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Abstract Background Delays in diagnostic and therapeutic processes are a potentially preventable cause of morbidity and mortality. Process improvement depends on accurate knowledge about as-is processes, historically collected from front-line workers and summarized in flowcharts. Such flowcharts can now be generated by process discovery algorithms supplied with chronological records from real-world cases. However, these algorithms may generate incomprehensible flowcharts when applied to complex unstructured processes, which are common in healthcare. The aim of this study is to evaluate methods for analysing data from real-world cases to determine causes of delay in complex healthcare processes. Methods Physician insurance claims and hospital discharge data were obtained for patients undergoing carotid endarterectomy at a single tertiary hospital between 2008 and 2014. All patients were recently symptomatic with vision loss. A chronological record of physician visits and diagnostic tests (activities) was generated for each patient using claims data. Algorithmic process discovery was attempted using the Heuristic Miner. The effect of activity selection on treatment delay was investigated from two perspectives: activity-specific effects were measured using linear regression, and patterns of activity co-occurrence were identified using K means clustering. Results Ninety patients were included, with a median symptom-to-surgery treatment time of 34 days. Every patient had a unique sequence of activities. The flowchart generated by the Heuristic Miner algorithm was uninterpretable. Linear regression models of waiting time revealed beneficial effects of emergency and neurology visits, and detrimental effects of carotid ultrasound and post-imaging follow-up visits to family physicians and ophthalmologists. K-means clustering identified two co-occurrence patterns: emergency visits, neurology visits and CT angiography were more common in a cluster of rapidly treated patients (median symptom to surgery time of 18 days), whereas family physician visits, carotid ultrasound imaging and post-imaging follow-up visits to eye specialists were more common in a cluster of patients with treatment delay (median time of 57 days). Conclusions Routinely collected data provided a comprehensive account of events in the symptom-to-surgery process for carotid endarterectomy. Linear regression and K-means clustering can be used to analyze real-world data to understand causes of delay in complex healthcare processes.

Background and purposeAdvancements in carotid revascularization have produced promising outcomes in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization procedures after symptomatic presentation remains unclear. The purpose of this study is to compare in-hospital outcomes of transcarotid artery revascularization (TCAR), transfemoral carotid stenting (TFCAS), or carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms.MethodsThis is a retrospective cohort study of United States patients in the vascular quality initiative. All carotid revascularizations performed for symptomatic carotid artery stenosis between September 2016 and November 2019 were included. Procedures were categorized as urgent (0-2 days after most recent symptom), early (3-14 days), or late (15-180 days). The primary outcome of interest was in-hospital stroke and death. Secondary outcomes include in-hospital stroke, death, and transient ischemic attacks. Multivariable logistic regression was used to compare outcomes.ResultsA total of 18 643 revascularizations were included: 2006 (10.8%) urgent, 7423 (39.8%) early, and 9214 (49.42%) late. Patients with TFCAS had the highest rates of stroke/death at all timing cohorts (urgent: 4.0% CEA, 6.9% TFCAS, 6.5% TCAR, P=0.018; early: 2.5% CEA, 3.8% TFCAS, 2.9% TCAR, P=0.054; late: 1.6% CEA, 2.8% TFCAS, 2.3% TCAR, P=0.003). TFCAS also had increased odds of in-hospital stroke/death compared with CEA in all 3 groups (urgent adjusted odds ratio [aOR], 1.7 [95% CI, 1.0-2.9] P=0.03; early aOR, 1.6 [95% CI, 1.1-2.4] P=0.01; and late aOR, 1.9 [95% CI, 1.2-3.0] P=0.01). TCAR and CEA had comparable odds of in-hospital stroke/death in all 3 groups (urgent aOR, 1.9 [95% CI, 0.9-4], P=0.10), (early aOR, 1.1 [95% CI, 0.7-1.7], P=0.66), (late aOR, 1.5 [95% CI, 0.9-2.3], P=0.08).ConclusionsCEA remains the safest method of revascularization within the urgent period. Among revascularization performed outside of the 48 hours, TCAR and CEA have comparable outcomes.

