Peter M. Hannon, MD

What factors might make an individual more likely to have a stroke after CEA or stenting for symptomatic stenosis? As part of the MRI substudy of the Internal Carotid Stenting Study (ICSS), authors looked to answer just this question. The original ICSS trial results in 2010 showed increased risk of stroke and all cause death in the stenting group, and increased risk of MI in the CEA group.  In this substudy, authors investigated 231 patients that had MRIs before and after intervention. Of those patients that had a 1 month follow-up MRI, they found that 28/44 (64%) in the stenting group and 6/10 (60%) in the CEA group had early DWI lesions with at least one persistent flair change at 1 month. Factors that predicted acute DWI lesions in the stenting group were age (>71yo), male gender and patients with stroke as the qualifying event. SBP > 158.5 was found to predict more acute lesions in the CEA group. More severe white matter disease was found to predict more acute lesions in both groups. Authors specifically note that while more acute and persist MRI lesions were found in the stenting group, that the probability of conversion from acute lesions to persistent lesions was less in the stenting group, which they feel was most likely explained by smaller acute lesions.

While the study sample size was small, these findings seem to mirror other studies such as CREST in which older patients did worse with stenting and more patients had peri-procedural strokes with stenting. Clearly, patient selection is critical in deciding the optimal treatment choice for symptomatic carotid disease, especially in our older patient. While stenting is certainly indicated in specific patient populations, the results of this study seem to reinforce the interim safety results of ICSS–that CEA “should remain the treatment of choice for patients suitable for surgery.”