Prospective analysis of cerebral infarction after carotid endarterectomy and carotid artery stent placement by using diffusion-weighted imaging.
OBJECTIVE
Small emboli arising from a friable plaque during carotid endarterectomy (CEA) and carotid artery stent placement (CAS) constitute a potentially important cause of periprocedural ischemic complications. To evaluate the frequency and significance of cerebral ischemic lesions of embolic origin after CEA and CAS, we examined patients with moderate to severe carotid stenosis by using diffusion-weighted (DW) imaging.


METHODS
Twenty-four patients undergoing 26 CEAs and 20 patients undergoing 22 CAS were prospectively studied with pre- and post-treatment DW imaging of the brain within 7 days (mean, 2.3 days) before and within 7 days (mean, 3.2 days) after treatment. DW images were analyzed by two neuroradiologists blinded to the clinical results after CEA and CAS. Any new hyperintense lesion on DW image was interpreted as a post-treatment ischemic lesion. We compared post-treatment ischemic lesions with change in neurologic status, presence of plaque ulcerations, and severity of stenosis and compared the frequency of overall post-treatment complications between the two procedures.


RESULTS
In 25 (96%) of 26 CEAs, post-operative brain DW images were unchanged. In one patient (4%), a new single asymptomatic hyperintensity was observed in the striatocapsule on the surgical side. In 14 (64%) of 22 CAS procedures, post-operative brain DW images were unchanged. In eight CAS cases (36%), new hyperintensities were seen on DW images. Among them, two were symptomatic with a major neurologic deficit lasting more than 7 days. Post-treatment brain or retinal major stroke rates were 4% (n = 1) for CEA and 14% (n = 3) for CAS. Overall symptomatic complication rates were 19.2% and 13.6%, respectively.


CONCLUSIONS
Rate of ischemic brain lesions was significantly lower after CEA than after CAS, although most of these brain lesions were silent. Also, CEA is a safer procedure carrying a lower risk of post-operative cerebral ischemia. CAS, however, may be a comparable procedure considering the total complication rate and can be a more reliable procedure with advances in neuroprotective means.
Roh
Hong Gee
HG
Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, Korea.
Byun
Hong Sik
HS
Ryoo
Jae Wook
JW
Na
Dong Gyu
DG
Moon
Won-Jin
WJ
Lee
Byung Boong
BB
Kim
Dong-Ik
DI
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002544:Cerebral Infarction / Q000175:diagnosis* / Q000209:etiology; D038524:Diffusion Magnetic Resonance Imaging; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015607:Stents / Q000009:adverse effects*