IgG-RBD Response Due to Inactivated SARS-CoV-2 Vaccine: Alteration in D-Dimer and Fibrinogen Concentrations, Association with Comorbidities and Adverse Effects.

OBJECTIVE: To examine the immunoglobulin G-receptor-binding domain (IgG-RBD) response and changes in fibrinogen and D-dimer concentrations in individuals with a past coronavirus infection and followed by CoronaVac. METHODS: The study consisted of a total of 116 participants. Blood samples were drawn from subjects 21-25 days after they received first and second doses of CoronaVac as well as from individuals with a past infection. Fibrinogen, D-dimer, and IgG-RBD concentrations were measured. RESULTS: The IgG concentrations of the vaccinated subjects were significantly higher (P < .001), fibrinogen levels were lower (P < .001), and D-dimer levels increased following the second vaccination compared with the first vaccination (P = .083). No difference was obtained in IgG-RBD between vaccinated and previously infected individuals (P = .063). The differences in fibrinogen and D-dimer were statistically nonsignificant between both groups. CONCLUSION: The CoronaVac vaccine appears to be safe and effective. It is essential for individuals to take personal protective measures, such as using masks and distancing.

Performance Evaluation of Sysmex CN-3000 and Stago STA R Max Coagulation Analyzers and Interference of Hemolysis.

BACKGROUND: In this study, our purpose was to evaluate the analytical performances of the STA R Max and CN-3000, and compare the results of both for PT, aPTT, fibrinogen, D-dimer, and factor VIII, and also to show the influence of hemolysis on PT, aPTT, and fibrinogen assays. METHODS: Three hundred ninety-five randomly-selected blood samples from residual material from Istanbul Faculty of Medicine, Central Laboratory workflow comprised the study group. PT, aPTT, fibrinogen, D-dimer, and factor VIII activity were done using both analyzers. Analytical performances were determined through precision, linearity, and comparability studies. Artificial hemolysis was performed through freezing-thawing and mechanical-sheer methods. RESULTS: Intra-assay and between-day CVs% of PT and aPTT were lower than 5% for STA R Max and CN-3000. Only the within-run and between-day CVs% of fibrinogen and the between-day CVs% of D-dimer were higher than 5%, but in acceptable targets. Intra-assay and between-day CVs% of FVIII on the CN-3000 were 3.5% and 12.3% at the low and 2.5% and 5.3% at high level, and 1.8% and 3.7% at the low and 6.3% and 5.9% at high level on the STA R Max. The comparison results of PT, aPTT, fibrinogen, and D-dimer were good (r > 0.91), also good correlations were obtained for FVIII activity > 40 IU/dL and FVIII between 5 - 40 IU/dL (r = 0.89). The results of the hemolysis study were within acceptable limits of the recommended criteria of Fraser and the manufacturer. CONCLUSIONS: CN-3000 and STA R Max coagulation analyzers are accurate and highly precise systems for safe use in clinical diagnostic applications. The interferences obtained for both analyzers were found to be within accepted targets.

The understanding of the immunopathology in COVID-19 infection.

Coronaviruses belonging to the Coronaviridae family are single-stranded RNA viruses. The entry of SARS-CoV-2 is accomplished via ACE-2 receptors. SARS-CoV-2 infection coactivates both innate and adaptive immune responses. Although SARS-CoV-2 stimulates antibody production with a typical pattern of IgM/IgG, cellular immunity is also impaired. In severe cases, low CD4 + and CD8 + T cell counts are associated with impaired immune functions, and high neutrophil/lymphocyte ratios accompanying low lymphocyte subsets have been demonstrated. Recently, high IFN -α/γ ratios with impaired T cell responses, and increased IL-1, IL-6, TNF-α, MCP-1, IP-10, IL-4, IL-10 have been reported in COVID-19 infection. Increased proinflammatory cytokines and chemokines in patients with severe COVID-19 may cause the suppression of CD4 + and CD8 + T cells and regulatory T cells, causing excessive inflammatory responses and fatal cytokine storm with tissue and organ damage. Consequently, novel therapeutics to be developed against host immune system, including blockade of cytokines (IL-6, IL-1, IFN) themselves, their receptors or signaling pathways- JAK inhibitors- could be effective as potential therapeutics.

Congenital Factor XIII Deficiency With the Presence of Inhibitor: A Case Study.

