Loading...
Patients with vascular risk factors such as hypertension and smoking frequently develop asymptomatic white-matter ischemic lesions. These lesions (“leukoaraiosis”) are frequently identified on neuroimaging studies such as brain computed tomography (CT) or magnetic resonance imaging (MRI). If one identifies these lesions in a patient with symptomatic carotid stenosis, should the lesions affect the choice between carotid endarterectomy and carotid artery stenting? To answer this question, researchers examined the brain images (55% CT, 45% MRI) that were available from 1036 of the 1713 participants in the International Carotid Stenting Study (NEJM JW Cardiol 2010 Apr 7).
Two reviewers blinded to clinical data assessed the scans using a rating scale for white-matter lesions. Among patients who underwent stenting, those with a higher burden of white-matter lesions (score ≥7) had a significantly higher rate of periprocedural stroke than those with a score <7 (hazard ratio, 2.76). White-matter lesion burden did not affect periprocedural stroke risk for endarterectomy patients. Among patients with a higher white-matter lesion burden, the stroke rate was significantly higher with stenting than with endarterectomy (HR, 2.98). In patients with a lesion score <7, there was no difference in the stroke rate with stenting versus endarterectomy.
Ederle J et al. Effect of white-matter lesions on the risk of periprocedural stroke after carotid artery stenting versus endarterectomy in the International Carotid Stenting Study (ICSS): A prespecified analysis of data from a randomised trial. Lancet Neurol 2013 Jul 12; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S1474-4422(13)70135-2)
Comment
Despite the frequent finding of white-matter ischemic changes in patients with vascular disease, the question of whether this finding affects outcomes of carotid revascularization has been relatively understudied. The same investigators previously found that stenting produces periprocedural lesions on MRI diffusion imaging more often than endarterectomy does.
The current findings suggest that patients with a higher burden of white-matter ischemic lesions may be less tolerant of procedural emboli and are more likely to have a symptomatic stroke. Therefore, carotid endarterectomy appears preferable for patients with extensive white-matter ischemic lesions. If the scan does not show a large burden of ischemic lesions, then either stenting or endarterectomy appears to be a reasonable option, especially in patients younger than 70.