ObjectiveTo compare the relationship between the dynamic changes of cerebral blood flow(CBF) before and after carotid artery stent （CAS） placement and perioperative events in patients with unilateral symptomatic carotid artery stenosis, providing reference for patients to choose surgical methods. Methods A total of 24 patients with moderate to severe （＞50%） symptomatic unilateral carotid artery stenosis admitted in Dongfang Hospital, Beijing University of Chinese Medicine from January 2018 to June 2020 were included, all of whom underwent CAS. All patients underwent magnetic resonance imaging （including DWI and 3D quasi continuous arterial spin labeled perfusion imaging） within 3 days before and 3 days after surgery. Changes in CBF and perioperative events were measured. According to whether there were new DWI high signals, they were divided into micro-embolic group and non-embolic group. ResultsWhile the incidence of new DWI lesions was high （17/24, 70.8%） and 176 lesions were observed among the 17 cases, there was only one subject showing the symptoms. The majority of the lesions were located at the cortex/subcortex of the ipsilateral frontal and parietal lobes （60.8%）, and 92.6% of the lesions size being less than 3mm. The CBF in the frontoparietal lobe were higher than that in the temporal lobe after surgery (lesion side 50.49±8.02vs47.94±9.08, t=2.179, P＜0.05; contralateral side 50.16±5.79 vs 48.00±5.98, t=3.835, P＜0.05); the CBF of the lesion side of the frontoparietal and temporal lobes increased significantly after surgery compared to before surgery （P＜0.05）. The preoperative relative CBF in the frontal parietal lobe of the micro-embolization group was lower than that of the non-embolization group （P＜0.05）. Conclusion The high incidence rate of micro-embolism in patients receiving CAS may not be the result of direct changes of hemodynamics in the brain but rather the loss of CBF regulation due to long-term hypoperfusion prior to the stenting.