Coagulation factor XIII (FXIII) is a fibrin-stabilizing factor with additional roles in wound healing and interactions between the decidua and fetus. Congenital FXIII deficiency is rare bleeding disorder. Inhibitor development against FXIII in inherited FXIII deficency is also uncommon, but may cause severe, life-threatening bleeding. FXIII is the last step in the coagulation cascade with normal coagulation paramaters (PT, aPTT), the detection of inhibitor to FXIII is quite difficult. The treatment of inhibitor-positive congenital FXIII deficiency is challenging due to the lack of a role of by-pass agents such as FVII. The best known ways of treatment in these cases are the use of high-dose FXIII concentrates and immunosuppression. Herein, we report the management of postoperative bleeding diathesis in a patient with FXIII deficiency who developed inhibitors, and to follow the clinical course of the disease with FXIII concentrate and immunosuppression.

Evaluation of Chromogenic Factor VIII Assay Compared with One-Stage Clotting Assay.

BACKGROUND: Congenital factor VIII (FVIII) deficiency causes hemophilia A due to different types of defects in the FVIII gene. Although the chromogenic measurement is the reference method and shows less variability, a one-stage assay is the most commonly preferred method for measurement of FVIII. In this study, we aimed to evaluate the analytical performances of chromogenic and one-stage assays, and compare the results prior to introduction of newly developed extended half-life recombinant FVIII products. METHODS: Sixty-six blood samples from residual material of Istanbul Faculty of Medicine, Central Laboratory workflow comprised the study group. Samples were classified; plasma FVIII > 40 IU and FVIII < 40 IU. FVIII activities were measured using one-stage clotting and chromogenic assays on a CS-2500 analyzer. Analytical performances were determined through precision, linearity, carryover, and comparability studies. RESULTS: The within-run CV% of the one-stage assay on the CS-2500 had 1.6%, 2.6%, the between day CV% were 8.5%, 4.9 % for low and high controls, respectively. The within-run CV% of chromogenic method had 1.2% and 0.9%. Both methods demonstrated good linearity (R2 > 0.998), and the comparisons of both assays exhibited good agreement with minor bias for FVIII activity > 40 IU. However, a significant bias was obtained for FVIII activity < 40 IU. CONCLUSIONS: We obtained higher results using the one-stage assay compared with the chromogenic assay, and a significant bias was found for the samples lower than 40 IU. The discrepancy can explained by the presence of a weak agreement for samples lower than 10 IU due to the lower detection limit of the chromogenic assay used in this study (1.5%).

Galectin-3 is associated with coronary plaque burden and obstructive sleep apnoea syndrome severity.

BACKGROUND: Obstructive sleep apnoea syndrome (OSAS) is reported to be associated with hypertension, coronary artery disease, atrial fibrillation, and heart failure. Galectin-3 plays an important role in the regulation of inflammation, development of cardiac fibrosis, and remodelling. A significant relationship between galectin-3 and the total number of coronary plaques and the macrocalcified plaque structures of patients with type 2 diabetes mellitus has been reported. AIM: The aim of this study was to investigate the association between galectin-3 level and coronary plaque burden as well as OSAS severity in patients with OSAS. METHODS: A total of 87 consecutive patients with a diagnosis of OSAS and 21 age- and gender-matched control subjects were recruited for the present study. The patients with OSAS were also categorised according to their apnoea hypopnoea index (AHI) as follows: mild (AHI = 5-15), moderate (AHI = 15-30), and severe (AHI > 30). All study subjects underwent coronary computed tomography angiography to detect coronary atherosclerosis. Also, all participants of serum galectin-3 concentrations were measured. RESULTS: Mean galectin-3 level was significantly higher in patients with OSAS compared to control subjects (p < 0.001) and in the severe OSAS group, compared to the moderate and mild OSAS groups (p < 0.001). Correlation analysis indicated significant positive relationships between galectin-3 concentrations and the total number of coronary plaques (p < 0.001), high-sensitivity C-reactive protein (p = 0.001), and severity of OSAS (p < 0.001). In multivariate analysis, galectin-3 (p = 0.01) and age (p = 0.025) were significant independent predictors of coronary atherosclerosis, after adjusting for other risk factors. Also, it has been found that galectin-3 concentration is a predictor of OSAS severity (p = 0.001). CONCLUSIONS: Galectin-3 is associated with coronary atherosclerosis and OSAS severity in OSAS patients.

Comparison of Edwards Sapien XT versus Lotus Valve Devices in Terms of Electrophysiological Study Parameters in Patients Undergoing TAVI.

