Management of neurological complications of carotid artery stenting

Purpose: To review the neurological complications associated with extracran ial carotid artery stenting and to preliminarily assess techniques used to manage these complications. Methods: Between April 1994 and August 2000, 450 patients (270 men; mean ag e 70.2 years, range 27-89) had stents implanted to treat 472 cervical carot id artery stenoses. Over half (257, 57%) of the patients were symptomatic. A variety of stents were implanted percutaneously after predilation of the lesion; a third of the patients received glycoprotein IIb/IIIa inhibitors i ntraprocedurally in addition to a standard oral antiplatelet regimen (aspir in and ticlopidine or clopidogrel). Occurrence and management of neurologic al complications within the 30-day periprocedural period were reviewed. Results: There were 14 (3.1%) transient ischemic attacks (TIAs), 10 (2.2%) minor strokes, and 3 (0.7%) major strokes. Among 6 (1.3%) procedure-related deaths, 4 had neurological causes. The total stroke and death rate was 4.2 % (n=19). All the TIAs, 4 of which occurred between 1 and 14 days poststent ing, were treated medically, as were the minor strokes, 3 of which occurred >24 hours after stenting. Only 2 minor stroke patients had mild residual u pper extremity motor deficits. Intra-arterial thrombolytic therapy was admi nistered in 5 cases (2 major strokes survivors and 3 patients who suffered a neurological ly-related death); occlusions were identified in the proxima l middle cerebral artery (MCA) in 3 and the distal MCA in 2. Angiographic i mprovement was noted in 4 (80%), but only the 2 (40%) with distal MCA occlu sions did well clinically. Conclusions: Neurological complications following carotid artery stenting a re inevitable. The occurrence of minor strokes >24 hours following stenting may indicate a possible late embolic phenomenon, which warrants investigat ion. Likewise, the marginal efficacy of intra-arterial thrombolytic therapy demonstrates an inability to lyse embolic plaque and underscores the need for effective distal protection.