Preoperative White Matter Lesions Are Independent Predictors of Long-Term Survival after Internal Carotid Endarterectomy

Oksala, Niku; Jaroma, Marianne; Pienimäki, Juha-Pekka; Kuorilehto, Tommi; Vänttinen, Teemu; Lehtomäki, Antti; Suominen, Velipekka; Dastidar, Prasun; Mäkinen, Kimmo; Erkinjuntti, Timo; Salenius, Juha-Pekka

doi:10.1159/000363128

Cited by 5 publications

(5 citation statements)

References 43 publications

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“…The finding that increased post-operative long term risk of cardiovascular death in symptomatic patients undergoing CEA is associated with reported SVD is in line with a previous small study, 8 which showed that CEA patients (predominantly symptomatic) with any quantified WML on preoperative brain CT had an increased five year mortality risk (predominantly of cardiovascular origin). It is now shown that, also based on standard brain imaging reports, SVD can be used as a predictor of cardiovascular death.…”

Section: Discussionsupporting

confidence: 90%

“…Yet, previous studies that did investigate the correlation between (semi-) quantitative WML measures and outcome in patients undergoing CEA used trained radiologists for assessment of these study parameters which has the disadvantage of not being part of standard clinical practice. 3,8,9 Fourth, only symptomatic patients were included, but assessment of peri-operative risk in asymptomatic patients may be even more relevant in the ongoing discussion about whether or not to perform revascularisation procedures in these patients. Finally, stroke was observed less frequently for excluded patients than in included patients (see Table S4), mainly because imaging reports were not attached in the referral from other hospitals.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…6,7 Previous studies in symptomatic CEA patients suggested an increased periand post-operative stroke and death risk in patients with more extensive WMLs. 3,8,9 The association between WMLs and an increased stroke risk may be related to impaired cerebral haemodynamics due to a reduced vessel density, impaired vessel autoregulation, or a reduced baseline cerebral blood flow. 6,10 Therefore, it can be hypothesised that a brain with more than age appropriate WMLs may be more vulnerable to develop subsequent ischaemic infarcts when challenged by acute thrombo-embolic or haemodynamic events.…”

Section: Introductionmentioning

confidence: 99%

“…While previous studies investigated the predictive value of specific (semi-)quantitative WML severity scores for adverse events in patients undergoing CEA, 3,8,9 thus far no studies have evaluated the clinical relevance of cerebral small vessel disease (SVD) as reported in daily practice. The current study aimed to assess the clinical relevance of baseline SVD in standard pre-operative brain imaging reports in relation to future adverse cardiovascular events following CEA.…”

Section: Introductionmentioning

confidence: 99%

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Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Timmerman

Rots

Koeverden

et al. 2020

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDSThis study investigated the clinical relevance of reported cerebral small vessel disease (SVD, including white matter lesions and lacunar infarcts) for post-operative stroke and death risk in symptomatic patients undergoing carotid endarterectomy (CEA). The study highlights that the presence of SVD in standard routine pre-operative brain imaging reports identifies patients at high risk of cardiovascular death. Yet, reported SVD is not associated with procedural or long term post-operative stroke risk and therefore this should not influence the decision whether CEA should be performed in symptomatic patients with high degree carotid artery stenosis.Objective: Cerebral white matter lesions (WMLs) and lacunar infarcts are surrogates of cerebral small vessel disease (SVD). WML severity as determined by trained radiologists predicts post-operative stroke or death in patients undergoing carotid endarterectomy (CEA). It is unknown whether routine pre-operative brain imaging reports as part of standard clinical practice also predict short and long term risk of stroke and death after CEA. Methods: Consecutive patients from the Athero-Express biobank study that underwent CEA for symptomatic high degree stenosis between March 2002 and November 2014 were included. Pre-operative brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) reports were reviewed for reporting of SVD, defined as WMLs or any lacunar infarcts. The primary outcome was defined as any stroke or any cardiovascular death over three year follow up. The secondary outcome was defined as the 30 day perioperative risk of stroke or cardiovascular death. Results: A total of 1038 patients were included (34% women), of whom 659 (63.5%) had CT images and 379 (36.5%) MRI images available. Of all patients, 697 (67%) had SVD reported by radiologists. Patients with SVD had a higher three year risk of cardiovascular death than those without (6.5% vs. 2.1%, adjusted HR 2.52 [95% CI 1.12e5.67]; p ¼ .026) but no association was observed for the three year risk of stroke (9.0% vs. 6.7%, for patients with SVD vs. those without, adjusted HR 1.24 [95% CI 0.76e2.02]; p ¼ .395). No differences in 30 day peri-operative risk were observed for stroke (4.4% vs. 2.9%, for patients with vs. those without SVD; adjusted HR 1.49 [95% CI 0.73e3.05]; p ¼ .28), and for the combined stroke/cardiovascular death risk (4.4% vs. 3.5%, adjusted HR 1.20 [95% CI 0.61e2.35]; p ¼ .59). Conclusion: Presence of SVD in pre-operative brain imaging reports can serve as a predictor for the three year risk of cardiovascular death in symptomatic patients undergoing CEA but does not predict peri-operative or long term risk of stroke.

