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This study from the University of Bologna, Italy examines how the presence and volume of cerebral ischemic lesions affect the outcome of carotid revascularization in patients with symptomatic stenosis. It analyzes data from a retrospective review of patients who underwent carotid revascularization between 2005 and 2014, looking at preoperative imaging and post-operative stroke occurrences. The results suggest that a CIL volume greater than 4000 mm3 is associated with a higher risk of post-operative stroke. Prospective patients with CIL volume less than 4000 mm3 may undergo revascularization with lower risk, independently of the timing of the procedure.
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Impact of Acute Cerebral Ischemic Lesions and their Volumeon the Revascularization Outcome of Symptomatic Carotid Stenosis • R Pini Vascular Surgery University of Bologna, Italy Alma Mater Studiorum
Background • Prompt carotid revascularization is recommended after neurological symptoms in order to avoid early recurrence • Type of symptoms seems to influence complication rate in this setting Alma Mater Studiorum University of Bologna, Italy
Background Summary of Evidence on EarlyCarotidIntervention for RecentlySymptomaticStenosisBased on Meta-Analysis of CurrentRisks Post-op stroke % De Rango et al, Stroke 2015 Preoperative symptoms Alma Mater Studiorum University of Bologna, Italy
Background Outcome of carotid revascularization 20% Reason for this high variability? Post-op stroke % 0% De Rango et al, Stroke 2015 Alma Mater Studiorum University of Bologna, Italy
Can the presence and volume of cerebral ischemic lesions predict the carotid revascularization otcome?
Background • The influence of cerebral lesions on revascularization outcome according to their size has not been studied effectively in the literature • Can the presence and extension of a cerebral lesion give a more accurate risk stratification? Alma Mater Studiorum University of Bologna, Italy
J Vasc Surg 2017; 65: 390-7 To evaluate the impact of cerebral lesions and their volume on carotid revascularization outcome Alma Mater Studiorum University of Bologna, Italy
Methods • Retrospective review of all patients submitted to carotid revascularization (CEA and CAS) for symptomatic carotid stenosis (2005-2014) • Evaluation of ipsilateral preoperative cerebral ischemic lesion (CIL) Alma Mater Studiorum University of Bologna, Italy
Methods Preoperative Cerebral Ischemic Lesion (CIL) • Preoperative computed tomography (CT) • Ipsilateral Embolic (Steven’s Classification) • Volume evaluation (mm3 - multi-planar evaluation) Alma Mater Studiorum University of Bologna, Italy
Volume: an easy calculation ABC/2for rapid clinical estimate of infarct, perfusion, and mismatch volumes Sims et al. Neurology 2009
Methods Exclusion Criteria • No preoperative cerebral imaging • Crescendo TIA • Stroke in evolution Alma Mater Studiorum University of Bologna, Italy
Methods Univariate analysis • χ2 • comparison of outcome in patients with and without CIL • Mann-Whitthney U test • comparison of preoperative CIL volume in patients with post-op stroke • Pearson’s correlation • correlation between CIL-volume and type and timing of carotid revascularization Alma Mater Studiorum University of Bologna, Italy
Methods Multivariate analysis • CIL-Volume cut-off multiple evaluations of values closest to the median CIL-volume • Multiple logistic regression identification of independent risk factors for stroke • ROC curve evaluation of sensibility and specificity of the volume cut-off identified Alma Mater Studiorum University of Bologna, Italy
Results Total pts # 489 (CIL # 251 - 51.4%) Alma Mater Studiorum University of Bologna, Italy
Results Epidemiology Alma Mater Studiorum University of Bologna, Italy
Results Preoperative Symptoms Alma Mater Studiorum University of Bologna, Italy
Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy
Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy
Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy
Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy
Results CIL volume evaluation Total median = 1000 mm3(IQR 7000mm3) P=.01 No events Postop stroke Alma Mater Studiorum University of Bologna, Italy
Results CIL volume evaluation P=.03 No events Postop stroke/death Alma Mater Studiorum University of Bologna, Italy
Results: CIL volume evaluation ROC curve CIL-vol>4000mm3 Area = .68 P = .02 Sensitivity = .75 Specificity = .63 Youden J statistic
Results CIL volume evaluation • CIL-volume cut-off (value of third IQR): 4000 mm3 Alma Mater Studiorum University of Bologna, Italy
Results CIL volume vs. stroke P=.01 OR: 5.1 95% CI: 1.3-19.5 % Alma Mater Studiorum University of Bologna, Italy
Results Multivariate analysis for risk of stroke Alma Mater Studiorum University of Bologna, Italy
Literature review: CIL effect on carotid revascularization
Literature review: CIL effect on carotid revascularization No studies on the volume of cerebral ischemic lesions
Conclusions • The presence of Ischemic Cerebral Lesion(CIL) does not affect CEA/CAS outcomes • CIL volume >4000 mm3, higher post-operative stroke risk
Conclusions The cerebral damage needs to be investigated for the carotid revascularization for risk stratification
Prospective Patient with CIL< 4000 mm3 can be revascularized without significant higher perioperative risk
Implications ABCD2 score CIL> 4000 mm3 higher risk(9%) independently from timing High risk stenosis (ABCD2-score): Early revascularization? Low risk stenosis: Wait and see?
