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Mechanism of procedural stroke following carotid endarterectomy or carotid artery stenting within the International Carotid Stenting Study (ICSS) randomised trial

Huibers, A; Calvet, D; Kennedy, F; Czuriga-Kovács, KR; Featherstone, RL; Moll, FL; Brown, MM; ... de Borst, GJ; + view all (2015) Mechanism of procedural stroke following carotid endarterectomy or carotid artery stenting within the International Carotid Stenting Study (ICSS) randomised trial. Eur J Vasc Endovasc Surg , 50 (3) pp. 281-288. 10.1016/j.ejvs.2015.05.017. Green open access

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Abstract

OBJECTIVE: To decrease the procedural risk of carotid revascularisation it is crucial to understand the mechanisms of procedural stroke. This study analysed the features of procedural strokes associated with carotid artery stenting (CAS) and carotid endarterectomy (CEA) within the International Carotid Stenting Study (ICSS) to identify the underlying pathophysiological mechanism. MATERIALS AND METHODS: Patients with recently symptomatic carotid stenosis (1,713) were randomly allocated to CAS or CEA. Procedural strokes were classified by type (ischaemic or haemorrhagic), time of onset (intraprocedural or after the procedure), side (ipsilateral or contralateral), severity (disabling or non-disabling), and patency of the treated artery. Only patients in whom the allocated treatment was initiated were included. The most likely pathophysiological mechanism was determined using the following classification system: (1) carotid-embolic, (2) haemodynamic, (3) thrombosis or occlusion of the revascularised carotid artery, (4) hyperperfusion, (5) cardio-embolic, (6) multiple, and (7) undetermined. RESULTS: Procedural stroke occurred within 30 days of revascularisation in 85 patients (CAS 58 out of 791 and CEA 27 out of 819). Strokes were predominately ischaemic (77; 56 CAS and 21 CEA), after the procedure (57; 37 CAS and 20 CEA), ipsilateral to the treated artery (77; 52 CAS and 25 CEA), and non-disabling (47; 36 CAS and 11 CEA). Mechanisms of stroke were carotid-embolic (14; 10 CAS and 4 CEA), haemodynamic (20; 15 CAS and 5 CEA), thrombosis or occlusion of the carotid artery (15; 11 CAS and 4 CEA), hyperperfusion (9; 3 CAS and 6 CEA), cardio-embolic (5; 2 CAS and 3 CEA) and multiple causes (3; 3 CAS). In 19 patients (14 CAS and 5 CEA) the cause of stroke remained undetermined. CONCLUSION: Although the mechanism of procedural stroke in both CAS and CEA is diverse, haemodynamic disturbance is an important mechanism. Careful attention to blood pressure control could lower the incidence of procedural stroke.

Type: Article
Title: Mechanism of procedural stroke following carotid endarterectomy or carotid artery stenting within the International Carotid Stenting Study (ICSS) randomised trial
Location: England
Open access status: An open access version is available from UCL Discovery
DOI: 10.1016/j.ejvs.2015.05.017
Publisher version: http://dx.doi.org/10.1016/j.ejvs.2015.05.017
Additional information: © 2015 The Authors. Published by Elsevier Ltd on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Keywords: Carotid artery stenting, Carotid endarterectomy, Carotid stenosis, Procedural stroke, Stroke mechanism, Angioplasty, Brain Ischemia, Carotid Stenosis, Endarterectomy, Carotid, Great Britain, Hemodynamics, Humans, Intracranial Hemorrhages, Randomized Controlled Trials as Topic, Retrospective Studies, Risk Factors, Severity of Illness Index, Stents, Stroke, Time Factors, Treatment Outcome
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > UCL Queen Square Institute of Neurology
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > Inst of Clinical Trials and Methodology
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > Inst of Clinical Trials and Methodology > MRC Clinical Trials Unit at UCL
URI: https://discovery.ucl.ac.uk/id/eprint/1473486
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