Impact of acute cerebral ischemic lesions and their volume on the revascularization outcome of symptomatic carotid stenosis

Abstract

Background: The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients.

Methods: All patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm³ and correlated with 30-day rates of stroke and stroke/death by χ², multivariate analysis, Pearson correlation, and receiver operating characteristic curves.

Results: A total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm³ (interquartile range [IQR], 7000 mm³). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm³ (IQR, 31,000 mm³) vs 1000 mm³ (IQR, 7000 mm³; P = .01) and 4500 mm³ (IQR, 17,450 mm³) vs 1000 mm³ (IQR, 7000 mm³; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm³ was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm³ was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of <4000 mm³ (odds ratio, 4.6; 95% confidence interval, 1.1-19.1; P = .03).

Conclusions: CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm³ could be considered a significant predictor for postoperative stroke after carotid revascularization.