Number Of New Ischemic Lesions Research Articles

Meta-Analysis of Usefulness of Cerebral Embolic Protection During Transcatheter Aortic Valve Implantation

One of the most feared complications of transcatheter aortic valve implantation (TAVI) is stroke, with increased mortality and disability observed in patients suffering a stroke after TAVI. There has been no significant decline in stroke rates seen over the last 5 years; attention has therefore been given to strategies for cerebral embolic protection. With the emergence of new randomized trial data, we sought to perform an updated systematic review and meta-analysis to examine the effect of cerebral embolic protection during TAVI both on clinical outcomes and on neuroimaging parameters. We performed a random-effects meta-analysis of randomized clinical trials of cerebral embolic protection during TAVI. The primary end point was the risk of stroke. The risk of stroke was not significantly different with the use of cerebral embolic protection: relative risk (RR) 0.88, 95% confidence interval (CI) 0.57 to 1.36, p = 0.566. Nor was there a significant reduction in the risk of disabling stroke, non-disabling stroke or death. There was no significant difference in total lesion volume on MRI with cerebral embolic protection: mean difference -74.94, 95% CI -174.31 to 24.4, p = 0.139. There was also not a significant difference in the number of new ischemic lesions on MRI: mean difference -2.15, 95% -5.25 to 0.96, p = 0.176, although there was significant heterogeneity for the neuroimaging outcomes. In conclusion, cerebral embolic protection during TAVI is safe but there is no evidence of a statistically significant benefit on clinical outcomes or neuroimaging parameters.

Impact of additional resection on new ischemic lesions and their clinical relevance after intraoperative 3 Tesla MRI in neuro-oncological surgery

Intraoperative MRI (ioMRI) has become a frequently used tool to improve maximum safe resection in brain tumor surgery. The usability of intraoperatively acquired diffusion-weighted imaging sequences to predict the extent and clinical relevance of new infarcts has not yet been studied. Furthermore, the question of whether more aggressive surgery after ioMRI leads to more or larger infarcts is of crucial interest for the surgeons’ operative strategy. Retrospective single-center analysis of a prospective registry of procedures from 2013 to 2019 with ioMRI was used. Infarct volumes in ioMRI/poMRI, lesion localization, mRS, and NIHSS were analyzed for each case. A total of 177 individual operations (60% male, mean age 45.5 years old) met the inclusion criteria. In 61% of the procedures, additional resection was performed after ioMRI, which resulted in a significantly higher number of new ischemic lesions postoperatively (p < .001). The development of new or enlarged ischemic areas upon additional resection could also be shown volumetrically (mean volume in ioMRI 0.39 cm3 vs. poMRI 2.97 cm3; p < .001). Despite the surgically induced new infarcts, mRS and NIHSS did not worsen significantly in cases with additional resection. Additionally, new perilesional ischemia in eloquently located tumors was not associated with an impaired neurological outcome. Additional resection after ioMRI leads to new or enlarged ischemic areas. However, these new infarcts do not necessarily result in an impaired neurological outcome, even when in eloquent brain areas.

Comparison of Embolic Protection with Proximal and Distal Protection Devices: Periprocedural Complications, Clinical Outcomes, and Cerebral Embolic Lesions on Diffusion-Weighted Magnetic Resonance Imaging

Two main types of embolic protection devices have been used during carotid artery stenting (CAS): distal protection devices (DPDs) and proximal protection devices (PPDs). We compared the complications, clinical outcomes, and new ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI) studies between patients who had undergone CAS using a DPD or PPD. We performed a retrospective review of the data from patients who had undergone CAS from March 2010 to January 2016. The periprocedural and 30-day adverse events and new ischemic lesions on DWI studies after CAS were evaluated. CAS was performed in 103 patients (DPD, n=60; PPD, n= 43). The number of patients with new ischemic lesions was greater in the DPD than in the PPD group (78% vs. 56%; P= 0.014). Most lesions (>90%) were tiny (≤3 mm), and the average number of new tiny lesions per patient was significantly greater in the DPD than in the PPD group (mean, 9.6 vs. 4.0; P= 0.008). No significant differences in the periprocedural or 30-day adverse rates were noted between the 2 groups. Intolerance during the procedure occurred in 5 patients (12%) in the PPD group, 4of whom had poor collateral circulation. The number of new ischemic lesions per patient and the incidence of ischemic lesions found on DWI were significantly greater in the DPD than in the PPD group. The lack of differences in the periprocedural and 30-day adverse rates between the 2 groups suggests that cerebral microemboli might not be associated with the clinical outcomes. For patients with poor collateral status, DPDs should be used preferentially to avoid the neurologic compromise associated with PPDs.

