Perioperative silent strokes in carotid artery surgery: a systematic review and meta-analysis

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BACKGROUND

Carotid artery (CA) atherosclerosis is responsible for up to 20% of all cases of cerebral ischemia and often requires surgical intervention. An important issue in contemporary medicine is perioperative silent brain infarctions (covert strokes) associated with postoperative neurocognitive disorders and subsequent ischemic strokes.

OBJECTIVE

To determine the frequency of covert strokes following elective CA surgery and to identify risk factors for this outcome.

MATERIAL AND METHODS

A meta-analysis was conducted in accordance with the PRISMA guidelines and the Cochrane Collaboration’s protocols. Literature searching was performed using PubMed (Medline) and Cochrane Library (CENTRAL) databases. Searching was supplemented by snowball sampling methods (Litmaps web application). The risk of systematic bias was assessed using the CLARITY tool. Internal validity and evidence level were evaluated using the GRADE system.

RESULTS

Analysis included 27 studies and 5644 patients. The incidence of covert strokes after CA surgery was 19%. Risk factors for this complication were diabetes mellitus (p<0.001) and hypertensive disease (p=0.036). Statin intake was a protective factor (p=0.012). Covert stroke detection rate was significantly higher for MRI compared to CT (22% versus 3%, p<0.001). The incidence of covert stroke after CA stenting was 38% compared to 10% after carotid endarterectomy (CEA) (p<0.001). The incidence of covert stroke was 3.75 (95% CI 2.89; 4.87) times higher after CA stenting compared to CEA (relative risk reduction [RRR] 73.3%, p<0.001).

CONCLUSION

About 20% of patients experience perioperative covert stroke (high evidence level) in elective CA surgery. The risk of covert stroke is 3.75 times higher for CA stenting compared to CEA (moderate evidence level). Moreover, 3 out of 4 covert strokes in patients with CA stenting could be avoided by changing the type of surgical intervention.

Keywords:

silent stroke

cerebral infarction

carotid endarterectomy

carotid artery stenting

carotid artery atherosclerosis

Authors:

Smirnova A.V.

Federal Research Clinical Center for Intensive Care and Rehabilitation

ORCID: 0000-0001-7860-6609

Berikashvili L.B.

Federal Research Clinical Center of Intensive Care and Rehabilitology

ORCID: 0000-0001-9267-3664

Polyakov P.A.

Federal Research Clinical Center for Intensive Care and Rehabilitation

ORCID: 0009-0009-6185-349X

Yadgarov M.Ya.

Federal Research and Clinical Centre of Intensive Care and Rehabilitology

ORCID: 0000-0003-3792-1682

Shemetova M.M.

Federal Research and Clinical Centre of Intensive Care and Rehabilitology

ORCID: 0000-0003-0872-1825

Makarevich D.G.

Federal Research and Clinical Centre of Intensive Care and Rehabilitology

Kuzovlev A.N.

Negovsky Research Institute of Intensive Care

SPIN RSCI: 8648-3771
Scopus AuthorID: 35201397900
ResearcherID: F-6462-2017
ORCID: 0000-0002-5930-0118

Kadantseva K.K.

Federal Research and Clinical Centre of Intensive Care and Rehabilitology

ORCID: 0000-0002-6593-8580

Likhvantsev V.V.

Federal Research Clinical Center of Intensive Care and Rehabilitology

ORCID: 0000-0002-5442-6950

Received:

16.09.2024

Accepted:

06.10.2024

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