this finding suggests that avoidance of periprocedural hypotension and bradycardia may reduce the risk of DWI lesions occurring during carotid artery stenting.”

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