Objectives: Carotid interventions are indicated for both patients with symptomatic and a subset of patients with severe asymptomatic carotid artery stenosis (CAS). Symptomatic CAS accounts for up to 12%-25% of overall carotid interventions, but predictors of symptomatic presentation remain poorly defined. The aim of this study was to identify factors associated with symptomatic CAS in our patient population., Methods: Between January 2015 and February 2022, an institutional retrospective cohort study of prospectively collected data on patients undergoing interventions for CAS was performed. Procedures included carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS). Demographic data, comorbidities, procedural details, and anatomic features from various imaging modalities were collected. Comparisons were made between symptomatic (symptoms within the prior 6 months) and asymptomatic patients., Results: During the study period, 279 patients who underwent intervention for symptomatic CAS were paired with a randomly selected cohort of 300 patients who underwent intervention for asymptomatic CAS from a total patient cohort of 1143 patients undergoing interventions for asymptomatic CAS. Demographic data did not differ between groups. Patients with symptomatic CAS more frequently had prior TIA/stroke (>6 months remote to the current event), but less frequently had coronary artery disease or chronic kidney disease and were less likely to receive adequate medical management including antihypertensive agents, lipid-lowering agents, and anti-platelet therapy. On multivariate analysis, remote prior TIA/stroke and lack of anti-platelet therapy remained significant. Among symptomatic patients presenting with stroke, lack of anti-platelet therapy was associated with an overall larger area of parenchymal involvement. No difference was observed with single versus dual anti-platelet therapy. Furthermore, symptomatic patients were more likely to have ulcerated plaques (30.9% vs 18%, p < .001), and symptomatic patients with ulcerated plaques more frequently had less than 50% compared to moderate/severe CAS. Nine patients who presented with symptoms had mild CAS and underwent intervention., Conclusions: Symptomatic CAS was associated with a history of remote prior symptoms and lack of anti-platelet therapy at time of presentation. Furthermore, symptomatic patients not on anti-platelet agents were more likely to have a greater area of parenchymal involvement when presenting with stroke and symptomatic patients with ulcerated plaques were more likely to have mild CAS, suggesting the role of plaque instability in symptomatic presentation. These findings underscore the importance of appropriate medical management and adherence in all patients with CAS and perhaps a role for more frequent surveillance in those with potentially unstable plaque morphology., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cerebral white matter disease and large vessel cerebral steno-occlusive are both associated with high incidence of strokes and mortality. There is a lack of literature correlating the cerebral perfusion downstream of a stenotic lesion with white matter changes in the cerebral hemispheres. The aim of this study was to correlate the white matter changes in magnetic resonance imaging (MRI) with computed tomography (CT) perfusion parameters in patients with symptomatic carotid stenosis. A total of 50 patients with symptomatic carotid stenosis underwent MRI brain and CT Perfusion. Percentage differences in cerebral blood flow (CBF) and mean transit time (MTT) were correlated with symmetric and asymmetric small vessel ischemic disease (SVID) on MRI. Receiver operating characteristic (ROC) curve analysis was performed to determine sensitivity and specificity for different values of percentage CBF and MTT difference. A total of 17 patients with symmetrical SVID had a mean CBF difference of 6.58 (SD of 3.17) and mean MTT difference of 11.61 (SD of 4.32). 33 patients with asymmetrical SVID had a mean CBF difference of 34.73 (SD of 6.87) and mean MTT difference of 44.63 (SD of 9.12). ROC curve analysis showed percentage CBF and MTT differences of 12.5% and 26.5% respectively to be associated with 100% specificity and sensitivity. In patients with symptomatic carotid stenosis, CT perfusion parameters correlate with MRI features of SVID. [ABSTRACT FROM AUTHOR]

Aim:Monocyte/high-density lipoprotein (HDL) ratio (MHR) is an inflammatory marker associated with vascular diseases. The aim of this study is to evaluate the MHR in patients with symptomatic carotid artery stenosis and to examine its relationship with the degree of stenosis.Methods:The study was conducted as a case-control study, with data obtained from patients’ files between January 2020 and May 2021. Ninety patients with symptomatic carotid stenosis and 40 healthy controls were included in the study. For vascular imaging, computed tomography angiography and/or digital subtraction angiography were used. Carotid artery stenosis was grouped according to North American Symptomatic Carotid Endarterectomy Trial criteria. Tests for monocyte and HDL cholesterol were performed, and the MHR was calcu-lated.Results:There were 67 male and 23 female patients with a mean age of 65.10±12.26 years in the study. In 46 (51.1%) of the patients, there was 50% or more carotid artery stenosis. The HDL cholesterol level was lower, and the MHR was higher in the patient group (p=0.042, p=0.041, respectively). Monocyte and MHR levels were higher in patients with 50% or more carotid stenosis (p=0.04).Conclusion:The MHR is a predictive biomarker for the degree of symptomatic stenosis in the carotid artery.

