title: The distribution and size of ischemic lesions after carotid artery angioplasty and stenting: evidence for microembolization to terminal arteries.
abstract: BACKGROUND
  Much of the brain is perfused by penetrating arteries that are the "single source" of blood to their surrounding tissues. These tissues should be equally vulnerable to ischemia from embolic occlusion, but there are questions about whether emboli have access to the penetrating arteries serving the deep brain tissues. To examine this issue in humans we recorded the number and distribution of new ischemic lesions on diffusion-weighted magnetic resonance imaging (DWMRI) after carotid artery stenting (CAS), a procedure producing showers of numerous small atheroemboli.
  
  
  METHODS
  Twenty-nine men (aged 62-81) underwent 30 CAS procedures with distal protection in place, and DWMRI 48 hours after the procedure documented new lesions had developed. Thirteen patients were asymptomatic, and 16 had experienced recent symptoms ipsilateral to the treated carotid stenosis. A DWMRI study was done in each patient ≤72 hours before the procedure. All MRI studies were read by the same neuroradiologist.
  
  
  RESULTS
  One patient sustained a minor stroke, which resolved. DWNRI found 131 new lesions (median, 3; range, 1-17; interquartile range, 2-4). Lesion size was <5 mm in 96.6% and 5 to 10 mm in 3.1%. Lesions were ipsilateral in 83.1% and contralateral in 16.9%. Lesions were in the distribution of the middle cerebral artery (91.6%), posterior cerebral artery (6.1%), and superior cerebellar artery subclavian artery (2.0%). Most lesions were in the cortex but at a depth where they were best described as cortical/subcortical (90.8%). The rest were in the periventricular white matter (6.1%) and deep gray matter (3.0%).
  
  
  CONCLUSIONS
  The ischemic areas developing after CAS were predominately in the deeper layers of the cortex in the distribution of the middle cerebral artery, but lesions were seen throughout the brain. The distribution of lesions caused by CAS-induced embolization coincided with estimates of blood flow to the respective areas of the brain. These data add to the evidence implicating microemboli in ischemic pathologies throughout the brain.
authors.affiliation: Vascular Surgery Service, the San Francisco Department of Veterans Affairs Medical Center, the University of California, San Francisco, Calif., USA.
authors.forename: Lei
authors.initials: L
authors.lastname: Zhu
authors.forename: Max
authors.initials: M
authors.lastname: Wintermark
authors.forename: David
authors.initials: D
authors.lastname: Saloner
authors.forename: Madison
authors.initials: M
authors.lastname: Fandel
authors.forename: Xian Mang
authors.initials: XM
authors.lastname: Pan
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Rapp
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects* / Q000295:instrumentation*; D058070:Asymptomatic Diseases; D002545:Brain Ischemia / Q000209:etiology* / Q000473:pathology / Q000503:physiopathology; D016893:Carotid Stenosis / Q000150:complications / Q000473:pathology / Q000628:therapy*; D002560:Cerebrovascular Circulation; D038524:Diffusion Magnetic Resonance Imaging; D006801:Humans; D020766:Intracranial Embolism / Q000209:etiology* / Q000473:pathology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012495:San Francisco; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000209:etiology* / Q000473:pathology / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome