Predictors of cerebral reperfusion injury after carotid stenting: the role of transcranial color-coded Doppler ultrasonography.
OBJECTIVE
To evaluate the possible role of transcranial color-coded Doppler ultrasonography (TCD) in predicting cerebral reperfusion injury (CRI) in patients undergoing carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis.


METHODS
TCD was obtained in 210 patients (149 men; mean age 64.2+/-8.4 years, range 44-83) who underwent CAS for ICA stenosis averaging 86.7%+/-8.4%. Contralateral ICA occlusion or near occlusion (stenosis >90%) was present in 67 (31.9%) patients. TCD was performed before and 24 hours after CAS with assessment of peak systolic velocities (PSVs) in the ipsilateral middle cerebral artery (iMCA) and contralateral middle cerebral artery (cMCA). PSV ratios (PSVR) in the iMCA and cMCA were calculated from the PSVs before and after CAS.


RESULTS
CRI syndrome occurred in 3 (1.4%) patients (2 intracranial bleedings, 1 subarachnoid hemorrhage). The mean iMCA and cMCA PSVRs were 2.66+/-0.19 and 4.16+/-2.77, respectively, in CRI patients, while the PSVRs in CAS patients without neurological sequelae were 1.56+/-0.46 and 1.21+/-0.39, respectively (both p<0.001). The combination of iPSVR>2.4 and cPSVR>2.4 occurred in 4 patients with bilateral ICA disease; 3 (75%) of them developed CRI (100% sensitivity and 99% specificity for CRI prediction). The following independent CRI predictors were identified: combined iPSVR>2.4 and cPSVR>2.4 (RR 2.06, CI 1.89 to 2.24; p<0.001), high cMCA PSV after CAS (RR 1.23, CI 1.13 to 1.34; p<0.001), and contralateral ICA occlusion (RR 1.13, CI 1.03 to 1.23; p = 0.007).


CONCLUSIONS
TCD is an important tool in CRI risk evaluation. The combination of iPSVR>2.4 and cPSVR>2.4 is an independent CRI risk factor, along with contralateral ICA occlusion and high cMCA PSVs after CAS.
Kablak-Ziembicka
Anna
A
Departments of Cardiac and Vascular Diseases and, The John Paul II Hospital, Krakow, Poland. kablakziembicka@op.pl
Przewlocki
Tadeusz
T
Pieniazek
Piotr
P
Musialek
Piotr
P
Tekieli
Lukasz
L
Rosławiecka
Agnieszka
A
Motyl
Rafal
R
Zmudka
Krzysztof
K
Tracz
Wieslawa
W
Podolec
Piotr
P
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation*; D001783:Blood Flow Velocity; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D002560:Cerebrovascular Circulation; D002561:Cerebrovascular Disorders / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000000981:diagnostic imaging / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology; D011044:Poland; D011237:Predictive Value of Tests; D015427:Reperfusion Injury / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015607:Stents; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging* / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color; D017585:Ultrasonography, Doppler, Transcranial