BACKGROUND: The purpose of this study is to assess the electrocardiographic and electrophysiological parameters of conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic valve stenosis. METHODS: The study included 55 patients who underwent TAVI using either the Boston Scientific Lotus (n:25) (Boston Scientific, Natick, MA, USA) or Edwards Sapien XT (n:30) (Edwards Lifesciences, Irvine, CA, USA) prostheses. An electrophysiological study (EPS) was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after prosthesis implantation. RESULTS: QRS duration and His-bundle to His-ventricle (HV) intervals, which were similar between the two groups before the procedure, were found to be significantly higher in the Lotus valve group postprocedure. Permanent pacemakers (PPMs) were required more frequently in the Lotus group than in the Sapien XT group at discharge (24.0% vs 6.7%, P = 0.07). With the exception of a higher prevalence of paravalvular leakage (P < 0.001) in patients undergoing Sapien XT implantation, other clinical outcomes were similar between the two groups. Multiple regression analysis revealed that baseline atrioventricular (AV) conduction disorders and HV intervals after the procedure were independently associated with PPM implantation after TAVI. CONCLUSION: In this first study comparing the findings of EPS and electrocardiography, the impact of the Lotus valve on AV conduction systems was greater than that of the Sapien XT. However, the need for PPM was higher in the Lotus valve than in the Sapien XT. PPM requirement is related to valve design; it may decrease with reduced frame height and metal burden in novel valve systems.

Red cell distribution width and end-organ damage in patients with systo-diastolic hypertension.

INTRODUCTION: Both end-organ damage and high red cell distribution width (RDW) values are associated with adverse cardiovascular events, inflammatory status, and neurohumoral activation in hypertensive disease and in the general population. In this study, we investigated the relationship between RDW and end-organ damage in hypertensive patients. MATERIAL AND METHODS: The 446 systo-diastolic hypertensive patients included in the study received 24-hour ambulatory blood pressure monitoring. Left ventricular mass index, glomerular filtration rate, and microalbuminuria were measured to identify end-organ damage. High-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels of all patients were also examined. RESULTS: The mean age of the participants was 49.96 ±11.04 years. The mean RDW was 13.06 ±1.05%. Red cell distribution width was positively correlated with left ventricular myocardial index (LVMI), urinary albumin, hs-CRP, and NT-proBNP (r = 0.298, p < 0.001; r = 0.228, p < 0.001; r = 0.337, p < 0.001; r = 0.277, p < 0.001, respectively), while RDW was negatively correlated with eGFR (r = -0.153, p < 0.001). Additionally, while there was a positive correlation between RDW and 24-h systolic blood pressure, no correlation was found between RDW and 24-h diastolic blood pressure (r = 0.132, p = 0.006 and r = 0.017, p = 0.725, respectively). Multiple linear regression analysis revealed that RDW levels were independently associated with eGFR, LVMI, and severity of albuminuria (ß = 0.126, p = 0.010; ß = -0.149, p = 0.002; ß = 0.114, p = 0.035). CONCLUSIONS: High RDW levels in systo-diastolic hypertensive patients were found to be an independent predictor of end-organ damage.

A New Specific Device in Transcatheter Prosthetic Paravalvular Leak Closure: A Prospective Two-Center Trial.

BACKGROUND: This study sought to compare various outcomes among a new specifically designed transcatheter paravalvular leak closure (TPVLC) device and the devices that are being utilized off-label. METHODS: Between April 2012 and January 2015, in a prospective two-center study, 52 patients who needed surgical reintervention due to a hemodynamically significant prosthetic paravalvular leak were studied. This study population was divided into two groups. Group I was composed of 32 patients who underwent paravalvular leak (PVL) closure with the currently available devices that are being utilized off-label, while group II consisted of 20 patients who were treated with the new specifically designed Occlutech PVL device. RESULTS: Demographic and clinical variables indicated a higher rate of atrial fibrillation (P = 0.027) and chronic obstructive airway disease (P = 0.009) in group II. The apical approach was the most commonly used intervention route used for group II (P = 0.019). The procedural success rate was 100% (29 of 29 leaks) in group II while the rate was 92% (39 of 42 leaks) in group I. However, more secondary events were observed in group I, but they did not reach statistical significance (8 vs. 1, P = 0.064). CONCLUSIONS: With its high procedural success rate and encouraging outcome results, the Occlutech device seems to satisfy the expectations of a specifically designed PVL closure device. © 2016 Wiley Periodicals, Inc.

