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Differences between CAS and CEA in the pathophysiological mechanism of procedural stroke

Differences between CAS and CEA in the pathophysiological mechanism of procedural stroke. GJ de Borst Department of Vascular Surgery. Background. Most data on CAS vs CEA focused on clinical outcomes

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Differences between CAS and CEA in the pathophysiological mechanism of procedural stroke

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  1. Differencesbetween CAS and CEA in the pathophysiologicalmechanism of proceduralstroke GJ de Borst Department of Vascular Surgery

  2. Background • Most data on CAS vs CEA focused on clinical outcomes • Few data characterizing the strokes that occur during carotid revascularization (and especially CAS) • Thus limiting understanding the potential mechanisms of procedural stroke … Fairman R, et al Ann Surg 2007 / de Borst et al EJVES 2001

  3. Micro-embolisation harmless ??

  4. Timing of procedural stroke Intra-operative stroke: 1) apparent at awakening 2) intra-procedural symptoms (in the awake patient) Post-operative stroke: 1) Symptom free interval between awakening and start of symptoms 2) Symptom free interval between procedure and start of symptoms

  5. Etiology (1) Intra-operativestroke • Embolisation • spontaneous (instable plaque) • Dissectionphase • Shunt insertion • Air embolisation (shunt dysfunction) • Embolisationendarterectomized zone • Thrombosis • Peri shunt thrombosis • Ontablecarotidthrombosis • Other • Unstablehaemodynamics (no shunt, uncontrolledhypotension). • Haemodynamicfailure: shunt dysfunction

  6. Etiology(2) Post-operativestroke • Embolisation • Embolisationfromendarterectomized zone • Embolisationfromexternalcarotidartery • Thrombosis • Secundary to technicalfailure • Secundary to hypotension • Secundary to carotidsiphonpathology • Secundary to disturbedhaemostasis • Other • Primaryintracerebralbleeding • Haemorrhagictransformation of ischemiccerebralinfarction • Hyperperfusionsyndrome

  7. Clinical outcome following CEA (1) Minor, major stroke, and death within 7 days • Up to 1990 (only EEG) : 4.8% intra operative ?? % post operative • from 1990 (EEG + TCD) : 1.0% intra operative 2.4% post operative de Borst GJ et al. Eur J Vasc Endovasc Surg. 2001.

  8. Clinical outcome following CEA (2) • ….. - 1992 Intra Operative Stroke (IOS) 4% • 1992 – 1994 TCD / angioscopy / routine shunting • IOS 1% • POS ? • 1994 – 1996 Intimal flap correction, thrombus removal • IOS 0% • POS 2.8% Lennard N et al. EJVES 1999 Naylor AR et al. J Vasc Surg 2000

  9. Goal ? Descriptors of stroke severity, location, and timing may provide insight into the mechanistic causes : • Major vs minor • Ipsilateral vs contralateral • Ischemic vs haemorrhagic • Intra-procedural vs post procedural • Pre-discharge vs post-discharge

  10. Goal ? Based on : intraoperative cerebral monitoring, postop cerebral monitoring, blood pressure data, angiography related events, postop imaging (treated area still patent ?), or re-exploration: • Most probable mechanism of stroke ? Potential problem: no standardized assessment of patients with procedural stroke……..

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