Objective To compare the cerebral blood flow (CBF) changes before and after carotid endarterectomy (CEA) and carotid artery stenting (CAS) and perioperative events in patients with unilateral symptomatic carotid artery stenosis, so as to provide references for patients to choose surgical methods. Methods Forty⁃three patients with unilateral symptomatic moderate to severe carotid artery stenosis (＞50%) were recruited from January 2018 to June 2020, including 19 cases in CEA group and 24 cases in CAS group. The dynamic changes of CBF values and perioperative events between 2 groups were compared. Results The hospitalization fee (t=⁃11.850, P=0.000) and the incidence of postoperative hypotension (χ2=3.634, P=0.022), bradycardia (χ2=3.634, P=0.022) and new DWI high signal (χ2=18.734, P=0.000) in CAS group were higher than those in CEA group. There were significant differences in heart rate (F=65.403, P=0.000), diastolic blood pressure (F=6.980, P=0.012), CBF values of the affected side and the healthy side (F=7.717, P=0.008; F=15.170, P=0.000) between 2 groups before and after operation. There were also significant differences in heart rate (F=2.452, P=0.048), systolic and diastolic blood pressure (F=13.296, P=0.001; F=5.814, P=0.020), CBF values of the affected side and the healthy side (F=48.959, P=0.000; F=57.758, P=0.000) between 2 groups at different observation time points. In CEA group the heart rate on the 1st to 3rd day after operation was higher than that before operation (P=0.000, 0.000, 0.003). The CBF values of the affected side on the 3rd and 7th day after operation (P=0.000, 0.001) and the CBF values of the healthy side on the 3rd day after operation (P=0.000) were higher than those before operation. In CAS group, the heart rate on the 1st and 2nd day after operation was lower than that before operation (P=0.000, 0.005). The CBF values of the affected side (P=0.000, 0.000) and healthy side (P=0.000, 0.000) on the 3rd and 7th day after operation were higher than those before operation. Conclusions The dynamic changes of CBF values, blood pressure and heart rate in the early stage after CEA and CAS were different, so we should choose the appropriate individualized treatment options for different patients to achieve better therapeutic effect.

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Introduction: About 30% of patients with carotid artery stenosis (CAS) develop dementia after a cerebral ischemic event (CIE), and 20–50% suffer from CIE recurrence during 6 months. Carotid artery revascularization (CAR) may prevent CIE recurrence, at the cost of new microembolic lesions (MES). The impact of CAR on cognitive function is debatable. Aim : To assess functional and cognitive outcome, cerebral flow on transcranial Doppler (TCD) and brain magnetic resonance imaging (MRI) in patients with symptomatic CAS referred for CAR. Material and methods : Twenty-two patients (aged 69.0 ±7.2 y.o., 15 male) with recent CIE (21.9 ±20.9 days to CAR) related to CAS of mean 89.8 ±3.9% lumen reduction were prospectively evaluated with TCD, diffusion and perfusion MRI, Montreal Cognitive Assessment (MoCA), Mini Mental State Examination (MMSE), modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS) 24 h before, at 24–48 h and 1 month following CAR. Results : New MES were found in 11 (50%) subjects following CAR. CAR resulted in a significant increase of cerebral flow velocity in the middle and anterior cerebral arteries (p < 0.002 and p = 0.003; respectively) and cerebral perfusion measured by time to peak (TTP) and mean transit time (MTT) (p = 0.0009 and p = 0.0002; respectively). Neurologic tests showed improvement in NIHSS (2.4 ±1.6 to 1.5 ±1.2, p = 0.003), mRS (from 1.3 ±0.9 to 0.7 ±0.9, p = 0.005), and MMSE (26.7 ±2.2 to 27.6 ±2.3, p = 0.019) at 1 month, while similar MoCA scores were observed before and 1 month after CAR (23.4 ±3.3 vs. 24.1 ±3.7, p = 0.136). Conclusions : Improvement of cerebral flow and perfusion and functional outcome, as well as at least no cognitive decline, is observed after CAR for symptomatic CAS.

