Risk of Intracranial Hemorrhage After Carotid Artery Stenting Versus Endarterectomy: A Population-Based Study - Journal of Vascular Surgery

This is a retrospective population-based study of patients comparing the rate of postprocedure intracranial hemorrhage (ICH) after carotid artery stenting (CAS) vs carotid endarterectomy (CEA) in Ontario, Canada between 2002 and 2015. A total of 16,688 patients underwent CEA (86%) or CAS (14%). ICH developed within 90 days in 0.85% after CAS vs 0.42% after CEA (P < .0001). Although patients who underwent CAS were more likely to have comorbidities, symptomatic carotid disease or cardiac disease and taking antiplatelet agents or warfarin preprocedure, the results were consistent after adjusting for these factors. The 6-month mortality rate for patients who suffered ICH was 43%. Carotid artery stenting is associated with a higher risk of intracranial hemorrhage compared to carotid endarterectomy. Hyperperfusion syndrome and ICH are associated with systemic hypertension after carotid revascularization. Hyperperfusion typically occurs within 12 hours after CAS (likely due to baroreceptor activation at the time of stent deployment) compared to peaking several days postoperatively after CEA. This large retrospective cohort study found that the risk of ICH was significantly higher after CAS (0.85%) than CEA (0.42%). However, this difference may not be clinically significant. This discrepancy in ICH was not due to differences in preprocedure antiplatelet or anticoagulant. Many factors were not assessed, such as the degree of contralateral disease, plaque characteristics, and, most importantly, postprocedure dual antiplatelet therapy, which the authors agree was almost certainly higher in stented patients. A review of patients who underwent CEA in the Vascular Quality Initiative showed that dual therapy with aspirin and clopidogrel was associated with increased reoperation for bleeding (P = .003), but the risk of ICH was not addressed.1 Nonetheless, use of dual therapy was associated with decreased risk of perioperative stroke compared to aspirin alone (P = .03) and the overall stroke risk was very low. There may not be much interventionalists can do to reduce the risk of this devastating complication after CAS, which may be due to the required use of clopidogrel before and after this intervention. Jones DW, Goodney PP, Conrad MF, et al. Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy. J Vasc Surg 2016:63:1262-70.