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DWMRI In Carotid Artery Interventions

DWMRI In Carotid Artery Interventions. Dr Sumaira Macdonald MBChB (Comm.), FRCP, FRCR, PhD, EBIR Consultant Vascular Radiologist & Honorary Clinical Senior Lecturer, Freeman Hospital, Newcastle, UK. CX 2013. How Does The Microembolic Burden of CAS

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DWMRI In Carotid Artery Interventions

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  1. DWMRI In Carotid Artery Interventions DrSumaira MacdonaldMBChB (Comm.), FRCP, FRCR, PhD, EBIR Consultant Vascular Radiologist & Honorary Clinical Senior Lecturer, Freeman Hospital, Newcastle, UK CX 2013

  2. How Does The Microembolic Burden of CAS (Assessed on DWI brain & TCD) Compare With “ The Gold Standard ”: CEA ?

  3. The Arch Is A Hostile Territory: CEA vs filter p = 0.001 CEA vs flow reversal p = 0.007 Flow reversal vs filter p = 0.053 N = 42 Gupta N et al. JVS. 2011;53:316-322

  4. FILTERS:

  5. Randomised Trials: Filter-Protected Vs. Unprotected CAS (Differences in microembolisation)

  6. Randomised Trial: MES on TCD Macdonald S et al Cerebrovasc Dis 2010;29:282-289.

  7. Randomised Trial - DWI Procedural new white lesions (new lesions at 1-3 hours plus 24 hours) Macdonald S et al Cerebrovasc Dis 2010;29:282-289.

  8. Randomised Trial (US): DWI Results Filter-Protected vs. Unprotected CAS Barbato J et al. JVS 2008;47:760-765

  9. Sample Size For An Adequately Powered DWI study “…120-140 patients would be needed...” Kastrup A et al. Incidence of New Brain Lesions After Carotid Stenting With And Without Cerebral Protection. Stroke 2006;37:2312-2316

  10. Relative Incidence DWMRI Lesions: CEA, Unprotected CAS & Filter - Protected Transfemoral CAS

  11. Systematic Review: 32 studies N = 1363 CAS (37% new lesion rate) p < O.O1 N = 754 CEA (10% new lesion rate) Multiple confounders….. Schnaudigel S et al Stroke 2008;39:1911-1919

  12. ICSS Primary Analysis CEA Vs. CAS in 1713 symptomatic patients ICSS Substudy: N = 231 New white lesions on DWI 62 of 124 (50%) transfemoral distal filter CAS 18 of 107 (17%) CEA (OR 5.21, 2.78-9.79; p < 0.0001) Lancet Neurol. 2010 Apr;9(4):353-62

  13. ICSS Substudy: N = 231 2/7 centres performed unprotected CAS * 5/7 centres performed filter-protected CAS *TransfemoralDistal - Filter Type EPD

  14. ICSS Substudy: N = 231 Lesion Volumes: Individual lesion volume significantly smaller for CAS vs. CEA (p < 0.001) Total lesion volume: Not significantly different (p = 0.18) Hensicke G et al Stroke 2013;44: 80 -86

  15. Influence of EPD Strategy On DWMRI Findings

  16. Proximal Protection 1: Randomized Trial: Filter- Protected Vs. MoMa

  17. Montorsi P et al. JACC 2011; 58: 1656-1663

  18. MO.MA Vs. Filters (DWMRI) p NS* *Insufficient power

  19. N = 62 Bijuklic K et al. JACC Epub 2012 Jan 19th

  20. PROXIMAL PROTECTION 2: Transcervical Access with High Flow Rate Flow Reversal (Silk Road Michi NPS)

  21. Michi System FAST-CAS

  22. PROOF DWI Sub Study • Baseline scan within 72 hours • Post-procedure scan within 12-48 hours • Submitted to core laboratory for blinded evaluation by two independent neuroradiologists

  23. 1 Lancet Neurol. 2010 Apr;9(4):353-62 2. J Am Coll Cardiol. 2012;59:1383-1389 3. JVS 2011;54:1317-1323 4. JVS 2012 ;56:1585-1590

  24. Clinical Relevance: Cognitive Function: A Dark Art ?

  25. N = 32 studies (25 CEA, 4 CAS) “ No consistent findings…” “ Assessment of cognition after carotid revascularisation is probably influenced by many confounding factors such as learning effect, type of test, type of patients, & control group ” De Rango P et al. Stroke 2008;39:3116 - 3127

  26. An ICSS Sub-Study: N = 177 patients recruited in two Dutch centres N = 140 Cognitive Function Assessment at baseline N = 120 Cognitive Function Assessment at 6/12 10 Domains including executive function Altinbas A et al Neurology 2011;77:1084 - 1090

  27. The Authors’ Conclusions: “ The findings support the assumptions that new brain lesions, as detected by DWI after CAS or CEA do not affect cognitive performance in a manner that is long-lasting or clinically relevant ” “ Despite the higher embolic load detected by DWI, CAS is not associated with greater cognitive decline than CEA ”

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