title: Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk.
abstract: BACKGROUND
  Brain lesions on diffusion-weighted imaging (DWI) are frequently found after carotid artery stenting (CAS), but their clinical relevance remains unclear.
  
  
  OBJECTIVE
  This study sought to investigate whether periprocedural ischemic DWI lesions after CAS or carotid endarterectomy (CEA) are associated with an increased risk of recurrent cerebrovascular events.
  
  
  METHODS
  In the magnetic resonance imaging (MRI) substudy of ICSS (International Carotid Stenting Study), 231 patients with symptomatic carotid stenosis were randomized to undergo CAS (n=124) or CEA (n=107). MRIs were performed 1 to 7 days before and 1 to 3 days after treatment. The primary outcome event was stroke or transient ischemic attack in any territory occurring between the post-treatment MRI and the end of follow-up. Time to occurrence of the primary outcome event was compared between patients with (DWI+) and without (DWI-) new DWI lesions on the post-treatment scan in the CAS and CEA groups separately.
  
  
  RESULTS
  Median time of follow-up was 4.1 years (interquartile range: 3.0 to 5.2). In the CAS group, recurrent stroke or transient ischemic attack occurred more often among DWI+ patients (12 of 62) than among DWI- patients (6 of 62), with a cumulative 5-year incidence of 22.8% (standard error [SE]: 7.1%) and 8.8% (SE: 3.8%), respectively (unadjusted hazard ratio: 2.85; 95% confidence interval: 1.05 to 7.72; p=0.04). In DWI+ and DWI- patients, 8 and 2 events, respectively, occurred within 6 months after treatment. In the CEA group, there was no difference in recurrent cerebrovascular events between DWI+ and DWI- patients.
  
  
  CONCLUSIONS
  Ischemic brain lesions discovered on DWI after CAS seem to be a marker of increased risk for recurrent cerebrovascular events. Patients with periprocedural DWI lesions might benefit from more aggressive and prolonged antiplatelet therapy after CAS. (A Randomised Comparison of the Risks, Benefits and Cost Effectiveness of Primary Carotid Stenting With Carotid Endarterectomy: International Carotid Stenting Study; ISRCTN25337470).
authors: Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
authors: Henrik
authors: H
authors: Gensicke
authors: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
authors: H Bart
authors: HB
authors: van der Worp
authors: Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands.
authors: Paul J
authors: PJ
authors: Nederkoorn
authors: Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.
authors: Sumaira
authors: S
authors: Macdonald
authors: Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom.
authors: Peter A
authors: PA
authors: Gaines
authors: Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors: Aad
authors: A
authors: van der Lugt
authors: Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.
authors: Willem P Th M
authors: WP
authors: Mali
authors: Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
authors: Philippe A
authors: PA
authors: Lyrer
authors: Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
authors: Nils
authors: N
authors: Peters
authors: Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, United Kingdom.
authors: Roland L
authors: RL
authors: Featherstone
authors: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors: Gert J
authors: GJ
authors: de Borst
authors: Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
authors: Stefan T
authors: ST
authors: Engelter
authors: Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, United Kingdom.
authors: Martin M
authors: MM
authors: Brown
authors: Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, United Kingdom. Electronic address: leo.bonati@usb.ch.
authors: Leo H
authors: LH
authors: Bonati
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D002545:Brain Ischemia / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D016893:Carotid Stenosis / Q000175:diagnosis / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D006113:United Kingdom / Q000453:epidemiology
keywords: DWI lesions; carotid stenosis; endarterectomy; long-term outcome; stenting