Predictors of Acute and Persisting Ischemic Brain Lesions in Patients Randomized to Carotid Stenting or Endarterectomy

Abstract

In the MRI substudy of the International Carotid Stenting Study (ICSS), acute ischemic brain lesions on diffusion-weighted imaging (DWI) were found more often after stenting than after endarterectomy.1,2 We investigated risk factors for acute periprocedural brain lesions and lesions persisting on follow-up imaging. MethodsMRI was performed 1 to 7 days before (pretreatment scan), 1 to 3 days after (early post-treatment scan), and 27 to 33 days after treatment (follow-up scan, performed in 6 of 7 centers) among patients with symptomatic carotid stenosis randomized to stenting or endarterectomy. Acute ischemic brain lesions were defined as new hyperintense DWI lesions on the early post-treatment scan and persisting lesions as hyperintense signal on fluid-attenuated inversion recovery (FLAIR) imaging on the follow-up scan at the site of previous acute lesions.Negative binomial regression models were used to compare the number of acute and persisting lesions (lesion count) between treatment groups. Negative binomial regression models with persisting lesion count as the dependent variable, which included an offset for acute lesion count, were used to compare the rate of conversion from acute to persisting lesions between treatment groups. The association between location (superficial versus deep and border-zone versus non border-zone) 2 and volume (A×B×C/2 converted to cubic root) of ResultsAt 7 centers taking part in the ICSS-MRI substudy, the numbers of patients randomized in ICSS and participating in the substudy were 189 and 124, respectively, in the stenting group and 190 and 107, respectively, in the endarterectomy group. Characteristics of patients participating and not participating in the substudy did not differ ( Table). 2 In the stenting group, acute lesion count was higher in older patients by trend (≥71 years; RR, 2.1; 95% CI, 1.0-4.6; P=0.067), men (RR, 2.4; 95% CI, 1.00-5.8; P=0.042), and patients with stroke as the qualifying event (RR, 2.5; 95% CI, 1.2-5.5; P=0.021; Figure). Higher systolic blood pressure (≥158.5 mm Hg) was associated with an increased acute lesion count in the endarterectomy group (RR, 4.2; 95% CI, 1.00-16.7; P=0.044). More severe white matter disease (age-related white matter changes 3 sum score, ≥5) increased the number of acute lesions both in the stenting (RR, 2.4; 95% CI, 1.1-5.3; P=0.028) and in the endarterectomy group (RR, 4.1; 95% CI, 1.1-15.4; P=0.035).Follow-up FLAIR was obtained at 6 centers, in 86 stenting and in 75 endarterectomy patients and showed signal-hyperintensity in 89 (27%) of 537 acute DWI lesions in the stenting group and 18 (53%) of acute DWI lesions in the endarterectomy group. Patients in the stenting group had more persisting lesions than patients in the endarterectomy group (RR, 4.2; 95% CI, 1.6-11.1; P=0.005; Table). However, the probability of conversion from acute to persisting lesions was lower in the stenting group (RR, 0.4; 95% CI, 0.2-0.8; P=0.007). None of the analyzed variables at patient level in both treatment groups combined predicted lesio...

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