Fiona M. McKevitt

Filter-Protected versus Unprotected Carotid Artery Stenting: A Randomised Trial

Background: Our aim was to determine whether filter protection reduces embolisation to the brain during carotid artery stenting (CAS). Methods: Thirty patients with symptomatic carotid artery stenosis ≧70% (North American Symptomatic Carotid Endarterectomy Trial) were randomly assigned to filter-protected or unprotected CAS. Diffusion-weighted magnetic resonance imaging (DWI) of the brain was performed before and at 3 time points after CAS. In a subset of patients, high-intensity transient signals on transcranial Doppler (TCD) were recorded with categorisation of emboli. Data were independently reviewed off-site. Results: There were no significant differences in mean age, proportion of octogenarians or presenting symptoms between the groups. On procedural DWI (1–3 and 24 h after stenting), there were 7/24 (29%) and 4/22 (18%) new lesions in protected and unprotected patients respectively (p = 0.38). At 30 days there were 9/33 (26%) and 4/33 (12%) lesions in protected and unprotected patients, respectively (p = 0.1). On TCD there were significantly more signals in total as well as particulate emboli during filter-protected CAS (426.5 and 251.3) than during unprotected CAS (165.2 and 92) – p = 0.01 and 0.03, respectively. Conclusions: Filter-protected CAS is associated with an increase in new lesions on DWI and significantly higher rates of total and particulate microembolisation on TCD than unprotected CAS. The clinical significance of these findings requires further study.

Effect of Treatment of Carotid Artery Stenosis on Blood Pressure A Comparison of Hemodynamic Disturbances After Carotid Endarterectomy and Endovascular Treatment

Background and Purpose— Carotid intervention by carotid endarterectomy (CEA) or endovascular treatment may cause hemodynamic change. The immediate and long-term effects on blood pressure after these procedures were assessed. Methods— Patients were randomized to CEA (n=49) or endovascular treatment (n=55) that comprised percutaneous transluminal angioplasty alone (n=31), balloon-expandable stent (n=13), or self-expandable stent (n=11). A baseline 24-hour ambulatory blood pressure recording was made before carotid intervention and repeated at 24 hours, 1 month, and 6 months after the procedure. Results— In the first 24 hours after the procedure, episodes of hypotension occurred in 75% of the CEA group and 76% of the endovascular group; hypertension occurred in 11% and 13%, respectively. There was a significant fall in blood pressure at 1 hour after the procedure in both groups (24 and 16 mm Hg fall in CEA and endovascular groups, respectively), but this was only sustained in the endovascular group. The pattern of blood pressure response in the first 24 hours was significantly different (P <0.0001, ANCOVA). Systolic blood pressure was significantly lower at 1 and 6 months only in the surgical group (6 and 5 mm Hg fall, respectively). Conclusions— Both CEA and endovascular treatment have an effect on blood pressure stability, particularly within the first 24 hours after the procedure.

Timing and frequency of complications after carotid artery stenting: what is the optimal period of observation?☆

OBJECTIVE Currently our standard of practice is that patients undergoing carotid artery stenting (CAS) may be safely discharged on the first day post-procedure. However, many patients are completely independent on the evening of procedure. Therefore we sought to establish the safety and feasibility of same-day discharge by assessing frequency and time of complications in the first 30 days after CAS. METHOD Case records for 208 consecutive patients who had undergone CAS from October 1999 to October 2002 were retrospectively reviewed. Excluded were four cases in which combined CAS and carotid endarterectomy was performed to treat synchronous stenosis. Of the remaining 204 cases, involving 201 patients (three patients underwent staged bilateral CAS), 173 (84.8%) were symptomatic and 31 (15.2%) were asymptomatic. RESULT Thirty-eight major events or death (inclusive of all neurologic events and any complications that required treatment) were recorded in the first 30 days after CAS, for an event rate of 18.6% per case. These were 7 (3.4%) major access site complications; 18 (8.8%) neurologic events, of which 10 (4.9%) were transient ischemic events and 8 (3.9%) were strokes (including minor, major, and fatal stroke); 8 (3.9%) cardiovascular complications; and five (2.5%) other events. Twenty (52.6%) events occurred in the first 6 hours after CAS, 2 (5.3%) between 6 and 12 hours, 3 (7.9%) between 12 and 24 hours, and 13 (34.2%) 24 hours to 30 days post procedure. Four (2.0%) deaths were recorded in this period, 1 secondary to stroke, 1 from a perforated myocardium from a temporary pacing wire, and 2 from unrelated causes. The 30-days stroke and death rate was 5.4% (11 of 204 patients). CONCLUSION Time of complications suggests that outpatient performance of CAS is feasible and safe in selected patients.

