Subclinical embolization after carotid artery stenting: New lesions on diffusion-weighted magnetic resonance imaging occur postprocedure
Subclinical embolization after carotid artery stenting: New lesions on diffusion-weighted magnetic resonance imaging occur postprocedure
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DOI：
10.1016/j.jvs.2006.12.058
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发表时间：
2007-05-01
影响因子：
4.3
通讯作者：
Wintermark, Max
中科院分区：
文献类型：
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作者：
Rapp, Joseph H.;Wakil, Laura;Wintermark, Max
目的：根据扩散加权磁共振成像 (DWI) 观察到的颈动脉支架置入术 (CAS) 后亚临床脑损伤的发生率从 10% 到 > 40% 不等。 CAS 后经颅多普勒的数据表明，栓塞可能会持续数天，这表明至少一些在 DWI 上看到的病变发生在术后。由于DWI病灶在栓塞发生小时出现，我们利用DWI对CAS前、CAS后1小时和CAS后48小时的患者进行前瞻性研究来回答这个问题。 方法：研究参与者为48名年龄59至83岁的男性患者。所有患者在术前和术后均由神经科医生进行检查，并在术前和术后48小时进行DWI检查。此外，23 名患者在 CAS 后 1 小时进行了 DWI。磁共振成像检查，包括轴向和冠状 DWI 以及液体衰减反转恢复图像，由两名不知道研究时间的神经放射科医生读取。所有患者均取出栓塞防护装置，清洗，并在数码显微镜下检查内容物是否有≥60μm的碎片。结果：有2例围手术期卒中和1例短暂性脑缺血发作（TIA），但随访期间未发生卒中或TIA。在术后 1 小时进行成像的 23 名患者中，有 2 名 (9%) 发现新病灶，18 名 (78%) 在 48 小时发现新病灶（P 60 μm，平均 8 个碎片（范围，2 至 21）大小 > 500 μm。术后 DWI 的结果与狭窄程度、血管成形术球囊大小或充气次数无关，也与结论：进行 CAS 时，临床上明显的神经系统事件的发生率非常低；然而，它与手术期间和手术后的栓塞有关，在手术后至少 48 小时内会出现明显的栓塞，当没有脑保护机制时，这些数据与持续的经颅多普勒报告相关。 CAS 后的栓塞治疗并表明应尽可能晚地进行 DWI，以准确评估 CAS 手术造成亚临床脑损伤的发生率。
Objectives: The reported rate of subclinical brain injury after carotid artery stenting (CAS) seen on diffusion-weighted magnetic resonance imaging (DWI) varies from 10% to > 40%. Data from transcranial Doppler after CAS indicate that embolization may continue for several days, suggesting that that at least some lesions seen on DWI occur postprocedure. Because DWI lesions appear hour of embolization, we used DWI to prospectively study patients before CAS, 1 hour after, and 48 hours after CAS to answer this question.Methods: The study participants were 48 male patients aged 59 to 83. All patients were examined by a neurologist before and after the procedure and had DWI preprocedure and 48 hours postprocedure. In addition, 23 patients had a DWI 1 hour post-CAS. Magnetic resonance imaging exams, including axial and coronal DWI and fluid-attenuated inversion recovery images, were read by two neuroradiologists blinded to the study timing. The embolic protection device was obtained from all patients, washed, and the contents examined under a digital microscope for fragments >= 60 mu m.Results: There were two periprocedural strokes and one transient ischemic attack (TIA), but no strokes or TlAs occurred during follow-up. In the 23 patients imaged 1 hour postprocedure, new lesions were found in two (9%), and 18 (78%) had new lesions at 48 hours (P 60 mu m and a mean of eight fragments (range, 2 to 21) sized > 500 mu m. Findings on postprocedure DWI did not correlate with the degree of stenosis, size of angioplasty balloon, or number of inflations, nor with the number or size of fragments retrieved from the protection device.Conclusions: CAS can be performed with a very low incidence of clinically evident neurologic events; however, it is associated with embolization during and after the procedure. Protection devices effectively prevent clinical and subclinical events during the procedure. Significant embolization continues for at least 48 hours postprocedure, causing lesions on DWI when there is no mechanism for cerebral protection. These data correlate with transcranial Doppler reports of continued embolization after CAS and indicate that DWI should be done as late as possible to accurately assess the rate of subclinical brain injury with CAS procedures.