Diffusion weight magnetic resonance imaging analisys with rapid software appication in symptomatic carotid stenosis revascularization

Abstract

Abstract Objectives The aim of this study was to evaluate whether the extension of preoperative neuroradiological lesions assessed by magnetic resonance imaging (MRI) with Diffusion Weighted sequences (DWI) and Rapid processing of Perfusion and Diffusion software are potentially related to post-operative neurological outcome in patients with symptomatic carotid stenosis (SCS) treated by carotid endarterectomy (CEA). Methods From January 2010 to June 2020, data from 134 consecutive patients affected by SCS, presenting with transient ischemic attack (TIA), and minor or moderate stroke, and submitted to urgent CEA in a single academic center, were prospectively collected and reviewed. All SCS patients underwent independent neurological evaluation, duplex ultrasound scan, computed tomographic angiography, and DW-MRI with RAPID evaluation. RAPID evaluation was performed to assess the volume of acute ischemic brain lesion (IBL); through this method it is possible to obtain the identification of the ischemic core milliliters (mL). According with clinical presentation, and imaging studies analysis CEA endarterectomies were performed within 48 hours, within 14 days or after 14 days from symptoms onset. Outcomes for presented analysis were the post-operative new neurological event, and deathat follow-up. Timing of CEA and IBL volume at RAPID evaluation were considered as risk factor potentially influencing outcomes. Results Among all the 134 enrolled patients, 68 patients (50.7%) presented with TIA, 49 (36.6%) with a minor Stroke, and 17 (12.7%) with a moderate Stroke. No intraoperative death occurred in any group. Overall, 6 (4.4%) new neurological events were noted in this series, 1 minor stroke (0.7%), and 5 TIAs (3.7%). One-hundred-fifteen (86%) underwent surgery within 14 days from neurological symptoms onset (Urgent patients – U), and 19 (14%) after 14 days (Delayed patients – D); U patients were also divided in two subgroups U1 47/115 patients (35%) submitted to CEA within 48 hours from symptoms onset, and U2 68/115 patients (51%) after 48 hours. No neurological complications were noted in group D, while 5 new adverse events occurred in U1, and 1 in U2 (p=0.01). Results from MRI with DWI sequences performed in 100/134 patients (74.6%) showed positive preoperative diffusion in 62 patients. The RAPID processing ascribed a 0 value, for punctiform lesions, and a value from 2 to 77 ml for single acute lesions; average volume lesion volume was 8.6 mL. Patients were then divided into two groups according to IBL volume: 84 <10 ml, and 16≥10 mL. Incidence of new neurological events was significantly higher in >10ml group (18.7% vs 3.6%; p=0.02). Conclusion Our experience seems to suggest that the optimal time for SCS revascularization is between 48 hours and 14 days. Moreover, IBL volume >10ml might greatly increase risk of postoperative adverse events occurrence. Funding Acknowledgement Type of funding sources: None.