Complications following Carotid Angioplasty and Carotid Stenting in Patients with Symptomatic Carotid Artery Disease

Background: We review a single centre’s experience of the endovascular treatment of carotid artery disease, present the 30-day and 1-year complication rates and assess whether changes in technique are associated with a change in clinical outcome. Methods: Patients who underwent carotid angioplasty with or without stenting for symptomatic ≧70% carotid artery stenosis secondary to atherosclerosis were included. 333 procedures were performed, i.e. angioplasty alone (86), stent without cerebral protection (150) and stent with cerebral protection (97). Results: At 30 days, the total major disabling stroke and all death rate was 3.0%. For angioplasty alone, this was 2.3%, for stent without cerebral protection 4.0% and for stent with cerebral protection 2.1%. If non-stroke-related deaths were excluded, it was 2.3, 3.3 and 0%, respectively. After 30 days, the 1-year ipsilateral stroke rate was 0.8%. Conclusions: Carotid artery stenting, in particular with a cerebral protection device, is a safe alternative to carotid endarterectomy for the treatment of symptomatic high-grade carotid artery disease.

Neurological Outcomes after Carotid Stenting Protected with the NeuroShield Filter Compared to Unprotected Stenting

PURPOSE To compare outcomes for two nonrandomized cohorts of patients with high-grade carotid disease who underwent either unprotected carotid stenting or stent implantation protected by the NeuroShield filter. METHODS Under this protocol, symptomatic patients with carotid stenoses >70% or asymptomatic patients with bilateral carotid stenoses who were being evaluated for coronary artery bypass grafting were eligible for carotid stenting. Between December 1998 and November 2001, 75 consecutive patients (57 men; median age 67 years range 45-85) underwent carotid stenting without cerebral protection; concurrently, 75 carotid stent procedures protected with the NeuroShield filter were performed in 73 patients (51 men; median age 66 years, range 47-83). A neurologist reviewed all patients before and after treatment. The groups were comparable for age, sex, and symptoms, but the protected group had a higher proportion of postsurgical restenoses (14.7% versus 1.3%; p=0.003). Outcome measures included death and neurological events at 24 hours and 30 days. RESULTS There were minor technical difficulties in 12 of the protected group, but none were clinically relevant. The procedural all-stroke/death rates in the unprotected versus protected groups, respectively, were 5.3% (4/75) and 2.7% (2/75; p=0.681), while the disabling stroke/death rates were 4% (3/75) and 1.3% (1/75; p=0.620). At 30 days, the all-stroke/death rates were 10.7% (8/75) in the unprotected group and 4.0% (3/75) in the protected group (p=0.117); the death/major-disability-from-stroke rates were 6.7% (5/75) and 2.7% (2/75), respectively (p=0.442). CONCLUSIONS Filter-related complications are well tolerated. Neuroprotection devices have the potential to reduce the procedural neurological event rate. Larger series and/or randomized trials are required for further evaluation.

Long-Term Results of Carotid Artery Stents to Manage Symptomatic Carotid Artery Stenosis and Factors That Affect Outcome

