title: Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy.
abstract: Complex vascular anatomy might increase the risk of procedural stroke during carotid artery stenting (CAS). Randomized controlled trial evidence that vascular anatomy should inform the choice between CAS and carotid endarterectomy (CEA) has been lacking.
  
  
  
  One-hundred eighty-four patients with symptomatic internal carotid artery stenosis who were randomly assigned to CAS or CEA in the ICSS (International Carotid Stenting Study) underwent magnetic resonance (n=126) or computed tomographic angiography (n=58) at baseline and brain magnetic resonance imaging before and after treatment. We investigated the association between aortic arch configuration, angles of supra-aortic arteries, degree, length of stenosis, and plaque ulceration with the presence of ≥1 new ischemic brain lesion on diffusion-weighted magnetic resonance imaging (DWI+) after treatment.
  
  
  
  Forty-nine of 97 patients in the CAS group (51%) and 14 of 87 in the CEA group (16%) were DWI+ (odds ratio [OR], 6.0; 95% confidence interval [CI], 2.9-12.4;P<0.001). In the CAS group, aortic arch configuration type 2/3 (OR, 2.8; 95% CI, 1.1-7.1;P=0.027) and the degree of the largest internal carotid artery angle (≥60° versus <60°; OR, 4.1; 95% CI, 1.7-10.1;P=0.002) were both associated with DWI+, also after correction for age. No predictors for DWI+ were identified in the CEA group. The DWI+ risk in CAS increased further over CEA if the largest internal carotid artery angle was ≥60° (OR, 11.8; 95% CI, 4.1-34.1) than if it was <60° (OR, 3.4; 95% CI, 1.2-9.8; interactionP=0.035).
  
  
  
  Complex configuration of the aortic arch and internal carotid artery tortuosity increase the risk of cerebral ischemia during CAS, but not during CEA. Vascular anatomy should be taken into account when selecting patients for stenting.
  
  
  
  URL: http://www.isrctn.com/ISRCTN25337470. Unique identifier: ISRCTN25337470.
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Mandy D
authors.initials: MD
authors.lastname: Müller
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Ahlhelm
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Alexander
authors.initials: A
authors.lastname: von Hessling
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: David
authors.initials: D
authors.lastname: Doig
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Nederkoorn
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Sumaira
authors.initials: S
authors.lastname: Macdonald
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Philippe A
authors.initials: PA
authors.lastname: Lyrer
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Aad
authors.initials: A
authors.lastname: van der Lugt
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Jeroen
authors.initials: J
authors.lastname: Hendrikse
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Christoph
authors.initials: C
authors.lastname: Stippich
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: H Bart
authors.initials: HB
authors.lastname: van der Worp
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Toby
authors.initials: T
authors.lastname: Richards
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Martin M
authors.initials: MM
authors.lastname: Brown
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
authors.forename: Stefan T
authors.initials: ST
authors.lastname: Engelter
authors.affiliation: From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.). leo.bonati@usb.ch.
authors.forename: Leo H
authors.initials: LH
authors.lastname: Bonati
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging*; D002545:Brain Ischemia / Q000209:etiology*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging*; D016893:Carotid Stenosis / Q000601:surgery*; D002533:Cerebral Angiography / Q000379:methods*; D000072226:Computed Tomography Angiography / Q000379:methods; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D012306:Risk; D015607:Stents; D020521:Stroke / Q000209:etiology*; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
keywords: anatomy; angiography; brain; carotid stenosis; endarterectomy; stents; stroke