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Lancet Neurol. 2013 Sep;12(9):866-72. doi: 10.1016/S1474-4422(13)70135-2. Epub 2013 Jul 12.

Effect of white-matter lesions on the risk of periprocedural stroke after carotid artery stenting versus endarterectomy in the International Carotid Stenting Study (ICSS): a prespecified analysis of data from a randomised trial.

Collaborators (360)

Algra A, Bamford J, Beard J, Bland M, Bradbury AW, Brown MM, Clifton A, Gaines P, Hacke W, Halliday A, Malik I, Mas JL, McGuire AJ, Sidhu P, Venables G, Bradbury A, Brown MM, Clifton A, Gaines P, Collins R, Molyneux A, Naylor R, Warlow C, Ferro JM, Thomas D, Bonati LH, Coward L, Dobson J, Ederle J, Featherstone RF, Tindall H, McCabe DJ, Wallis A, Brooks M, Chambers B, Chan A, Chu P, Clark D, Dewey H, Donnan G, Fell G, Hoare M, Molan M, Roberts A, Roberts N, Beiles B, Bladin C, Clifford C, Fell G, Grigg M, New G, Bell R, Bower S, Chong W, Holt M, Saunder A, Than PG, Gett S, Leggett D, McGahan T, Quinn J, Ray M, Wong A, Woodruff P, Foreman R, Schultz D, Scroop R, Stanley B, Allard B, Atkinson N, Cambell W, Davies S, Field P, Milne P, Mitchell P, Tress B, Yan B, Beasley A, Dunbabin D, Stary D, Walker S, Cras P, d'Archambeau O, Hendriks JM, Van Schil P, Bosiers M, Deloose K, van Buggenhout E, De Letter J, Devos V, Ghekiere J, Vanhooren G, Astarci P, Hammer F, Lacroix V, Peeters A, Verhelst R, DeJaegher L, Peeters A, Verbist J, Blair JF, Caron JL, Daneault N, Giroux MF, Guilbert F, Lanthier S, Lebrun LH, Oliva V, Raymond J, Roy D, Soulez G, Weill A, Hill M, Hu W, Hudion M, Morrish W, Sutherland G, Wong J, Albäck A, Harno H, Ijäs P, Kaste M, Lepäntalo M, Mustanoja S, Paananen T, Porras M, Putaala J, Railo M, Sairanen T, Soinne L, Vehmas A, Vikatmaa P, Goertler M, Halloul Z, Skalej M, Brennan P, Kelly C, Leahy A, Moroney J, Thornton J, Koelemay MJ, Nederkoorn PJ, Reekers JA, Roos YB, Hendriks JM, Koudstaal PJ, Pattynama PM, van der Lugt A, van Dijk LC, van Sambeek MR, van Urk H, Verhagen HJ, Bruijninckx CM, de Bruijn SF, Keunen R, Knippenberg B, Mosch A, Treurniet F, van Dijk L, van Overhagen H, Wever J, de Beer FC, van den Berg JS, van Hasselt BA, Zeilstra DJ, Boiten J, de Mol van Otterloo JC, de Vries AC, Lycklama a Nijeholt GJ, van der Kallen BF, Blankensteijn JD, De Leeuw FE, Schultze Kool LJ, van der Vliet JA, de Borst GJ, de Kort GA, Kapelle LJ, Lo TH, Mali WP, Moll F, van der Worp HB, Verhagen H, Barber PA, Bourchier R, Hill A, Holden A, Stewart J, Bakke SJ, Krohg-Sørensen K, Skjelland M, Tennøe B, Bialek P, Biejat Z, Czepiel W, Czlonkowska A, Dowzenko A, Jedrzejewska J, Kobayashi A, Lelek M, Polanski J, Kirbis J, Milosevic Z, Zvan B, Blasco J, Chamorro A, Macho J, Obach V, Riambau V, San Roman L, Branera J, Canovas D, Estela J, Gimenez Gaibar A, Perendreu J, Björses K, Gottsater A, Ivancev K, Maetzsch T, Sonesson B, Berg B, Delle M, Formgren J, Gillgren P, Kall TB, Konrad P, Nyman N, Takolander R, Andersson T, Malmstedt J, Soderman M, Wahlgren C, Wahlgren N, Binaghi S, Hirt L, Michel P, Ruchat P, Bonati LH, Engelter ST, Fluri F, Guerke L, Jacob AL, Kirsch E, Lyrer PA, Radue EW, Stierli P, Wasner M, Wetzel S, Bonvin C, Kalangos A, Lovblad K, Murith N, Ruefenacht D, Sztajzel R, Higgins N, Kirkpatrick PJ, Martin P, Varty K, Adam D, Bell J, Bradbury AW, Crowe P, Gannon M, Henderson MJ, Sandler D, Shinton RA, Scriven JM, Wilmink T, D'Souza S, Egun A, Guta R, Punekar S, Seriki DM, Thomson G, Brennan JA, Enevoldson TP, Gilling-Smith G, Gould DA, Harris PL, McWilliams RG, Nasser HC, White R, Prakash KG, Serracino-Inglott F, Subramanian G, Symth JV, Walker MG, Clarke M, Davis M, Dixit SA, Dorman P, Dyker A, Ford G, Golkar A, Jackson R, Jayakrishnan V, Lambert D, Lees T, Louw S, Macdonald S, Mendelow AD, Rodgers H, Rose J, Stansby G, Wyatt M, Baker T, Baldwin N, Jones L, Mitchell D, Munro E, Thornton M, Baker D, Davis N, Hamilton G, McCabe D, Platts A, Tibballs J, Beard J, Cleveland T, Dodd D, Gaines P, Lonsdale R, Nair R, Nassef A, Nawaz S, Venables G, Belli A, Clifton A, Cloud G, Halliday A, Markus H, McFarland R, Morgan R, Pereira A, Thompson A, Chataway J, Cheshire N, Gibbs R, Hammady M, Jenkins M, Malik I, Wolfe J, Adiseshiah M, Bishop C, Brew S, Brookes J, Brown MM, Jäger R, Kitchen N, Ashleigh R, Butterfield S, Gamble GE, McCollum C, Nasim A, O'Neill P, Wong J, Edwards RD, Lees KR, MacKay AJ, Moss J, Rogers P.

Erratum in

  • Lancet Neurol. 2014 Nov;13(11):1070.

Abstract

BACKGROUND:

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.

METHODS:

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.

FINDINGS:

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.

INTERPRETATION:

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.

FUNDING:

Medical Research Council, the Stroke Association, Sanofi-Synthélabo, the European Union Research Framework Programme 5.

Copyright © 2013 Elsevier Ltd. All rights reserved.

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