Background—Limited data are available about the long-term outcomes of the use of carotid artery stents in symptomatic patients and the impact of patient variables on the durability of endovascular carotid procedures. Outcome data previously reported from registry series mix symptomatic and asymptomatic patients. We present analysis of long-term follow-up, with independent neurological assessment, for patients with symptomatic high-grade carotid lesions undergoing stenting to identify patients at risk of recurrence. Methods and Results—Prospectively collected data on 563 carotid stenting procedures in a single center were analyzed. Univariate and multivariate techniques were used to identify risk groups and beneficial technical adaptations. Ipsilateral stroke rates for all patients were 4.8%, 7.0%, and 9.5% at 30 days, 1 year, and 4 years, respectively. The rates improved to 2.7%, 4.1%, and 4.5% when patients were treated with optimal therapy. Retinal events had a lower risk of long-term recurrent ipsilateral stroke (hazard ratio=0.228, CI=0.082 to 0.632, P=0.004) than cerebral events. A recurrent or residual stenosis of >50% had a statistically significant effect on long-term stroke recurrence in multivariate analysis (hazard ratio=2.187, CI=1.173 to 4.078, P=0.014). Conclusions—Patients with retinal presentations are a lower risk group to treat. Residual stenosis or restenosis >50% has a statistically significant trend to an increased risk of recurrence for ipsilateral stroke in the long term in this population. In our patients, a combination of procedural modifications and pharmacological changes seems to improve outcomes.

Is the Endovascular Treatment of Carotid Stenosis in High-Risk Patients Really Safer than Carotid Endarterectomy?

Background: We assess the outcomes of patients who would have been considered at high-risk from carotid endarterectomy (CEA), who have undergone endovascular treatment. Methods: High-risk patients were classed as those with occlusion of the contralateral internal carotid artery, recurrent stenosis following CEA, stenosis secondary to neck irradiation or treatment prior to coronary bypass surgery. Results: 103 procedures fulfilled at least one inclusion criterion. 58.3% had symptomatic disease. The all stroke/death rate was 9.7%. The major disabling stroke/stroke-related death rate was 3.9%. 63 had a contralateral occlusion, 15 post-CEA, 17 post-radiation and 33 pre-coronary surgery. The major disabling stroke/stroke-related death rates for each subset were 4.8, 6.7, 0 and 0%, respectively. Conclusions: These results suggest that this category of patients is at high-risk of stroke regardless of method of carotid intervention.

‘Low grade glioma’: an update for radiologists

With the recent publication of a new World Health Organization brain tumour classification that reflects increased understanding of glioma tumour genetics, there is a need for radiologists to understand the changes and their implications for patient management. There has also been an increasing trend for adopting earlier, more aggressive surgical approaches to low-grade glioma (LGG) treatment. We will summarize these changes, give some context to the increased role of tumour genetics and discuss the associated implications of their adoption for radiologists. We will discuss the earlier and more radical surgical resection of LGG and what it means for patients undergoing imaging.

Imaging in low-grade glioma: a guide for neurologists

The management of low-grade glioma (LGG) is shifting as evidence has emergedthat refutes the previously commonplace imaging-based ‘watch and wait’ approach, in favour of early aggressive surgical resection. This coupled with the recent 2016 update to the World Health Organisation Classification of Tumours of the Central Nervous System is changing LGG imaging and management. Recently in Practical Neurology the contemporary management of low-grade glioma and the changes to this grading system were discussed in detail. 1 In this complementary article, we discuss the role of imaging in the diagnosis, surgical planning and post-treatment follow-up of LGG. We describe the principles of imaging these tumours and use several cases to highlight some difficult scenarios.

Focal cortical dysplasia mimicking neoplasia

Focal cortical dysplasia (FCD) is a well-recognised cause of epilepsy.1 We describe the case of a patient with histologically proven FCD, who initially was thought to have a malignant tumour on MR brain scan. A 19-year-old right-handed woman reported three episodes of loss of consciousness since the age of 13 years, each preceded by light-headedness and burning in the throat and with amnesia and confusion after the event. She had also experienced occasional vacant episodes suggestive of complex partial seizures and mild self-limiting headaches. The frequency of the vacant episodes had increased to once monthly with temporary episodes of dysphasia lasting a few minutes. Neurological examination was normal. She was started on levetiracetam. MRI scan of the brain showed a small spherical enhancing mass within the cortex along the depths of the superior temporal sulcus, involving the upper bank of the middle temporal gyrus on the left (figure 1). The perfusion imaging showed a regional cerebral blood volume of 1.1 ml/100 g. Spectroscopy demonstrated low N-acetyl aspartate and an inverted peak at 1.33 ppm suggesting lactate. Diffusion-weighted …