Reperfusion Injury After Carotid Stenting

Neurological complications, cognitive
dysfunction and cognitive improvement after CAS
Iris Quasar Grunwald,Wolfgang Reith,
Dept. for Interventional and Diagnostic Neuroradiology
University Clinic of the Saarland
Homburg/Saar
Germany
Complications after CAS
neurological complications
•
•
•
•
•
•
TIA
minor stroke
major stroke
Reperfusion/Hyperperfusion syndrome
ICH
death
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•
acute stent thrombosis
dissection
local problems
other
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•
•
•
groin hematoma, aneurysma spurium, AV fistula,
allergic reaction
nephropathy
hyperthyreosis
USA Carotid Stenting Studies
30-Day Composite Endpoint
Patients (%)
7.8%
5.2%
7.2%
5.8%
5.8%
3.8%
CABERNET
N=454
MAVErIC
N=52
BEACH
N=747
ARCHeR2
N=278
SAPPHIRE
SECuRITY
N=305
Reperfusion Injury After Carotid Stenting
„Reperfusion injury“ (RPI) or „cerebral hyperperfusion Syndrom“
after Carotid OP or Stent is a well known phenomena.
Causes:
- Failure of autoregulation of the cerebral vessels
- Vessels previously perfused with low pressure
- sudden increase of perfusion pressure
=> No compensation of this sudden change in pressure
Spetzler R F: Normal perfusion-pressure breakthrough theory, Clin Neurosurg 25: 651-672, 1978
Sundt T M: The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid
Endarterectomy, STROKE 14: 93-98, 1983
Clinical symptoms:
Reperfusion injury
• ipsilateral headache, nausea, vomiting
• focal seizures
• focal neurologic symptoms
• focal or parenchymal bleeding, or subarachnoid and /or subdural/-pial
Literature
• no ischemia
• onset of symptoms: hours to days after Carotid TEA/stent
• Incidence: up to 1 to 2%
• Risikfactor: Hypertension post OP/Stent
Abou-Chebl A: Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting, Risk factors,
prevention and treatment, J Am Coll Cardiol 43 (9): 1596-1601, 2004
Results
Homburg patients:
7/2000 bis 12/2006: 340 Carotid stent procedures with DWI after CAS
Mean age: 67.6 years, 21% female, 79% male
62.6% symp, 37.4% asymptomatic
Degree of stenosis: mean 84%
MRT: T2, FLAIR, DWI, PWI within 24 hours after stent
Anticoagulation: ASS, Plavix, Heparin
Clinical examination: Neurology
Reperfusion injury after Carotid Stenting
Homburg patients:
Perfusion MRI: using MedX
bolus tracking, 0,2 mmol/kg KG, T2* gradient echo
percentage change right to left hemisphere: TTP, MTT, CBV, CBF
Results
340 Stent procedures were evaluated
Î9 patients with reperfusion injury (9/340) (2.6%)
Î7 symptomatic and 2 asymptomatic stenoses
Reperfusion injury after Carotid Stenting
Case 1:
Patient M.SCH., 75 y, stenosis of the left ICA 90% 50 % on the right ICA
Symptoms with frequent TIA`S, no infarction on MRI
10 hours after the stent procedure: acute hemiplegia, aphasia, no hypertonus
Î ICB
Reperfusion injury after Carotid Stenting
case 2:
Patient E.E., 63 years, stenosis of the ICA 95%, asymptomatic
pre
24 h
5d
24 h
12 hours after the stent procedure dizziness
Reperfusion injury after Carotid Stenting
case 2:
Patient E.E., 63 years, stenosis of the ICA 95%, asymptomatic
pre
pre
Pre-stent:
post
post
TTP within the media and anterior circulation with slight delay (3 s Differenz
MTT, CBV, CBF identical
After-stent: TTP, MTT, CBV, CBF identical
Reperfusion injury after Carotid Stenting
case 4:
patient H. B., female, 80 years, 99% stenosis of the right ICA,
Clinical symptoms: TIA
24 h
before and
72 h
after the stent procedure headache
Reperfusion injury after Carotid Stenting
case 4:
patient H. B., female, 80 years, 99% stenosis of the right ICA,
Clinical symptoms: TIA
pre
Pre-stent:
post
pre
post
TTP within the media and anterior teritories delayed (4 s difference),
MTT, CBV, CBF identic
After-stent: TTP, MTT, CBV, CBF identic
Reperfusion injury after Carotid Stenting
Results:
frequency:
2,6% (9/340)
ICB:
0,49% (n=2)
- no significant difference concerning:
- mean age,
- degree of stenosis,
3/9 Pat. with contralateral stenosis
3/9 diabetes
9/9 hypertension
4/9 Subcortical arterosclerotic Encephalopathy
No patient showed angiographical signs of infarction and other abnormalities
Reperfusion injury after Carotid Stenting
Summary:
Reperfusion injury is seldom!
Risik factors:
Î older patients??
Î high grade stenosis??
Î contralaterale stenosis?
