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Isolated Middle Cerebral Artery Significantly Increases Risk of Postoperative Stroke after Transcarotid Revascularization in Asymptomatic Patients
Natalie G Ray1, Fanny S Alie-Cusson1, Halim Yammine1, Charles S Briggs1, Gregory A Stanley1, Hector Crespo-Soto1, Conall T Monahan1, Jeremy M Hackworth2, Joe D Bernard, Jr.3, Frank R Arko, III1
1Atrium Health Sanger Heart & Vascular Institute, Charlotte, NC;2Charlotte Radiology, Charlotte, NC;3Carolina Neurosurgery & Spine Associates, Charlotte, NC

Background: Limited research has been conducted to demonstrate the safety and efficacy of flow reversal in transcarotid revascularization (TCAR) patients with an ipsilateral isolated middle cerebral artery (iMCA). We hypothesize that an iMCA decreases tolerance to flow reversal and increases the risk of ipsilateral ischemic stroke after TCAR.
Methods: Clinical data and outcomes for TCAR were prospectively collected through our multihospital single-institution VQI between January 2019 and April 2024. Patient characteristics, imaging, and outcomes were retrospectively reviewed. Symptomatic patients and patients with inadequate intracranial imaging for appropriate CoW assessment were excluded. All anatomical segments of the CoW were evaluated by the same research assistant and radiologist and classified as normal, hypoplastic, or absent. The anterior semicircle and both the ipsilateral and contralateral posterior semicircles were then classified as complete, incomplete, and hypoplastic accordingly. Ipsilateral MCA was defined as isolated (iMCA) if there were incomplete segments in both the anterior semicircle and the ipsilateral posterior semicircle. Patients were then divided into iMCA and non-iMCA groups for comparison. Primary outcome was immediate ipsilateral neurologic event (INE), defined as any TIA or stroke diagnosed immediately after the intervention.
Results: A total of 230 TCARs (218 patients) performed for asymptomatic severe carotid artery stenosis were included in our analysis. Baseline characteristics did not differ significantly between groups (Table I). Lesion lengths and degrees of stenosis were similar between both groups. After imaging analysis, no patient was found to have a complete CoW. An ipsilateral iMCA was found in 27 patients (11.7%). A total of 4 patients (1.7%) suffered an INE. Patients with INE had significantly longer flow reversal times (13.5 mins vs 9 mins, p=0.0142), but did not differ between iMCA and non-iMCA groups. INE occurred in 3 patients (11.1%) in the iMCA group vs 1 (0.5%) in the non-iMCA group (p=0.005). iMCA was significantly associated with risk of INE on univariable logistic regression (OR 25.3, 95% CI [2.5-252.4], p=0.006).
Conclusions: In patients treated with TCAR for asymptomatic carotid stenosis, iMCA is associated with a 25-fold higher risk of ipsilateral immediate neurologic event. Comprehensive intracranial imaging should be performed on all patients to optimally assess the CoW anatomy prior to flow reversal. Reducing flow reversal time is unlikely to be sufficient as a stroke preventative measure in these patients. We strongly recommend avoiding flow reversal in this patient population and considering alternative treatment methods such as carotid endarterectomy with shunting.
Table 1. Baseline characteristics

TotalNon-iMCAiMCAp-value
N=230N=203N=27
Age (years)71 (8)71 (8)73 (7)0.17
Sex0.83
Male158 (69%)140 (69%)18 (67%)
Female72 (31%)63 (31%)9 (33%)
BMI (kg/m2)27.9 (4.8)28.0 (4.7)27.0 (5.3)0.32
Race0.80
White207 (90%)183 (90%)24 (89%)
Black20 (9%)17 (8%)3 (11%)
Asian2 (1%)2 (1%)0 (0%)
Native1 (0%)1 (0%)0 (0%)
Hypertension214 (93%)188 (93%)26 (96%)0.70
Diabetes86 (37%)73 (36%)13 (48%)0.29
CHF32 (14%)28 (14%)4 (15%)0.78
CAD115 (50%)101 (50%)14 (52%)1.00
Dysrhythmia38 (17%)31 (15%)7 (26%)0.17
COPD55 (24%)49 (24%)6 (22%)1.00
Smoking0.23
Current50 (22%)46 (23%)4 (15%)
Prior116 (50%)98 (48%)18 (67%)
Never64 (28%)59 (29%)5 (19%)
Creatinine1 (1-1)1 (1-1)1 (1-1)0.40
Pre-operative P2Y12 inhibitor therapy0.91
None28 (12%)25 (12%)3 (11%)
Clopidogrel194 (84%)171 (84%)23 (85%)
Ticagrelor7 (3%)6 (3%)1 (4%)
Prasugrel1 (0%)1 (0%)0 (0%)
Pre-operative aspirin208 (90%)184 (91%)24 (89%)0.73
Pre-operative anticoagulation29 (13%)23 (11%)6 (22%)0.12
Pre-operative statin186 (81%)165 (81%)21 (78%)0.61
Prior carotid intervention64 (28%)56 (28%)8 (30%)0.82
Prior TIA or stroke78 (34%)65 (32%)13 (50%)0.080
High-risk criteria for CEA194 (84%)171 (84%)23 (85%)1.00
Both43 (19%)35 (17%)8 (30%)
Medical59 (26%)54 (27%)5 (19%)
Anatomic92 (40%)82 (40%)10 (37%)
No36 (16%)32 (16%)4 (15%)


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