Long-term prognostic significance of admission plateletcrit values in patients with non-ST elevation myocardial infarction.

The plateletcrit has been investigated as a new predictor of cardiovascular risk. The objective of our study was to investigate the role of admission plateletcrit in predicting long-term cardiovascular mortality in patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI). We enrolled 296 patients with NSTEMI (mean age 59.2 ±â€Š11.8 years; 228 men, 68 women) in this study. The study population was divided into tertiles on the basis of admission plateletcrit values. A high plateletcrit (n = 98) was defined as a value in the upper third tertile (plateletcrit >0.23), and a low plateletcrit (n = 198) was defined as any value in the lower two tertiles (plateletcrit ≤0.23). The median follow-up time was 38 months. In multivariate analyses, a significant association was noted between high plateletcrit values and the adjusted risk of long-term mortality (odds ratio = 12.15, 95% confidence interval = 1.78-82.77; P < 0.001). In the Kaplan-Meier survival analysis, the long-term mortality rate was 20.4% in the high plateletcrit group versus 4.5% in the low plateletcrit group (P < 0.001). Long-term major advanced cardiac events (MACE), hospitalization for heart failure and reinfarction were significantly higher in patients with high plateletcrit. Admission plateletcrit is a strong and independent predictor of long-term cardiovascular mortality in patients with NSTEMI.

The prognostic value of admission red cell distribution width-to-platelet ratio in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVE: Red cell distribution width (RDW) is a measure of variation in the size of circulating red blood cells. Recent studies have reported a strong independent relation between elevated RDW and short- and long-term prognosis in various disorders. The aim of the present study was to investigate the relationship between admission RDW-to-platelet ratio (RPR) and in-hospital and long-term prognosis in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS: A total of 470 consecutive patients with a diagnosis of STEMI who underwent primary PCI were included in this prospective study. The patients were divided into two groups based on their admission RPR: high (>0.061) RPR group and low (≤0.061) RPR group. The patients were followed for adverse clinical outcomes in-hospital and for up to one year after discharge. RESULTS: In-hospital cardiovascular mortality, major adverse cardiovascular events (MACE), advanced heart failure and cardiogenic shock were significantly higher in the high RPR group (p<0.05). All-cause and cardiovascular mortality, MACE, fatal reinfarction, advanced heart failure, and rehospitalization for cardiac cause were more frequent in the high RPR group in one-year follow-up (p<0.05). High RPR was found to be a significant independent predictor of one-year cardiovascular mortality in multivariate analysis (p=0.003, OR: 3.106, 95% CI: 1.456-6.623). CONCLUSION: RPR is an inexpensive and readily available biomarker that provides an additional level of risk stratification beyond that provided by conventional risk parameters in predicting long-term MACE and cardiovascular mortality in STEMI.

Comparison of periprocedural and long term outcomes of proximal versus distal cerebral protection method during carotid artery stenting.

BACKGROUND: The aim of this study was to assess the periprocedural and one-year outcomes of two different cerebral protection systems used during carotid artery stenting (CAS). PATIENTS AND METHODS: We enrolled 90 consecutive patients with carotid artery stenosis who underwent CAS with a proximal flow blockage protection system (mean age 69.7 ± 8) or distal protection with a filter (mean age 70.8 ± 7). RESULTS: CAS was performed successively on 89 patients (99 %). Adverse events were defined as major stroke, minor stroke, transient ischemic attack (TIA), myocardial infarction, and death. Two strokes, one TIA, one death, and one myocardial infarction were observed in-hospital. There were no significant differences in safety or benefits between the proximal flow blockage embolic protection system (n = 45) and the distal filter protection system (n = 45) in terms of clinically apparent cerebral embolism, TIA, death, or myocardial infarction during the periprocedural stage or during the one-year follow-up period. CONCLUSIONS: Although it has been shown that the proximal flow blockage cerebral protection system decreases the risk of silent cerebral embolism, it has no advantage over the distal filter protection system in terms of adverse cerebrovascular or cardiac events during the periprocedural stage or during the long-term follow-up period.

Assessment of Mean Platelet Volume in Patients with Resistant Hypertension, Controlled Hypertension and Normotensives.