Introduction: A carotid endarterectomy (CEA) has certain risks, of which peri-operative cardiovascular risk is one. Peri-operative neurological monitoring can be done with electroencephalography (EEG) and transcranial Doppler (TCD). No previous reports have been published demonstrating the actual changes in cerebral and cardiac activity during a peri-operative asystole. Report: The case of a 70 year old man with a symptomatic (bilateral) carotid stenosis is described. The patient complained of amaurosis fugax in both eyes. Duplex ultrasound showed a stenosis of >70% in both carotid arteries. The most severe symptoms were on the right side, so a staged approach was chosen, starting with a right sided eversion CEA (eCEA). Peri-operatively, the patient experienced an asystolic cardiac arrest after external carotid artery revascularisation, requiring brief cardiopulmonary resuscitation, which was recorded on the EEG. Post-operatively, the patient recovered fully, with no post-operative neurological or cardiac sequelae. The (symptomatic) contralateral stenosis was treated conservatively with best medical therapy (BMT; dual antiplatelets and statin). The patient is currently in good clinical condition, 1.5 years later. Conclusion: This case shows the unique EEG recording of a cardiological event during eCEA. The cause of asystole was most likely a vasovagal syncope as a result of the surgical procedure by iatrogenic damage to the carotid sinus fibres, causing impairment of the baroreflex and chemoreflex mechanisms, which is greater during eCEA. The unilateral eCEA and contralateral BMT in this symptomatic (bilateral) stenosis seemed appropriate when cardiological risk was increased but follow up ruled out any cardiological cause.

ABSTRACT Background: Carotid artery stenosis increases cerebral ischemic event risk through changing different cerebral hemodynamic parameters. Objective: To investigate how cerebral hemodynamics in the M1 segment of middle cerebral artery change in patients with carotid artery stenosis, after motor tasks using transcranial Doppler sonography (TCD). Methods: Thirty-two healthy subjects and 30 patients with unilateral symptomatic carotid artery stenosis were recruited. The patient population was divided into three groups according to the degree of stenosis (group 1: ≥50 to 69%, group 2: 70 to 89% and group 3: ≥90 to 99%). TCD was used to measure the pulsatility index (PI) and cerebral vasomotor reactivity (CVR). Results: In the patient group, significant differences for symptomatic side PI values (p=0.01) and mean CVR increases (p=0.05) were observed, compared with the healthy controls. However, the difference was not statistically significant for asymptomatic side PI values and mean CVR increases. The results from the intergroup comparison showed significantly higher percentages of symptomatic and asymptomatic side CVR increases in group 1, compared with groups 2 and 3 (p=0.001 and p=0.002, respectively). Conclusions: Our study showed that cerebral autoregulation and hemodynamic mechanisms are impaired in patients with carotid artery stenosis. Furthermore, the impairment of PI and CVR tends to get worse with increasing degrees of stenosis. In addition, this study demonstrated that assessment of these two hemodynamic parameters in clinical practice might be helpful for monitoring the progress of carotid artery stenosis.

Yi-An Ouyang, Yugang Jiang, Mengqiang Yu, Yunze Zhang, Hao HuangDepartment of Neurosurgery, Second Xiang-Ya Hospital of Central South University, Changsha, People’s Republic of ChinaObjective: To investigate both short-term and long-term therapeutic efficacy and safety of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for elderly patients with severe and symptomatic carotid artery stenosis.Methods: PubMed, EMBASE, Cochrane Library, Clinical Trials Register Centers, and Google Scholar were comprehensively searched. After identifying relevant randomized controlled trials, methodological quality was assessed by using Cochrane tools of bias assessment. Meta-analysis was performed by RevMan software, and subgroup analyses according to different follow-up periods were also conducted.Results: Sixteen articles of nine randomized controlled trials containing 6,984 patients were included. Compared with CEA, CAS was associated with high risks of stroke during periprocedural 30 days (risk ratio [RR]=1.47, 95% confidence interval [CI]: 1.15–1.88), 48 months (RR=1.37, 95% CI: 1.11–1.70), and >48 months (RR=1.76, 95% CI: 1.34–2.31). There was no significant difference in the aspects of death, disabling stroke, or death at any time between the groups. For other periprocedural complications, CAS decreased the risk of myocardial infarction (RR=0.44, 95% CI: 0.26–0.75), cranial nerve palsy (RR=0.09, 95% CI: 0.04–0.22) and hematoma (RR=0.31, 95% CI: 0.14–0.68) compared with CEA, while it increased the risk of bradycardia or hypotension (RR=8.45, 95% CI 2.91–24.58).Conclusion: Compared with CEA, CAS reduced hematoma, periprocedural myocardial infarction, and cranial nerve palsy, while it was associated with higher risks of both short-term and long-term nondisabling stroke. And they seemed to be equivalent in other outcome measures. As regards to its minimal invasion, it should be applied only in specific patients.Keywords: symptomatic carotid artery stenosis, carotid artery stenting, carotid artery endarterectomy

