***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Background Brain lesions on diffusion-weighted imaging ( DWI ) are frequently found after carotid artery stenting ( CAS ) , but their clinical relevance remains unclear . Objectives This study sought to investigate whether periprocedural ischemic DWI lesions after CAS or carotid endarterectomy ( CEA ) are associated with an increased risk of recurrent cerebrovascular events . Methods In the magnetic resonance imaging ( MRI ) sub study of ICSS ( International Carotid Stenting Study ) , 231 patients with symptomatic carotid stenosis were r and omized to undergo CAS ( n = 124 ) or CEA ( n = 107 ) .  MRIs were performed 1 to 7 days before and 1 to 3 days after treatment . The primary outcome event was stroke or transient ischemic attack in any territory occurring between the post-treatment MRI and the end of follow-up . Time to occurrence of the primary outcome event was compared between patients with ( DWI+ ) and without ( DWI– ) new DWI lesions on the post-treatment scan in the CAS and CEA groups separately . Results Median time of follow-up was 4.1 years ( interquartile range : 3.0 to 5.2 ) . In the CAS group , recurrent stroke or transient ischemic attack occurred more often among DWI+ patients ( 12 of 62 ) than among DWI– patients ( 6 of 62 ) , with a cumulative 5-year incidence of 22.8 % ( st and ard error [ SE ] : 7.1 % ) and 8.8 % ( SE : 3.8 % ) , respectively ( unadjusted hazard ratio : 2.85 ; 95 % confidence interval : 1.05 to 7.72 ; p = 0.04 ) . In DWI+ and DWI– patients , 8 and 2 events , respectively , occurred within 6 months after treatment . In the CEA group , there was no difference in recurrent cerebrovascular events between DWI+ and DWI– patients . Conclusions Ischemic brain lesions discovered on DWI after CAS seem to be a marker of increased risk for recurrent cerebrovascular events . Patients with periprocedural DWI lesions might benefit from more aggressive and prolonged antiplatelet therapy after CAS . ( A R and omised Comparison of the Risks , Benefits and Cost Effectiveness of Primary Carotid Stenting With Carotid Endarterectomy : International Carotid Stenting Study ; IS RCT N25337470 OBJECTIVE Cranial nerve injury ( CNI ) is the most common neurologic complication of  carotid endarterectomy ( CEA ) and can cause significant chronic disability . Data from prior r and omized trials are limited and provide no health-related quality of life ( HRQOL ) outcomes specific to CNI . Incidence of CNIs and their outcomes for patients in the Carotid Revascularization Endarterectomy vs Stenting Trial ( CREST ) were examined to identify factors predictive of CNI and their impact on HRQOL . METHODS Incidence of CNIs , baseline and procedural characteristics , outcomes , and HRQOL scores were evaluated in the 1151 patients r and omized to CEA and undergoing surgery ≤30 days . Patients with CNI were identified and classified using case report forms , adverse event data , and clinical notes . Baseline and procedural characteristics were compared using descriptive statistics . Clinical outcomes at 1 and 12 months were analyzed . All data were adjudicated by two neurologists and a vascular surgeon . HRQOL was evaluated using the Medical Outcomes Short-Form 36 ( SF-36 ) Health Survey to assess general health and Likert scales for disease-specific outcomes at 2 weeks , 4 weeks , and 12 months after CEA . The effect of CNI on SF-36 subscales was evaluated using r and om effects growth curve models , and Likert scale data were compared by ordinal logistic regression . RESULTS CNI was identified in 53 patients ( 4.6 % ) . Cranial nerves injured were VII ( 30.2 % ) , XII ( 24.5 % ) , and IX/X ( 41.5 % ) , and 3.8 % had Horner syndrome . CNI occurred in 52 of 1040 patients ( 5.0 % ) receiving general anesthesia and in one of 111 patients ( 0.9 % ) operated on under local anesthesia ( P = .05 ) . No other predictive baseline or procedural factors were identified . Deficits resolved in 18 patients ( 34 % ) at 1 month and in 42 of 52 patients ( 80.8 % ) by 1 year . One patient died before the 1-year follow-up visit . The HRQOL evaluation showed