Kuliha et al. performed a randomized, blinded, controlled trial comparing carotid endarterectomy (CEA) and carotid stenting (CAS) for the treatment of asymptomatic and symptomatic severe (>70%) stenosis at a single institution. The primary endpoint was new DWI-positive strokes on MRI 24 hours after procedure. Secondary endpoints included changes in cognitive tests after 24 h and 30 days, postop stroke or TIA, death, or any stroke/MI within 30 days. 73 patients underwent CEA, while 77 underwent CAS; demographics were matched except for a significantly higher rate of diabetes in the CAS group. New radiographic infarcts were more frequent after CAS (49%) than CEA (25%, p = 0.002). Stroke/TIA occurred in 1 patient after CEA and in 2 patients after CAS. No significant cognitive deficits were detected. The authors did report 'other' complications such as nerve palsy and pseudoaneurysm to be higher after CEA (N=15) than CAS (N=1; p<0.001). This publication was limited, however, by several factors. First, it was a single institution study using a single set of operative techniques. For CEA, the authors selectively used carotid shunting. For CAS, while the authors used distal embolic protection devices in all but 3 cases, they routinely performed post-stenting balloon angioplasty. Furthermore, the authors referred to the use of covered stents but did not detail the types of stents or balloons used. Despite these limitations, the publication importantly highlights an often unrecognized risk of neurointerventional procedures - the risk of silent DWI changes. Efforts should be taken by neurointerventional practitioners to target and reduce the incidence of such events to minimize risk to patients, as the clinical relevance of such findings is yet unknown.
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