Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK.
Lysholm Department of Neuroradiology, UCL Institute of Neurology, Queen Square, London, UK.
Lancet Neurol. 2013 Sep;12(9):866-872. doi: 10.1016/S1474-4422(13)70135-2. Epub 2013 Jul 12.
Findings from randomised trials have shown a higher early risk of stroke after carotid artery stenting than after carotid endarterectomy. We assessed whether white-matter lesions affect the perioperative risk of stroke in patients treated with carotid artery stenting versus carotid endarterectomy.
Patients with symptomatic carotid artery stenosis included in the International Carotid Stenting Study (ICSS) were randomly allocated to receive carotid artery stenting or carotid endarterectomy. Copies of baseline brain imaging were analysed by two investigators, who were masked to treatment, for the severity of white-matter lesions using the age-related white-matter changes (ARWMC) score. Randomisation was done with a computer-generated sequence (1:1). Patients were divided into two groups using the median ARWMC. We analysed the risk of stroke within 30 days of revascularisation using a per-protocol analysis. ICSS is registered with controlled-trials.com, number ISRCTN 25337470.
1036 patients (536 randomly allocated to carotid artery stenting, 500 to carotid endarterectomy) had baseline imaging available. Median ARWMC score was 7, and patients were dichotomised into those with a score of 7 or more and those with a score of less than 7. In patients treated with carotid artery stenting, those with an ARWMC score of 7 or more had an increased risk of stroke compared with those with a score of less than 7 (HR for any stroke 2·76, 95% CI 1·17-6·51; p=0·021; HR for non-disabling stroke 3·00, 1·10-8·36; p=0·031), but we did not see a similar association in patients treated with carotid endarterectomy (HR for any stroke 1·18, 0·40-3·55; p=0·76; HR for disabling or fatal stroke 1·41, 0·38-5·26; p=0·607). Carotid artery stenting was associated with a higher risk of stroke compared with carotid endarterectomy in patients with an ARWMC score of 7 or more (HR for any stroke 2·98, 1·29-6·93; p=0·011; HR for non-disabling stroke 6·34, 1·45-27·71; p=0·014), but there was no risk difference in patients with an ARWMC score of less than 7.
The presence of white-matter lesions on brain imaging should be taken into account when selecting patients for carotid revascularisation. Carotid artery stenting should be avoided in patients with more extensive white-matter lesions, but might be an acceptable alternative to carotid endarterectomy in patients with less extensive lesions.
Medical Research Council, the Stroke Association, Sanofi-Synthélabo, the European Union Research Framework Programme 5.
随机试验的结果表明，颈动脉支架置入术后早期中风的风险高于颈动脉内膜切除术。我们评估了在接受颈动脉支架置入术与颈动脉内膜切除术治疗的患者中，脑白质病变是否会影响围手术期中风的风险。
纳入国际颈动脉支架置入研究（ICSS）的有症状颈动脉狭窄患者，随机分配接受颈动脉支架置入术或颈动脉内膜切除术。两名研究人员对基线脑影像学进行分析，使用年龄相关性脑白质改变（ARWMC）评分评估脑白质病变的严重程度。采用计算机生成的序列（1:1）进行随机分组。根据 ARWMC 的中位数将患者分为两组。我们使用方案分析评估血管重建后 30 天内中风的风险。ICSS 在 controlled-trials.com 上注册，编号为 ISRCTN 25337470。
1036 名患者（536 名随机分配至颈动脉支架置入术组，500 名分配至颈动脉内膜切除术组）有基线影像学资料。ARWMC 评分中位数为 7，将患者分为 ARWMC 评分≥7 分和评分<7 分两组。在接受颈动脉支架置入术的患者中，ARWMC 评分≥7 分者与评分<7 分者相比，中风风险增加（任何中风的 HR 为 2.76，95%CI 1.17-6.51；p=0.021；非致残性中风的 HR 为 3.00，1.10-8.36；p=0.031），但在接受颈动脉内膜切除术的患者中未观察到类似的关联（任何中风的 HR 为 1.18，0.40-3.55；p=0.76；致残性或致死性中风的 HR 为 1.41，0.38-5.26；p=0.607）。在 ARWMC 评分≥7 分的患者中，颈动脉支架置入术与颈动脉内膜切除术相比，中风风险更高（任何中风的 HR 为 2.98，1.29-6.93；p=0.011；非致残性中风的 HR 为 6.34，1.45-27.71；p=0.014），但在 ARWMC 评分<7 分的患者中，风险无差异。
在选择颈动脉血运重建的患者时，应考虑脑影像学上脑白质病变的存在。对于白质病变更广泛的患者，应避免颈动脉支架置入术，但对于白质病变范围较小的患者，颈动脉支架置入术可能是颈动脉内膜切除术的可接受替代方法。
医学研究委员会、中风协会、赛诺菲-安万特、欧盟研究框架计划 5。
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