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Section: Discussionsupporting

confidence: 90%

Section: Strengths and Limitationsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Timmerman

Rots

Koeverden

et al. 2020

European Journal of Vascular and Endovascular Surgery

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“…White matter lesions (WML) are a surrogate for cerebral small vessel disease (SVD), which is the major cause of accumulating vascular burden in aging populations. Severe WML in stroke patients are associated with a risk of complications after thrombolysis [1] and poor prognosis after carotid endarterectomy [2]. Other well-documented consequences of severe WML are cognitive impairment, gait disturbances, depression, urine incontinence, and the eventual loss of independence and risk for permanent institutionalization [3,4].…”

Section: Introductionmentioning

confidence: 99%

Evaluating severity of white matter lesions from computed tomography images with convolutional neural network

et al. 2020

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Purpose Severity of white matter lesion (WML) is typically evaluated on magnetic resonance images (MRI), yet the more accessible, faster, and less expensive method is computed tomography (CT). Our objective was to study whether WML can be automatically segmented from CT images using a convolutional neural network (CNN). The second aim was to compare CT segmentation with MRI segmentation. Methods The brain images from the Helsinki University Hospital clinical image archive were systematically screened to make CT-MRI image pairs. Selection criteria for the study were that both CT and MRI images were acquired within 6 weeks. In total, 147 image pairs were included. We used CNN to segment WML from CT images. Training and testing of CNN for CT was performed using 10-fold cross-validation, and the segmentation results were compared with the corresponding segmentations from MRI. Results A Pearson correlation of 0.94 was obtained between the automatic WML volumes of MRI and CT segmentations. The average Dice similarity index validating the overlap between CT and FLAIR segmentations was 0.68 for the Fazekas 3 group. Conclusion CNN-based segmentation of CT images may provide a means to evaluate the severity of WML and establish a link between CT WML patterns and the current standard MRI-based visual rating scale.

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Pre-Operative Masseter Area is an Independent Predictor of Long-Term Survival after Carotid Endarterectomy

Oksala

Lindström

Khan

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS Masseter muscle area (MA) can be measured reliably from pre-operative computed tomography angiography and is a significant predictor of long-term mortality after carotid endarterectomy, independent of other risk factors, anthropometric measures, and dental status. To understand its potential in risk stratification and longterm mortality, the results need to be validated in independent cohorts and studies powered to stratify for different indication categories. Objective/Background: Sarcopenia is a predictor of mortality in elderly patients. Masseter area (MA) reflects sarcopenia in trauma patients. It was hypothesised that MA and Masseter density (MD) could be evaluated reliably from pre-operative computed tomography angiography (CTA) scans and that they predict postoperative survival in carotid endarterectomy (CEA) patients. Methods: This was an observational registry study. Patients (n ¼ 242) were operated on for asymptomatic stenosis (n ¼ 32; 13.2%), amaurosis fugax (n ¼ 41; 16.9%), transient ischaemic attack (n ¼ 85; 35.1%), or ischaemic stroke (n ¼ 84; 34.7%). Internal carotid artery stenoses were graded angiographically. Intraclass correlation coefficient (ICC) was used to analyse measurement reliability by three independent observers. Cox regression analysis was used to study the effect of MA and MD on survival (hazard ratio [HR]). Results: Median patient age was 71.0 years (interquartile range [IQR] 13.0) and follow up time was 68.5 months (range 3e163 months); at the end of follow up (1 October 2017), 104 (43.0%) patients had died according to the National Population Register. The average MA (MAavg, the mean of left and right MA [median 394.0 mm 2 ; IQR 110.1 mm 2 ]) and MD (MDavg, the mean of left and right MD [median 53.5 HU; IQR 16.5 HU]) could be measured with excellent reliability (ICC > 0.865, p < .001 for all). In multivariable analyses only body surface area (BSA) (p < .001) and dental status were associated with MAavg (p ¼ .021). Increased MAavg predicted lower mortality (HR 0.76, 95% confidence interval [CI] 0.61e0.96; p ¼ .023) independent of age (HR 1.05, 95% CI 1.02e1.07; p ¼ 0.001), female sex, body mass index, renal insufficiency, ipsilateral stenosis, indication category, and presence of teeth. MDavg was not associated with mortality. After further adjustment, BSA (the most significant determinant of MAavg) did not alter the association between MAavg and mortality (0.75, 95% CI 0.58e0.97; p ¼ .031). Conclusion: Average MA but not MD measured from the pre-operative CTA scan provides a reliable estimate of post-operative long-term survival in CEA patients independent of other risk factors, anthropometric measurements, and dental status.

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Preoperative White Matter Lesions Are Independent Predictors of Long-Term Survival after Internal Carotid Endarterectomy

Cited by 5 publications

References 43 publications

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Evaluating severity of white matter lesions from computed tomography images with convolutional neural network

Pre-Operative Masseter Area is an Independent Predictor of Long-Term Survival after Carotid Endarterectomy

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