Introduction: Criteria and optimal timing for carotid artery revascularization have been polarizing subjects for investigators and clinicians dedicated to carotid artery atherosclerotic disease. A topical review was performed with the purpose of 1) providing an overview of the evidence on the definition of index event and on the definition of delay of intervention; 2) summarizing the rationale for the current definition for the optimal timing for carotid intervention, and 3) drawing a sketch for future directions implementing the aspect of timing in daily clinical practice., Evidence Acquisition: A literature search was performed using the Medline database and the following query ("Endarterectomy, Carotid"[Mesh]) AND ("Stroke" [Mesh] OR Symptomatic) AND "Randomized Controlled Trial"). A comprehensive review of manuscripts addressing timing of intervention was also performed., Evidence Synthesis: A total of eleven RCTs were identified and data on index event definition, timing of intervention and BMT were resumed. The definition of the index event can have a significant impact on the delay times but has (surprisingly) received little attention. Different definitions in itself may be correct, but in terms of stroke prevention, it is most important to understand and emphasize that the risk of recurrent stroke. The optimal timing of CEA after stroke remains an important but unresolved question. No prospective, randomized study has ever been undertaken to specifically determine which patients and when they might safely undergo expedited CEA after recent stroke., Conclusions: Collecting data on events during waiting time to intervention and developing reporting standards for these waiting times seem to be the key for unraveling this controversy.

Patients with stroke or transient ischemic attacks (TIAs) and internal carotid artery stenosis harbor an increased risk of recurrent stroke especially within 2 weeks after the first event. In addition, the revascularization procedure itself (carotid endarterectomy [CEA] or carotid artery stenting [CAS]) is associated with both clinically apparent and silent brain infarctions, mainly caused by the embolic nature of the ruptured carotid plaque. The glycoprotein VI (GPVI) fusion protein Revacept is a highly specific antithrombotic drug without direct inhibition of systemic platelet function that might reduce periprocedural distal embolization from the vulnerable ruptured plaque located at the internal carotid artery. By shielding collagen at the site of vascular injury, Revacept inhibits plaque-mediated platelet adhesion and aggregation, while not directly affecting systemic hemostasis. In this phase II study, 158 patients with symptomatic carotid artery stenosis with recent TIA or stroke were randomized to receive a single dose of either Revacept (40 or 120 mg) or placebo. All patients were on standard secondary preventive therapy (statins and platelet inhibition) and underwent CEA, CAS, or best medical therapy according to current guidelines. The efficacy of Revacept was evaluated by exploratory assessment of new diffusion-weighted imaging lesions on magnetic resonance imaging after the revascularization procedure; a combination of cardiovascular events (ischemic and hemorrhagic stroke, TIA, myocardial infarction, or coronary intervention) and bleeding complications served to assess clinically critical patients' outcome and safety. This exploratory phase II randomized, double-blind clinical trial provides valuable insights on the safety, tolerability, and efficacy of Revacept in patients with symptomatic carotid artery stenosis.