no statistical difference between groups with and without CNI at any interval . By Likert scale analysis , the group with CNI showed a significant difference in the difficulty eating/swallowing parameter at 2 and 4 weeks ( P < .001 ) but not at 1 year . CONCLUSIONS In CREST , CNI occurred in 4.6 % of patients undergoing CEA , with 34 % resolution at 30 days and 80.8 % at 1 year . The incidence of CNI was significantly higher in patients undergoing general anesthesia . CNI had a small and transient effect on HRQOL , negatively affecting only difficulty eating/swallowing at 2 and 4 weeks but not at 1 year . On the basis of these findings , we conclude that CNI is not a trivial consequence of CEA but rarely results in significant long-term disability OBJECTIVES This single-center , r and omized , clinical trial was design ed to determine the 10-year comparative efficacy and durability of carotid angioplasty and stenting ( CAS ) versus carotid endarterectomy ( CEA ) in preventing ipsilateral ischemic stroke in symptomatic and asymptomatic patients with high- grade carotid artery stenosis . BACKGROUND Modern clinical trials with short-term follow-up indicate CAS and CEA are equivalent in reducing the risk for ipsilateral ischemic stroke secondary to carotid stenosis . A paucity of data exists regarding long-term outcomes . METHODS Patients of all surgical risks with symptomatic and asymptomatic carotid stenosis ( > 70 % ) were r and omly selected for CEA or CAS and followed a minimum of 10 years . RESULTS Long-term follow-up was achieved in 173 patients ( 91 % ) . Eighty-seven ( 50.2 % ) died within this period , most commonly of nonvascular causes . No difference in the risk of stroke ipsilateral to the treated artery was noted among treatment groups ( p > 0.05 ) . Restenosis determined by sequential ultrasound was assessed only in the CAS group ( 3.3 % ) and remained asymptomatic . The combined risk of fatal or nonfatal heart attack over the 10-year period was highest in individuals with symptomatic versus asymptomatic stenosis ( 27.5 % vs. 11.0 % ; hazard ratio [ HR ] : 2.32 , 95 % confidence interval [ CI ] : 1.298 to 4.146 , p = 0.005 ) and was higher in all patients treated with CEA ( HR : 2.27 , 95 % CI : 1.35 to 3.816 , p = 0.002 ) . CONCLUSIONS Long-term protection against ipsilateral stroke provided by CAS and CEA did not differ in this trial . The 10-year risk of fatal/nonfatal myocardial infa rct ion was highest in all patients harboring symptomatic carotid stenosis at enrollment . The risk of fatal/nonfatal heart attack was significantly more prevalent in those symptomatic or asymptomatic patients r and omized to CEA Background : With patients living a decade or longer post-procedure , long-term data are needed to assess the durability of carotid artery stenting versus carotid endarterectomy . Identifying characteristics of those consenting or declining to continue in long-term follow-up may suggest strategies to improve retention in clinical trials . Purpose : This report describes differences between patients choosing or declining to continue follow-up for up to 10 years in the Carotid Revascularization Endarterectomy versus Stenting Trial . Methods : Following completion of the primary outcome , patients who were in active Carotid Revascularization Endarterectomy versus Stenting Trial follow-up were asked to continue beyond their original 4-year commitment for a maximum of 10 years . The characteristics of those who consented were compared with those who declined . Univariate and multivariable logistic regression were used for analysis , and backwards stepwise logistic regression ( the most parsimonious model ) was used to determine the factors associated with continuation . Results : Of the 1921 active Carotid Revascularization Endarterectomy versus Stenting Trial participants for whom consent to extend follow-up was requested , 1695 ( 88 % ; mean age : 68.4 ) consented ; 226 ( 12 % ; mean age : 69.6 ) declined . Of those who did not consent versus those who consented , 66 % versus 48 % were symptomatic at baseline ( p < 0.0001 ) , at follow-up 28 % versus 20 % were smokers ( p = 0.009 ) , 85 % versus 90 % were hypertensive ( p = 0.01 ) , and 84 % versus 94 % were dyslipidemic ( p < 0.0001 ) . Additional factors that differed between those who did not consent and those who consented included the mean number of years in the study at time of consent ( 4.8 years vs 3.7 years ( p = < 0.0001 ) ) and patients from sites that enrolled < 30 patients compared to sites r and omizing 30 or more ( 70 % vs 52 % ( p < 0.0001 ) ) . Multivariable logistic regression indicated that those with lesser odds of consenting to the extended follow-up were older ( odds ratio : 0.80 ; 95 % confidence interval : 0.67 , 0.96 ) , more likely to be symptomatic ( odds ratio : 0.58 ; 95 % confidence interval : 0.42 , 0.80 ) , smokers ( odds ratio : 0.48 ; 95 % confidence interval : 0.34 , 0.70 ) , were in the study 5 + years versus <3 ( odds ratio : 0.21 ; 95 % confidence interval : 0.13 , 0.34 ) , and at a site that r and omized < 30 patients ( odds ratio : 0.46 ; 95 % confidence interval : 0.33 , 0.63 ) , while patients with dyslipidemia at follow-up had increased odds of consenting ( odds ratio : 2.28 ( 1.47 , 3.54 ) ) . Conclusion : Symptomatic status , increasing age , r and omized at lower volume centers , and longer time in follow-up were associated with reduced odds of consenting to long-term follow-up . Identifying factors associated with reduced willingness to extend participation long-term can suggest targeted strategies to improve retention in future clinical trials Summary Background In the Carotid and Vertebral Artery Transluminal Angioplasty Study ( CAVATAS ) , early recurrent carotid stenosis was more common in patients assigned to  endovascular treatment  than it was in patients assigned to endarterectomy ( CEA ) , raising concerns about the long-term effectiveness of endovascular treatment . We aim ed to investigate the long-term risks of restenosis in patients included in CAVATAS . Methods 413 patients who were r and omly assigned in CAVATAS and completed treatment for carotid stenosis ( 200 patients had endovascular treatment and 213 patients had endarterectomy ) had prospect i ve clinical follow-up at a median of 5 years and carotid duplex ultrasound at a median of 4 years . We investigated the cumulative long-term incidence of carotid restenosis after endovascular treatment and endarterectomy , the effect of the use of stents on restenosis after endovascular treatment , risk factors for the development of restenosis , and the effect of carotid restenosis on the risk of recurrent cerebrovascular events . Analysis was by intention to treat . This study is registered , number IS RCT N01425573 . Findings Severe carotid restenosis ( ≥70 % ) or occlusion occurred significantly more often in patients in the endovascular arm than in patients in the endarterectomy arm ( adjusted hazard ratio [ HR ] 3·17 , 95 % CI 1·89–5·32 ; p<0·0001 ) . The estimated 5-year incidence of restenosis was 30·7 % in the endovascular arm and 10·5 % in the endarterectomy arm . Patients in the endovascular arm who were treated with a stent ( n=50 ) had a significantly lower risk of developing restenosis of 70 % or greater compared with those treated with balloon angioplasty alone ( n=145 ; HR 0·43 , 0·19–0·97 ; p=0·04 ) . Current smoking or a history of smoking was a predictor of restenosis of 70 % or more ( 2·32 , 1·19–4·54 ; p=0·01 ) and the early finding of moderate stenosis ( 50–69 % ) up to 60 days after treatment was associated with the risk of progression to restenosis of 70 % or more ( 3·76 , 1·88–7·52 ; p=0·0002 ) . 
    Output:
    
Conclusions : Among patients with asymptomatic stenosis undergoing carotid intervention , there is moderate‐ quality evidence to suggest that CEA had significantly lower 30‐day stroke and also stroke or death rates compared with CAS at the cost of higher CNI and nonsignificantly higher MI rates .
The long‐term efficacy of CEA in ipsilateral stroke prevention , taking into account perioperative stroke and death , was preserved during follow‐up .
There is an urgent need for high‐ quality research before a firm recommendation is made that CAS is inferior or not to CEA