Prediction of cerebral ischemia during carotid stenting depending on the intensity of the preoperative ultrasound signal from the plaque

Carotid stenting is an effective method for improving cerebral perfusion; risk assessment of cerebral embolism associated with this intervention remains a hot research topic.
Objective: to identify predictors of cerebral embolism associated with carotid angioplasty with stenting (CAS).
Material and methods. A prospective exploratory research included 46 patients (age from 44 to 81 years, median 65 years) with atherosclerotic stenosis of the internal carotid artery, who underwent CAS and were treated at the Scientific Center of Neurology (Moscow). The study did not include patients with restenosis, stroke with severe disability, contraindications for antiplatelet therapy, statins, and MRI examination. All patients underwent preoperative ultrasonographic (US) examination and postoperative histological examination of particles in carotid stent embolic protection devices. The state of the brain was assessed before and 24 hours after CAS using diffusion-weighted MRI. To identify predictors of the development of cerebral embolism, the clinical characteristics of patients, together with ultrasonographic and morphological data, were examined in a multivariate statistical analysis.
Results. Preoperative US signal from an atherosclerotic plaque of high (estimated above 35 dB) intensity was associated with dense matter (in a protective device) of the "fibrosis with calcification" and "calcification" type and with a high probability (80%; 95% confidence interval 71–85% ) predicted intraoperative embolization of cerebral vessels with the acute ischemic lesions (AIL) formation. In a low (not higher than 35 dB) intensity of the preoperative ultrasound signal, the probability of AIL formation was statistically significantly lower (50%).
Conclusion. There is a direct correlation between the intensity of the ultrasound signal and the density of the substance in the protective device. A high intensity of the preoperative ultrasound signal (estimated above 35 dB) is an unfavorable predictor of AIL, associated with CAS (with a probability of about 80%).

1. Alekian BG, Pokrovskiy AV, Karapetian NG, Revishvili ASh. Modern trends in development of surgical and endovascular treatment of patients with arterial pathology. Angiologiya i sosudistaya khirurgiya. 2019;25(4):55-63. doi: 10.33529/ANGIO2019401 (In Russ.).

2. Medvedev RB, Tanashyan MM, Kuntsevich GI, et al. Ischaemic lesions of cerebral after carotid stenting. Angiologiya i sosudistaya khirurgiya. 2015;21(1):65-71 (In Russ.).

3. Yoshimura S, Yamada K, Kawasaki M, et al. High-intensity signal on time-of-flight magnetic resonance angiography indicates carotid plaques at high risk for cerebral embolism during stenting. Stroke. 2011;42(11):3132-7. doi: 10.1161/STROKEAHA.111.615708

4. Yuan C, Mitsumori LM, Ferguson MS, et al. In vivo accuracy of multispectral magnetic resonance imaging for identifying lipid-rich necrotic cores and intraplaque hemorrhage in advanced human carotid plaques. Circulation. 2001;104(17):2051-6. doi: 10.1161/hc4201.097839

5. Matsukawa H, Fujii M, Uemura A, et al. Pathology of embolic debris in carotid artery stenting. Acta Neurol Scand. 2015;131(4):197-202. doi: 10.1111/ane.12303

6. Gulevskaya TS, Anufriev PL, Tanashyan ММ. Morphology and pathogenesis of white matter changes in chronic cerebrovascular disease. Annaly klinicheskoy i eksperimental'noy nevrologii = Annals of Clinical and Experimental Neurology. 2022;16(2):78-88. doi: 10.54101/ACEN.2022.2.9 (In Russ.).

7. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998;339(20):1415-25. doi: 10.1056/NEJM199811123392002

8. Goessens BM, Visseren FL, Kappelle LJ, et al. Asymptomatic carotid artery stenosis and the risk of new vascular events in patients with manifest arterial disease: the SMART study. Stroke. 2007 May;38(5):1470-5. doi: 10.1161/STROKEAHA.106.477091. Epub 2007 Mar 15.

9. Medvedev RB, Tanashyan MM, Skrylev SI, et al. Relation between ultrasonographic and morphological characteristics of atherosclerotic plaques of carotid sinus. Angiologiya i sosudistaya khirurgiya. 2018;24(4):43-8 (In Russ.).

10. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy (SAPPHIRE) in high-risk patients. N Engl J Med. 2008 Apr 10;358(15):1572-9. doi: 10.1056/NEJMoa0708028

11. Biller J, Love BB, Marsh EE, et al. Spontaneous improvement after acute ischemic stroke. A pilot study. Stroke. 1990;21(7):1008-12. doi: 10.1161/01.str.21.7.1008

12. Brott T, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20(7):864-70. doi: 10.1161/01.str.20.7.864

13. Fairman R, Gray WA, Scicli AP, et al; CAPTURE Trial Collaborators. The CAPTURE registry: analysis of strokes resulting from carotid artery stenting in the post approval setting: timing, location, severity, and type. Ann Surg. 2007 Oct;246(4):551-6; discussion 556-8. doi: 10.1097/SLA.0b013e3181567a39

14. Tanashian MM, Medvedev RB, Evdokimenko AN, et al. Prediction of ischaemic lesions of the brain in reconstructive operations on internal carotid arteries. Angiologiya i sosudistaya khirurgiya. 2017;23(1):59-66 (In Russ.).

15. Theron JG, Payelle GG, Coskun O, et al. Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. Radiology. 1996 Dec;201(3):627-36. doi: 10.1148/radiology.201.3.8939208

16. Angelini A, Reimers B, Della Barbera M, et al. Cerebral protection during carotid artery stenting: collection and histopathologic analysis of embolized debris. Stroke. 2002 Feb;33(2):456-61. doi: 10.1161/hs0202.102337

17. Martin JB, Pache JC, Treggiari-Venzi M, et al. Role of the distal balloon protection technique in the prevention of cerebral embolic events during carotid stent placement. Stroke. 2001 Feb;32(2):479-84. doi: 10.1161/01.str.32.2.479

18. Altaf N, MacSweeney ST, Gladman J, Auer DP. Carotid intraplaque hemorrhage predicts recurrent symptoms in patients with high-grade carotid stenosis. Stroke. 2007 May;38(5):1633-5. doi: 10.1161/STROKEAHA.106.473066. Epub 2007 Mar 22.

19. Yamada K, Yoshimura S, Kawasaki M, et al. Embolic complications after carotid artery stenting or carotid endarterectomy are associated with tissue characteristics of carotid plaques evaluated by magnetic resonance imaging. Atherosclerosis. 2011 Apr;215(2):399-404. doi: 10.1016/j.atherosclerosis.2011.01.002. Epub 2011 Jan 19.

20. Van Laanen JH, Hendriks JM, Verhagen HJ, van Beusekom HM. Quantity, particle size, and histologic composition of embolic debris collected in a distal protection filter after carotid angioplasty and stenting: Correlation with patient characteristics, timing of carotid artery stenting, and procedural details. J Thorac Cardiovasc Surg. 2013 Aug;146(2):492-5. doi: 10.1016/j.jtcvs.2013.03.024. Epub 2013 Apr 12.

21. Sorimachi T, Kakita A, Morita K, et al. Routine aspiration method during filter-protected carotid stenting: histological evaluation of captured debris and predictors for debris amount. Acta Neurochir (Wien). 2011 Nov;153(11):2159-67. doi: 10.1007/s00701-011-1093-3. Epub 2011 Jul 31.

22. Sorimachi T, Nishino K, Morita K, et al. Blood flow changes caused by distal filter protection and catheter aspiration in the internal carotid artery during carotid stenting: evaluation using carotid Doppler sonography. AJNR Am J Neuroradiol. 2011 Feb;32(2):288-93. doi: 10.3174/ajnr.A2276. Epub 2010 Nov 4.

23. Sorimachi T, Nishino K, Shimbo J, et al. Routine use of debris aspiration before retrieval of distal filter protection devices in carotid arterial stenting: analysis of captured debris and evaluation of clinical results. Neurosurgery. 2010 Nov;67(5):1260-7; discussion 1267. doi: 10.1227/NEU.0b013e3181ef5e85

24. Finol EA, Siewiorek GM, Scotti CM, et al. Wall apposition assessment and performance comparison of distal protection filters. J Endovasc Ther. 2008 Apr;15(2):177-85. doi: 10.1583/07-2272.1

25. Maleux G, Demaerel P, Verbeken E, et al. Cerebral ischemia after filter-protected carotid artery stenting is common and cannot be predicted by the presence of substantial amount of debris captured by the filter device. AJNR Am J Neuroradiol. 2006 Oct;27(9):1830-3.

26. Faggioli G, Ferri M, Rapezzi C, et al. Atherosclerotic aortic lesions increase the risk of cerebral embolism during carotid stenting in patients with complex aortic arch anatomy. J Vasc Surg. 2009 Jan;49(1):80-5. doi: 10.1016/j.jvs.2008.08.014. Epub 2008 Oct 22.

27. Macdonald S, Evans DH, Griffiths PD, et al. Filter-protected versus unprotected carotid artery stenting: a randomised trial. Cerebrovasc Dis. 2010 Feb;29(3):282-9. doi: 10.1159/000275505. Epub 2010 Jan 15.