title: Cerebral embolization in asymptomatic versus symptomatic patients after carotid stenting.
abstract: BACKGROUND
  Previous studies have investigated the development of new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) after carotid artery stenting (CAS). The rate of ischemic brain injury after CAS for asymptomatic stenosis has not been extensively studied but is presumed to be less likely than in symptomatic patients. This study assessed the occurrence of cerebral embolization after CAS for asymptomatic vs symptomatic carotid stenosis.
  
  
  METHODS
  During an 18-month period, 40 patients undergoing CAS under filter embolic protection were prospectively evaluated. Transcranial Doppler (TCD) during CAS and preprocedural and 24-hour postprocedural DW-MRI were used to assess cerebral embolization. Univariate and nonparametric analyses were used to compare differences in cerebral embolization after CAS in asymptomatic and symptomatic patients.
  
  
  RESULTS
  CAS was performed for 23 asymptomatic (58%) and 17 symptomatic (42%) carotid stenoses. The median microembolic counts detected by TCD were 285 (interquartile range [IQR], 182-376) for asymptomatic and 313 (IQR, 170-426) for symptomatic carotid stenosis (P=.6). DW-MRI was available for assessment in 20 asymptomatic and 14 symptomatic patients. New acute cerebral emboli detected with DW-MRI occurred in 10 asymptomatic (50%) and 7 symptomatic patients (50%) undergoing CAS (P=.9). The ipsilateral and total median number of DW-MRI lesions between groups were not statistically significantly different at, respectively, 1 (IQR, 0-2.5) and 1.5 (IQR, 0-3) for asymptomatic vs 0.5 (IQR, 0-2) and 0.5 (IQR, 0-3) for symptomatic carotid stenosis (P>.5). One asymptomatic patient sustained a minor stroke after CAS. No new neurologic events occurred in symptomatic patients. The 30-day stroke-death rate was 2.5% in this series.
  
  
  CONCLUSIONS
  Cerebral embolization, as detected by TCD and DW-MRI, occurs with a similar frequency after CAS for asymptomatic and symptomatic carotid stenosis. Because postprocedural ischemic brain injury occurs in approximately half of asymptomatic patients, the safety of CAS under filter embolic protection for asymptomatic carotid stenosis is uncertain and warrants further study.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, the University of Texas Southwestern Medical Center, Dallas, TX 75390-9157, USA.
authors.forename: Hans H
authors.initials: HH
authors.lastname: Tulip
authors.forename: Eric B
authors.initials: EB
authors.lastname: Rosero
authors.forename: Adriana J
authors.initials: AJ
authors.lastname: Higuera
authors.forename: Adriana
authors.initials: A
authors.lastname: Ilarraza
authors.forename: R James
authors.initials: RJ
authors.lastname: Valentine
authors.forename: Carlos H
authors.initials: CH
authors.lastname: Timaran
mesh_terms: D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation; D016893:Carotid Stenosis / Q000150:complications* / Q000175:diagnosis / Q000601:surgery*; D016022:Case-Control Studies; D015331:Cohort Studies; D038524:Diffusion Magnetic Resonance Imaging; D057505:Embolic Protection Devices; D004867:Equipment Design; D006801:Humans; D015994:Incidence; D020766:Intracranial Embolism / Q000175:diagnosis* / Q000453:epidemiology* / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D015607:Stents / Q000009:adverse effects; D017585:Ultrasonography, Doppler, Transcranial