OBJECTIVE: Patients with resistant hypertension are at increased risk for cardiovascular events. Mean platelet volume (MPV) is an accepted biomarker of platelet activation and considered as a risk factor for cardiovascular disease. The aim of this study was to determine whether MPV levels are higher in resistant hypertensive (RHTN) patients than in controlled hypertensive (CHTN) patients and healthy normotensive controls. MATERIALS AND METHODS: 279 consecutive patients were included in this study. Patients were divided into three groups: Resistant hypertension patient group [n=78; mean age 56.8±9.8; 42 males (53.8%)]; controlled hypertension patient group [n=121; mean age 54.1±9.6; 49 males (40.5%)]; and normotensive control group [n=80; mean age 49.8±8.5; 34 males (42.5%)]. Physical examination, laboratory work-up, and 24-hour ambulatory blood pressure measurement (ABPM) were performed in all participants. RESULTS: The mean platelet volume levels were significantly higher in RHTN group than in the CHTN and normotensive groups (p<0.001). In correlation analysis office systolic and diastolic blood pressure was positively correlated with MPV. CONCLUSION: Our study demonstrated that MPV, as an important indicator of platelet activation, was statistically higher in RHTN patients than in CHTN and in normotensive subjects. Elevated MPV levels may help to determine a high risk group for atherosclerosis in RHTN patients.

Concomitant Transapical Transcatheter Valve Implantations: Edwards Sapien Valve for Severe Mitral Regurgitation in a Patient with Failing Mitral Bioprostheses and JenaValve for the Treatment of Pure Aortic Regurgitation.

Transcatheter valve implantation is a novel interventional technique, which was developed as an  alternative therapy for surgical aortic valve replacement in inoperable patients with severe aortic stenosis. Despite limited experience in using transcatheter valve implantation for mitral and aortic regurgitation, transapical transcatheter aortic valve implantation and valve-in-valve implantation for degenerated mitral valve bioprosthesis can be performed in high-risk patients who are not candidates for conventional replacement surgery. In this case, we present the simultaneous transcatheter valve implantation via transapical approach for both degenerated bioprosthetic mitral valve with severe regurgitation and pure severe aortic regurgitation.

The assessment of relationship between fragmented QRS complex and left ventricular wall motion score index in patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention.

OBJECTIVES: Fragmented QRS (fQRS) has been found to be associated with high mortality and arrhythmic events in acute coronary syndromes. Regional systolic function using wall motion score index (WMSI) is an alternative to left ventricular ejection fraction (LVEF) for the assessment of left ventricular systolic function. The aim of this study was to investigate the relation between the presence of fQRS on admission electrocardiogram (ECG) and WMSI in ST elevation myocardial infarction (STEMI) underwent primary coronary intervention (PCI). The in-hospital and long-term prognostic significance of persistent fQRS was also evaluated. METHODS: In this retrospective study, 542 patients with a diagnose of STEMI underwent primary PCI were included. Study patients were divided into two groups according to the presence (n = 153) or absence (n = 389) of a fQRS on admission ECG. RESULTS: WMSI was found to be significantly higher in fQRS(+) group compared to the fQRS(-) group (P < 0.001). In multivariete analysis, WMSI was found to be an independent predictor of fQRS, and fQRS was inversely associated with LVEF. The in-hospital reinfarction (P = 0.003), MACE (P = 0.024), intraaortic balloon pump use (P = 0.014), and advanced heart failure (P < 0.001) were found to be significantly more frequent in the fQRS(+) group. The presence of fQRS on admission was found to be associated with an increase in long-term cardiovascular mortality (P = 0.028), and long-term all-cause mortality (P = 0.022). CONCLUSION: WMSI was significantly related with the presence of the fQRS, which reflects the linking between impairment of regional left ventricular systolic function and the presence of severe myocardial injury in STEMI.

Long-term prognostic value of admission haemoglobin A1c (HbA1c) levels in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

