Silent cerebral ischemia after thoracic endovascular aortic repair: a neuroimaging study.
BACKGROUND
The risk of clinically apparent, periprocedural stroke after thoracic endovascular aortic repair (TEVAR) due to dislodgement and embolization of aortic debris from intravascular manipulation of guidewires, catheters, and large-bore delivery systems ranges between 2% and 6% and has been associated with increased postoperative mortality. The rate of clinically silent cerebral ischemia is yet unknown, but may be even higher.


METHODS
Nineteen patients (13 male, 6 female) who underwent TEVAR were included into this descriptive study. Periprocedural apparent and silent cerebral ischemia was assessed by daily clinical neurologic assessment and serial cerebral diffusion-weighted magnetic resonance imaging (DW-MRI) at baseline and 5 days (median, interquartile range: 3.5) after the procedure.


RESULTS
The TEVAR was successful in all patients without immediate clinically apparent neurologic deficits. Postinterventional cerebral DW-MRI detected a total of 29 new foci of restricted diffusion in 12 of 19 TEVAR patients (63%). Lesions were usually multiple (1 to 6 lesions per patient) and ranged in size between 15 mm3 and 300 mm3; 16 lesions were found in the left hemisphere, 13 lesions in the right hemisphere. Overstenting of the left subclavian artery was performed in 8 cases, but was not associated with lateralization of lesions. There were no additional apparent neurologic events during the in-hospital period.


CONCLUSIONS
Thoracic endovascular aortic repair resulted in a high incidence of new foci of restricted diffusion on cerebral DW-MRI in a pattern suggestive of periprocedural embolization. Although multiple lesions per patients were found, these lesions were not associated with apparent neurologic deficits during the in-hospital period. Further developments in TEVAR should be directed toward reducing the risk of periprocedural cerebral embolization.
Department of Cardiology, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany. Electronic address: philipp.kahlert@uk-essen.de.
Philipp
P
Kahlert
Department of Cardiology, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Holger
H
Eggebrecht
Department of Cardiology, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Rolf A
RA
Jánosi
Department of Cardiology, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Heike A
HA
Hildebrandt
Department of Cardiology, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Björn
B
Plicht
Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Konstantinos
K
Tsagakis
Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Christoph
C
Moenninghoff
Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Felix
F
Nensa
Department of Neurology, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Petra
P
Mummel
Institute for Pathophysiology, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Gerd
G
Heusch
Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Heinz G
HG
Jakob
Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Michael
M
Forsting
Department of Cardiology, West-German Heart Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Raimund
R
Erbel
Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
Marc
M
Schlamann
D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects; D002545:Brain Ischemia / Q000175:diagnosis / Q000209:etiology*; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000379:methods; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D015203:Reproducibility of Results; D014057:Tomography, X-Ray Computed / Q000379:methods*; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods; D017585:Ultrasonography, Doppler, Transcranial / Q000379:methods*