Î hypertension, SAE
Reperfusion injury can remain asymptomatic (only seen in MRI)
MRI necessary pre-and post stent
Perfusion seems to be normal in Patients with minimal variants
Patients should undergo RR control for at least 24 hours
Reperfusion injury after Carotid Stenting
Case 3:
Patient G.W., 58 years, stenosis of the left ICA 99% , 75% on the right ICA
Clinical symptoms: TIA`s
pre
24 h
72 h
CT
After 24 hours headache
Reperfusion injury after Carotid Stenting
Case 3:
Patient G.W., 58 years, stenosis of the left ICA 99% , 75% on the right ICA
Clinical symptoms: TIA`s
pre
Pre
Pre-stent:
post
post
TTP within the media territory and both anterior teritories with delay
(2 s difference), MTT, CBV, CBF identic
After-stent: TTP, MTT, CBV, CBF identic
Cognitive changes
after carotid artery stenting
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Purpose:
- to evaluate changes in cognitive performance after CAS
- has been done for CEA
- no consensus in the literature for the effect of CEA on cognition
previous studies
Lunn et al. cerebrovascular disease 1999: Systemic review of the literature 16/28 found an improvement (CEA)
Johnston et al. Ann Intern med 2004 : high grade stenosis of the left internal carotid artery
was associatet with cognitive impairment
4006 right handed, no previous TIA/Stroke
2.4 versus 18%
Aleksic Eur J Vasc Endovasc Surg 2006: 33 CEA; 3-5d, Cognitive function does not change following CEA
memory
Moftakhar et al 2005: 79% had improved cognitive scores after CAS; 21stents, 10 extracran carotid,
IQ Questionnaire, 3-14 months,chart review, phone interview,
Mlekusch et al. Radiology 2006: CAS seems to exert beneficial effects on the course of depressive symptoms
143 pat >80% asympt, 102 controls lower limb, 34% depressed before 10% after stent
- studies differ on methological issues:
- sample size
- type of patients (demographic, mood, TIA, stroke)
- control group
- range of cognitive tests used
-type of analysis used
- most studies lack information about:
- Degree and side of stenosis
- Perfusion
- Handedness
- Depression
- Outcome after intervention (DWI)
Patients and Method
• n= 46 with stenosis of the ICA
• 12 women, 34 men
• age: 68.3 (women); 69.57 (men)
•19 stented on right, 27 on left hand side
• mean degree of stenosis left 85.2%, right 83.8
• all: right handed, asymptomatic
• tests for cognitive speed, memory function
• cognitive tests before and 3 months after stent
Inclusion criteria:
age : 40-80
no paresis in the upper extremity
no impairment in eye sight, no hemianopsia
informed consent
Exclusion criteria:
psychiatric disease ( schizophrenia, depression, organic psychosyndrome)
insufficient command of the german language
Neuropsychological tests:
Cognitive speed
Memory function
• connect the numbers test
• repeat the numbers
(general cog. achievement
tempo)
(short time memory)
• labyrinth test (visual
and memory)
organization+visual-motor
coordination)
• image test (pictorial
• figure symbol test (decision
taking and processing)
• colour word test (optical and
verbal area+
gen.cogn.achievement tempo)
• word list (verbal lerning
information+ delayed
recall)
• word pairs (associative
verbal capacities)
• symbol test (visual
memory without verbal
associations)
• latent learning
Affective state was determined by the BECK depression Inventory
MMSE (screening for dementia) (28.58)
Materials and Method
• Statistical analyzis using SPSS
• parametrical T-test versus zero
• When comparing results before and after stenting
(related samples) we used the Wilcoxon test
MRI : 24h before and 48h after intervention
Clinical Results
- successfull stenting in all cases
- no neurological deficit
- DWI: new lesions in 10 cases; in 34 cases no new lesions
Purandare et al. BMJ 2006: Cerebral emboli as a potential course of Alzheimer´s disease and vascular dementia
case-control study
Stenting of the carotid artery significantly
increased cognitive speed function
p<0.001
Results
Results
Changes in cognitive function
might be due to changes in perfusion
-the higher degree of stenosis the more marked was perfusion deficit
- increase in brain perfusion after stenting
- increase in brain perfusion after stenting
correlated with increase in memory function (p<0.05)
Time to Peak
right ICA stenosis >90%
Marked improvement after stent
concerning - cognitive speed (CNT)
- verbal fluency and
- delayed recall
Time to Peak
right ICA stenosis, 75%
only slight change
in cognitive function after stent
Discussion
Stenting of the ICA seems to improve functions that involve cognitive speed
regardless of
- patients age
- side of stenosis
- degree of stenosis
Stenting led to a significant increase in cognitive speed function (p<0.028)
Correlation between degree of stenosis and perfusion deficit
- the higher degree of stenosis the more marked was perfusion deficit
- increase in brain perfusion after stenting correlated with
- increase in memory function (p<0.05)
Stenting may offer more than reduced stroke risk
Impressions from the Saarland, Germany

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