INTRODUCTION: Many studies have reported the diagnostic and prognostic value of haemoglobin A1c (HbA1c) levels in patients with acute coronary syndrome. However, the short- and long-term prognostic value of HbA1c level in patients with ST elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is controversial. AIM: To investigate whether admission HbA1c level has a prognostic value for in-hospital, short-, and long-term cardiovascular (CV) mortality and major adverse cardiovascular events in patients with STEMI undergoing primary PCI. MATERIAL AND METHODS: This prospective study included 443 consecutive patients with STEMI who underwent primary PCI between September 2010 and July 2012. The patients were divided into three groups based on admission HbA1c levels: group I (HbA1c ≤ 5.6%), group II (HbA1c 5.7-6.4%), and group III (HbA1c ≥ 6.5%). The in-hospital, 1-month, and 1-year CV events of all 3 patient groups were followed up. RESULTS: A significant association was found between HbA1c level and 1-year primary clinical outcomes, including CV mortality, non-fatal reinfarction, and stroke (p = 0.037). In addition, age, Killip class > 1, and left ventricular ejection fraction were found to be independent predictors of long-term CV mortality in multivariate analysis (hazard ratios (95% confidence interval) 1.081 (1.020-1.146), 4.182 (1.171-14.935), and 0.832 (0.752-0.920); p = 0.009, p = 0.028, and p < 0.001, respectively). CONCLUSIONS: In this study, we demonstrated that increased admission HbA1c levels were associated with higher rates of major adverse CV events, including mortality, non-fatal reinfarction, and stroke, in patients with STEMI who underwent primary PCI.

Assessment of the relation between mean platelet volume, non-dipping blood pressure pattern, and left ventricular mass index in sustained hypertension.

BACKGROUND: Elevated mean platelet volume may reflect presence of active large platelets, which lead to fatal or non-fatal cardiovascular events. In recent studies, lack of nocturnal blood pressure fall was presented as an independent predictor of poor prognosis in essential hypertension. The relation of raised MPV with left ventricular hypertrophy has also been reported in hypertension. The aim of this study was to investigate the relation between MPV, non-dipping blood pressure pattern, and left ventricular mass index (LVMI) in sustained hypertension. MATERIAL AND METHODS: A total of 2500 patients, whose ambulatory blood pressure (ABP) records had been evaluated retrospectively between January 2010 and December 2012, were included. Patients were divided into 3 groups according to their ABP values: non-dipper hypertensive (n=289), dipper hypertensive (n=255), and normotensive (n=306). The MPV levels and biochemical analyses were recorded from patient files and, LVMI were automatically calculated using a regression equation. RESULTS: The non-dipper and dipper hypertensive groups had significantly higher MPV levels than normotensives (8.4±1 fL, 8.3±1 fL, and 8.1±0.6 fL, respectively, p<0.001). However, there was no difference among the non-dipper and dipper groups in terms of MPV level (p=0.675). Although LVMI was significantly different between non-dipper, dipper, and normotensive groups (p=0.009), no correlation was found between MPV level and LVMI in dipper and non-dipper hypertensive patients (r=-0.080, p=0.142). There was a weak correlation between MPV level and ambulatory 24-h diastolic and systolic blood pressure (r=0.076, p=0.027, and r=0.073, p=0.033, respectively). CONCLUSIONS: We demonstrated that there was no correlation between MPV level, non-dipping pattern of blood pressure, and LVMI in sustained hypertension.

Cerebral microemboli and neurocognitive change after carotid artery stenting with different embolic protection devices.

OBJECTIVES: Proximal cerebral protection devices have been developed as an alternative to filter protection devices for reducing neurological complications during carotid artery stenting (CAS). The aim of the present study was to evaluate the frequency of silent cerebral embolism after CAS using different cerebral embolic protection devices and the impact of silent cerebral embolism on neurocognitive function. METHODS: One hundred consecutive patients who underwent CAS were enrolled. The patients were randomized to either proximal balloon occlusion or filter protection. Neurocognitive tests were performed before and six months after CAS. Cerebral embolisms were evaluated with diffusion-weighted magnetic resonance imaging (DW-MRI). RESULTS: The number and volume of new ischemic lesions found with DW-MRI were higher in the filter protection group than in the proximal balloon occlusion group. According to our definition, nine (21%) patients in the balloon occlusion group and 16 (36%) patients in the filter protection group showed neurocognitive decline, and ten (23%) patients in the balloon occlusion group and four (9%) patients in the filter protection group showed neurocognitive improvement (NS). Regarding the group of patients with new cerebral ischemic lesions on DW-MRI, neurocognitive decline occurred in 14 (31%) of 45 patients with DW-MRI lesions and 11 (26%) of 43 patients without DW-MRI lesions (NS). CONCLUSION: Neurocognitive outcome after CAS is unpredictable; both neurocognitive decline and improvement can occur. In this study, the proximal balloon occlusion system significantly decreased cerebral microemboli during CAS compared to filter protection. Cerebral microembolism was not found to be associated with neurocognitive decline.