Complications and Predictors of Hypotension Requiring Vasopressor after Carotid Artery Stenting

A significant controversy exists regarding the clinical impact of hemodynamic depression on major adverse events after carotid artery stenting (CAS). The purpose of this study was to evaluate the incidence, predictors, and clinical significance of hypotension after CAS. A total of 118 cases of carotid artery stenosis were treated with CAS. Hypotension was defined as sustained systolic blood pressure <80 mmHg and requiring intravenous administration of vasopressor to maintain adequate systolic blood pressure after the procedure. Baseline characteristics, procedural characteristics, and periprocedural major adverse events were retrospectively compared between postprocedural hypotension group and non-hypotension group. Morphological and procedural characteristics were not significantly different between the two groups. Periprocedural major adverse events, presence of new ischemic lesions, and number of new ischemic lesions were not significantly different between the two groups (P = 1, P = 0.36, P = 0.68). Hypertension was an independent protective factor (P = 0.037), and use of proximal protection and the distance from carotid bifurcation to maximum stenotic lesion ≤ 10 mm were independent risk factors for developing hypotension after CAS (P = 0.034, P = 0.027). There was no significant relationship between hypotension after CAS and major adverse events in this study. Maintenance of periprocedural adequate cerebral perfusion is thought to be important to prevent ischemic complications due to hypotension after CAS, especially in these cases.

TCT-658 Neurologic Outcomes with Embolic Protection Devices in Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Clinical or subclinical cerebral embolization is a relatively frequent complication of transcatheter aortic valve replacement (TAVR). Randomized controlled trials (RCTs) investigating the efficacy of embolic protection devices during TAVR were relatively underpowered to detect meaningful differences in imaging and clinical endpoints. Methods: We performed a systematic review and study-level meta-analysis of RCTs that tested the efficacy and safety of EP during TAVR. RCTs using any type of EP and TAVR vascular access were included. Primary imaging efficacy endpoints were total lesion volume (TLV; in mm 3 ) and number of new ischemic lesions. Primary clinical efficacy endpoints were any deterioration in National Institute of Health Stroke Scale (NIHSS) and Montreal Cognitive Assessment (MoCA) score at hospital discharge. Primary analyses were performed with the intention-to-treat approach. Results: A total of 4 RCTs (total n=252) have been included. Use of EP was associated with lower TLV (Figure; standardized mean difference [SMD]: -0.65; 95% confidence interval [CI]: -1.06 to -0.25; p=0.002) and lower number of new ischemic lesions (Figure; SMD: -1.27; 95% CI: -2.45 to -0.09; p = 0.03). EP was associated with a trend to lower risk of deterioration in NIHSS at discharge (RR: 0.55; 95% CI: 0.27 to 1.09; p=0.09) and higher MoCA score (SMD: +0.40; 95% CI: +0.04 to +0.76; p = 0.03). Risk of overt stroke and all-cause mortality were non-significantly lower in the EP group. Conclusions: Use of EP seems to be associated with a reduction of imaging markers of cerebral infarction and early clinical neurologic effectiveness in patients undergoing TAVR. Key Words: TAVR; Embolic Protection; Stroke.

Subclinical ischemic events in patients undergoing carotid artery stent placement: comparison of proximal and distal protection techniques

ObjectiveTo determine the relative effectiveness of proximal and distal protection in prevention of cerebral ischemic events during carotid artery stent (CAS) placement using diffusion-weighted MRI (DW-MRI).MethodsWe analyzed data from patients...

Neurological Outcomes With Embolic Protection Devices in Patients Undergoing Transcatheter Aortic Valve Replacement

The aim of this study was to investigate the efficacy and safety of intraprocedural embolic protection (EP) during transcatheter aortic valve replacement (TAVR). Randomized controlled trials (RCTs) investigating the efficacy of EP devices during TAVR were relatively underpowered. A systematic review and study-level meta-analysis was performed of randomized controlled trials that tested the efficacy and safety of EP during TAVR. Trials using any type of EP and TAVR vascular access were included. Primary imaging efficacy endpoints were total lesion volume and number of new ischemic lesions. Primary clinical efficacy endpoints were any deterioration in National Institutes of Health Stroke Scale and Montreal Cognitive Assessment scores at hospital discharge. Primary analyses were performed using the intention-to-treat approach. Four randomized clinical trials (total n= 252) were included. Use of EP was associated with lower total lesion volume (standardized mean difference-0.65; 95% confidence interval [CI]:-1.06 to-0.25; p= 0.002) and smaller number of new ischemic lesions (standardized mean difference-1.27; 95% CI:-2.45 to-0.09; p= 0.03). EP was associated with a trend toward lower risk for deterioration in National Institutes of Health Stroke Scale score at discharge (risk ratio: 0.55; 95% CI: 0.27 to 1.09; p= 0.09) and higher Montreal Cognitive Assessment score (standardized mean difference 0.40; 95% CI: 0.04 to 0.76; p= 0.03). Risk for overt stroke and all-cause mortality were nonsignificantly lower in the EP group. Use of EP seems to be associated with reductions in imaging markers of cerebral infarction and early clinical neurological effectiveness in patients undergoing TAVR.

