Carotid revascularization and cognitive impairment: the neglected role of cerebral small vessel disease

Intracranial Aneurysms and Cerebral Small Vessel Disease: Is There an Association between Large- and Small-Artery Diseases?

Background/Objectives: Intracranial aneurysms (IAs) may be connected to interactions between large and small intracranial vessels. We aimed to investigate the association between IAs and cerebral small-vessel disease (CSVD) and assess CSVD impact on IA patient management. Methods: This retrospective study analyzed clinical data and MRI features of CSVD in 192 subarachnoid hemorrhage (SAH) patients: 136 with incidental IA, 147 with severe CSVD without SAH/IA, and 50 controls without SAH, IA, or severe CSVD. MRI assessments followed the Standards for Reporting Vascular Changes on Neuroimaging (STRIVE), with a total burden of small-vessel disease (TBSVD) score calculated. Statistical analyses included forward selection and binary logistic regression. Results: TBSVD differed significantly across groups (p < 0.001), except between SAH and IA groups (p = 0.8). Controls had the lowest TBSVD (1.00; 1.22 ± 0.996), followed by SAH (2.00; 2.08 ± 1.013) and IA groups (2.00; 2.04 ± 1.141), with the highest in the CSVD group (1.00; 1.22 ± 0.996). White-matter hyperintensity (WMH) patterns varied with IA rupture status (p = 0.044); type A was prevalent in SAH patients and type D in the IA group. Incorporating MRI CSVD features and TBSVD into risk assessments did not enhance IA prediction or outcome models. Conclusions: IA patients exhibit a higher CSVD burden than controls, suggesting a link between small and large intracranial vessels. WMH patterns distinguish between ruptured and unruptured IA patients, offering potential markers for IA rupture risk assessment and signaling a paradigm shift in understanding IAs and CSVD.

Long-term cognitive and neurovascular changes after carotid endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) has been associated with both cognitive decline and improvement, but the underlying neurovascular mechanisms are unclear. The aim of this study was to investigate the relationship between neurovascular indices and cognitive changes after CEA.

METHODS

We studied 55 patients with severe (≥70%) symptomatic or asymptomatic carotid stenosis before and six months after CEA. A wide array of neuropsychological tests was arranged in eight cognitive domains and cognitive functions specific to hemisphere ipsilateral to operation. Differences in cognitive performance between patients and 38 matching healthy controls were studied with linear mixed models. Neurovascular functioning and microembolic signals were assessed with transcranial Doppler ultrasound of the middle cerebral artery. Associations between neurovascular indices and cognitive change were assessed with linear regression analyses.

RESULTS

On group level, the CEA patients improved more than controls in working memory, whereas no cognitive deterioration was detected. Also on individual level, improvement was most frequently observed in working memory. Worse preoperative cerebrovascular reactivity was related with improvement in cognitive functions of the ipsilateral hemisphere. Low preoperative pulsatility index was associated with improvement in executive functioning and ipsilateral cognitive functions. Poorer preoperative blood flow velocity associated with improvement in complex attention. Microembolic signals were rare.

CONCLUSION

The present findings suggest that CEA may have beneficial long-term effects on cognition. These effects may specifically involve patients with impaired preoperative circulatory adaptive mechanisms.

The risk factors of postoperative cognitive dysfunction in patients undergoing carotid endarterectomy: an updated meta-analysis

OBJECTIVE

The purpose of the current meta-analysis was to determine the incidence and risk factors to provide a scientific basis for prevention and treatment of postoperative cognitive dysfunction (POCD) after carotid endarterectomy (CEA).

METHODS

Relevant articles published before October 2022 were searched from Pubmed/MEDLINE, Cochrane and Embase databases. The outcomes were the incidence and risk factors for POCD. A random-effects model was applied to estimate the overall odds ratios (ORs) and mean differences (MDs) for all risk factors through STATA 14.0 and RevMan 5.4. The quality of eligible studies was evaluated by Newcastle-Ottawa Scale (NOS) as previously described.

RESULTS

A total of 22 articles involving 3459 CEA patients were finally identified. The weighted mean incidence of POCD was 19% (95% confidence intervals (95% CI) 0.16-0.24, P < 0.001). Of the 16 identified risk factors, hyperperfusion (OR: 0.54, 95% CI 0.41-0.71) and degree of internal carotid artery (ICA) stenosis (OR: 5.06, 95% CI 0.86-9.27) were the potential risk factors of POCD, whereas patients taking statins preoperative had a lower risk of POCD (OR: 0.54, 95% CI 0.41-0.71). Subgroup analysis revealed that the risk of POCD at 1 month after CEA was higher in patients with diabetes (OR: 1.70, 95% CI 1.07-2.71).

CONCLUSION

The risk factors of POCD were hyperperfusion and degree of ICA stenosis, while diabetes could significantly increase the incidence of POCD at 1 month after surgery. Additionally, preoperative statin use could be a protective factor for POCD following CEA.

Intracranial carotid artery calcification morphology differs in patients with lacunar and nonlacunar acute ischemic strokes

BACKGROUND AND PURPOSE

Intracranial carotid artery calcifications (ICACs) are a common finding on noncontrast computed tomography (NCCT) and have been associated with an increased risk of ischemic stroke. However, no data are available about the association between ICAC patterns and stroke etiology. We investigated the association between ICAC patterns and etiological subtypes of ischemic stroke.

METHODS

We retrospectively analyzed a single center cohort of patients admitted for ischemic stroke with known etiology. Each carotid artery was evaluated separately on NCCT scans to define the ICAC pattern (intimal, medial, mixed). The association between ICAC patterns and stroke etiology was investigated using logistic regression models adjusting for relevant confounders.

RESULTS

A total of 485 patients were included (median age = 78 [interquartile range (IQR) = 70-85] years, 243 [50%] female, median National Institutes of Health Stroke Scale = 6 [IQR = 3-12]). Frequencies of ICAC patterns were: intimal, n = 96 (20%); medial, n = 273 (56%); mixed, n = 51 (11%), indistinct/absent, n = 65 (13%) patients. Intimal pattern was more frequent in lacunar compared with nonlacunar (33% vs. 16%, p < 0.001) stroke etiology, whereas medial pattern was less frequent in lacunar compared with nonlacunar stroke (36% vs. 62%, p < 0.001). After adjustment for confounders, intimal ICAC predominant pattern remained associated with lacunar stroke etiology in two multivariate models (Model 1: adjusted odds ratio [aOR] = 2.08, 95% confidence interval [CI] = 1.20-3.56; Model 2: aOR = 2.01, 95% CI = 1.16-3.46).

CONCLUSIONS

Our study suggests that intimal ICAC pattern is associated with lacunar stroke and may serve as a marker for lacunar stroke etiology, possibly strengthening the relation between endothelial dysfunction and lacunar stroke.