Objective To apply computed tomography perfusion (CTP) to study the changes in cerebral hemodynamics during carotid endarterectomy (CEA) in patients with unilateral symptomatic carotid artery stenosis. To explore the relationship between the changes and perioperative complications. Methods The clinical data of 21 patients with unilateral symptomatic carotid artery stenosis admitted in Dongfang Hospital, Beijing University of Chinese Medicine and Chinese PLA General Hospital from March 2018 to July 2020 were analyzed retrospectively. All patients underwent CEA, and CTP was performed before and after surgery. CTP pseudo-color map and quantitative data of the region of interest were obtained. The CTP parameters before and after CEA were compared. Perioperative complications were recorded. △CBF was used to represent the changes of cerebral blood flow (CBF) in the affected MCA blood supply area. Results Compared with the healthy side before CEA, CBF in the affected side was lower than that in the healthy side, and the time to peak (TTP) in the affected side was longer than that in the healthy side. CBF and cerebral blood volume (CBV) in the affected side were significantly higher than those in the healthy side after CEA. CBF and CBV increased and TTP shortened before and after CEA. △CBF＜0 occurred in one case,0 ≤△CBF ≤50% occurred in 21 cases,and △CBF was ＞ 50% in five cases． △CBF was ＞ 50% in three patients with hyperperfusion syndrome. One patient whose △CBF was ＜ 0 and TTP was prolonged was diagnosed with a cerebral infarction,which was confirmed by postoperative CT. This group of patients recovered well by discharge,and none died. Conclusions CTP sensitively reflects the early changes in cerebral hemodynamics postoperatively,and is useful to assess cerebral autoregulatory function,predicted complications,such as hyperperfusion syndrome and cerebral infarction,which can be an important auxiliary means of monitoring during CEA. [ABSTRACT FROM AUTHOR]

PURPOSE:To evaluated the changes in choroidal vasculature in patients with ocular ischemic syndrome (OIS) and in the ipsilateral eyes of patients with symptomatic carotid artery stenosis (CAS). METHOD:A total of 50 patients (15 patients with OIS, 10 patients with symptomatic CAS, 25 patients of age-and sex-matched control group) were included, and the medical records were retrospectively reviewed. The mean subfoveal choroidal thickness (SFCT) of each eye was measured, and binary images of the choroid were evaluated to compare the mean choroidal area and the luminal area. RESULTS:The mean SFCT was 170.5±75.3 μm in the eyes with OIS, 154.8±62.9 μm in the ipsilateral eyes with symptomatic CAS, and 277.5±73.2 μm in the right eyes of the control group patients (P

In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with ( n = 13, 44.8%) or without ulceration ( n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque ( n = 7, 25%) ( p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.

The effect of carotid artery stenting and medication on improvement of cognitive function in patients with severe symptomatic carotid artery stenosis is unknown. To investigate the effect of stenting compared with medication alone for severe carotid atherosclerotic stenosis on cognitive impairment. Patients with carotid stenosis and cognitive impairment were prospectively randomly divided into 2 groups of stenting or medication alone. Cognitive function was evaluated with the Montreal cognitive assessment (MoCA), Mini-Mental State Examination, and Barthel Index of Activities of Daily Living (BI). Continuous data in normal distribution were tested with the t-test but with the Mann-Whitney U test if not in normal distribution. Categorical data were presented as frequency and percentages and tested with the Fisher exact test. A P value < .05 was regarded as statistical significant. Carotid artery stenting was successfully performed in all patients (100%) in the stenting group. Compared with before treatment, the Mini-Mental State Examination, MoCA and BI scores at 6 months in the medication alone group and at 1, 3, and 6 months in the stenting group were significantly (P < .005) improved. The stenting group had significantly (P < .05) better scores than the medication alone group at the same time. At 6-month follow-up, the visuospatial/executive functions (3.69 ± 1.42 vs 2.42 ± 1.23), attention (5.24 ± 1.52 vs 3.63 ± 1.47), and language (2.64 ± 0.71 vs 1.96 ± 0.69) were significantly (P < .05) improved in the stenting group compared with the medication alone group. Carotid artery stenting may significantly improve cognitive impairment and neurological function compared with medication alone in patients with severe carotid atherosclerotic stenosis concurrent with cognitive impairment., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)