Periprocedural Hemodynamic Depression Is Associated With a Higher Number of New Ischemic Brain Lesions After Stenting in the International Carotid Stenting Study-MRI Substudy

Carotid artery stenting (CAS) is associated with a higher risk of both hemodynamic depression and new ischemic brain lesions on diffusion-weighted imaging than carotid endarterectomy (CEA). We assessed whether the occurrence of hemodynamic depression is associated with these lesions in patients with symptomatic carotid stenosis treated by CAS or CEA in the randomized International Carotid Stenting Study (ICSS)-MRI substudy. The number and total volume of new ischemic lesions on diffusion-weighted imaging 1 to 3 days after CAS or CEA was measured in the ICSS-MRI substudy. Hemodynamic depression was defined as periprocedural bradycardia, asystole, or hypotension requiring treatment. The number of new ischemic lesions was the primary outcome measure. We calculated risk ratios and 95% confidence intervals per treatment with Poisson regression comparing the number of lesions in patients with or without hemodynamic depression. A total of 229 patients were included (122 allocated CAS; 107 CEA). After CAS, patients with hemodynamic depression had a mean of 13 new diffusion-weighted imaging lesions, compared with a mean of 4 in those without hemodynamic depression (risk ratio, 3.36; 95% confidence interval, 1.73-6.50). The number of lesions after CEA was too small for reliable analysis. Lesion volumes did not differ between patients with or without hemodynamic depression. In patients treated by CAS, periprocedural hemodynamic depression is associated with an excess of new ischemic lesions on diffusion-weighted imaging. The findings support the hypothesis that hypoperfusion increases the susceptibility of the brain to embolism. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN25337470.

Intravenous Versus Enteral Nimodipine in Aneurysmal Subarachnoid Hemorrhage: Is There an Advantage?

T p l t n d l s i g t d a f w w t d 9 t i s S oppi et al. from Kuopio University Hospital have conducted a randomized trial comparing the efficacy of standard enteral nimodipine versus intravenous nimodipine in patients with neurysmal subarachnoid hemorrhage (SAH). One hundred seventyne patients with acute aneurysmal SAH were randomized to eceive either enteral (n 84) or intravenous (n 87) nimodipine. he incidence of delayed ischemic neurologic deficit (DIND) was imilar between groups (20% vs. 16% in the enteral and intraenous nimodipine groups, respectively, P 0.61). In addition, he number of new ischemic lesions on magnetic resonance maging (MRI) conducted 12 months after the hemorrhage emonstrated no significant differences (34% in both groups, 0.99). Similarly, clinical outcomes assessed at 12 months sing the Glasgow outcome scale, modified Rankin scale, Karofsky scale, and the 15D questionnaire (to evaluate healthelated quality of life) were also similar between the groups.

Microemboli during carotid angiography. Association with stroke risk factors or subsequent magnetic resonance imaging changes?

Carotid angiography is associated with a 1% risk of major stroke. Recently, transcranial Doppler ultrasonography (TCD) has shown cerebral microemboli during carotid angiography. To determine their significance, we correlated the number of microemboli during angiography with clinical characteristics, angiography findings, and preangiography and postangiography cerebral magnetic resonance imaging (MRI). One middle cerebral artery was monitored with TCD in 24 patients during angiography for carotid territory ischemia. The number of microemboli was correlated with angiographic and clinical characteristics. T2-weighted cerebral MRI was performed before and < or = 48 hours after angiography, and the number of new ischemic lesions was determined in a blinded review. Microemboli were seen in all patients, with an average of 51 per procedure (range, 12 to 154). The majority of microemboli had signal characteristics typical of air. Sixteen of the 24 patients had both preangiography and postangiography MRI. One of 24 patients had an angiographic stroke, with a single new thalamic lesion on MRI. No other patient had a new lesion. The microembolus count correlated with the angiographic contrast volume (P < .001) but not with any other radiological or clinical characteristic. This study confirmed the presence of numerous cerebral microemboli during carotid angiography. The microembolic signal characteristics and the correlation with contrast volume indicate that introduced air is the cause. These microemboli are usually clinically silent and do not lead to new changes on cerebral MRI.