Comparison of domain-specific cognitive function after carotid endarterectomy and stenting

The Effects of Carotid Revascularization on 1-Year Cognitive Performance in Patients With Carotid Artery Stenosis

PURPOSE

The impact of carotid revascularization on cognitive function for patients with severe carotid artery stenosis remains uncertain. This study is aimed to investigate the 1-year neurocognitive outcomes of patients who accept carotid revascularization and identify the risk factors associated with postoperative cognitive decline.

METHODS

From April 2019 to April 2021, patients with ≥70% carotid artery stenosis who were treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS) were recruited for this study. The Montreal Cognitive Assessment (MoCA) instrument was used to evaluate cognitive function preoperatively and at 3, 6, and 12 months postoperatively. Logistic regression analysis was built to identify potential risk factors for postoperative long-term cognitive decline.

RESULTS

A total of 89 patients who met the criteria were enrolled and completed 1-year follow-up. At 3, 6, and 12 months after carotid revascularization, the total MoCA score, attention, language fluency, and delayed recall score were significantly improved compared with the baseline scores (p<0.05). At 12 months, there was also a significant improvement in cube copying compared with baseline (p=0.034). Logistic regression analysis showed that the advancing age, left side, and symptomatic carotid artery stenosis were independent risk factors for cognitive deterioration at 12 months after surgery.

CONCLUSIONS

Overall, carotid revascularization has a beneficial effect on cognition function in patients with severe carotid artery stenosis, while advancing age, left side, and symptomatic carotid artery stenosis were significantly related to a decreased cognitive score after carotid revascularization.

CLINICAL IMPACT

This study focused on the changes in cognitive function within 1 year after carotid revascularization in patients with severe carotid stenosis. Of course, carotid revascularization can improve the cognition function in these patients. On the other hand, we found the advancing age, left side and symptomatic carotid artery stenosis were significantly associated with decreased cognitive scores at 1 year after carotid revascularization, which suggests that clinicians may need to be aware of patients with these characteristics.

Comparison of Perioperative Safety of Carotid Artery Stenting and Endarterectomy in the Treatment of Carotid Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Current management guidelines for the treatment of carotid stenosis are controversial. We performed this meta-analysis to evaluate the perioperative safety of carotid artery stenting (CAS) and endarterectomy.

METHODS

We systematically searched EMBASE, PubMed, Web of Science, and the Cochrane Library from inception to November 10, 2022, for randomized controlled trials that compared CAS with carotid endarterectomy (CEA) among patients with carotid stenosis. The analyzed outcomes mainly included stroke, death, myocardial infarction (MI), cranial nerve palsy, the cumulative incidence of mortality, stroke, or MI and the cumulative incidence of death or stroke in the perioperative periods. The risk ratio (RR) and 95% confidence interval (95% CI) were calculated and pooled. Subgroup analyses were based on whether patients were symptomatic or asymptomatic. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

Seventeen randomized controlled trials with 12,277 participants (6514 and 5763 in the CAS and CEA groups, respectively) were included. Pooled analysis demonstrated that compared with CEA, CAS was associated with decreased risks of perioperative MI (RR = 0.47, 95% CI = 0.29∼0.77) and perioperative cranial nerve palsy (RR = 0.02, 95% CI = 0.01∼0.06) but higher risks of perioperative stroke (RR = 1.48, 95% CI = 1.18∼1.87) and cumulative incidence of death or stroke (RR = 1.52, 95% CI = 1.20∼1.93).

CONCLUSIONS

The perioperative safety was equivalent between CAS and CEA. However, CEA may be preferred when considering both procedural safety and long-term efficacy in preventing recurrent stroke.

Cognitive functions and sense of coherence in patients with carotid artery stenosis-Preliminary report

Background

There is scarcely any data in the available literature on the relationship between sense of coherence (SOC) and cognitive functioning, and no information on the relationship between SOC and cognitive parameters in patients with carotid atherosclerosis.

Aim

The aim of this paper was to determine the relationship of SOC measured prior to carotid artery stenting (CAS) with neurocognitive functioning in patients with carotid atherosclerosis 12 months after CAS.

Methods

A total of 35 patients with carotid atherosclerosis completed the SOC-29 Orientation to Life Questionnaire (SOC-29) and completed a cognitive test battery twice, i.e., before (baseline-T1) and 12 months after stent implantation (follow-up-T2). Selected cognitive functions such as memory, attention, perception, visuospatial and executive functions and non-verbal fluency were assessed.

Results

One year after the procedure, patients with a higher SOC and sense of manageability present better performance in visual memory. Higher SOC and sense of meaningfulness are positively related to the speed of understanding the changing rules of card sorting (WCST).

Conclusion

Higher overall SOC and a component of sense of meaningfulness and manageability may be related to better cognitive functioning 1 year after the procedure.

Does Carotid Intervention Improve Cognitive Function?

Carotid artery disease has been linked to baseline cognitive impairment, even in asymptomatic patients. Therefore, there has been a persistent interest in investigating the impact of carotid revascularization on cognitive functions, but the results have been heterogeneous. Our recent prospective evaluation showed improved cognitive scores across multiple cognitive measures following carotid intervention. Herein, we summarize the studies published to date, identify the potential contributors to the inconsistency of post-interventional cognitive outcomes, and explore further opportunities in cognitive evaluations.

Cognitive function after carotid endarterectomy in asymptomatic patients

Asymptomatic carotid stenosis has been shown to be associated with progressive neurocognitive decline, but the effects of carotid endarterectomy (CEA) on this are not well defined. Due to the wide heterogeneity of studies and lack of standardization in cognitive function tests and study design, there is mounting scientific evidence to support the notion that CEA is effective in reversing or slowing neurocognitive decline; however, definitive conclusions are difficult to make. Further, while the association between ACS and cognitive decline has been well document, a direct etiological role has not been established. More research is required to elucidate the relationship between asymptomatic carotid stenosis and the benefit of carotid endarterectomy and its potential protective effects regarding cognitive decline. This article aims to review current evidence in preoperative and postoperative cognitive function in asymptomatic patients with carotid stenosis undergoing CEA.

Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis

OBJECTIVE

Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS.

METHODS

A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed.

RESULTS

Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA.

CONCLUSION

Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.

Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis

Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.

Cognitive Functions after Carotid Artery Stenting-1-Year Follow-Up Study

Background: The revascularization of carotid arteries minimizes the risk of future cerebral stroke and usually improves cognitive functions. The aim of this study was to assess changes in cognitive function and verify the hypothesis assuming an improvement of selected cognitive functions—psychomotor speed, visuospatial episodic memory, executive function and verbal fluency—in patients after carotid artery stenting during a 12-month follow-up. Methods: 47 persons subject to CAS, including 13 symptomatic persons, were examined before and 12 months after a procedure with a psychological test battery (digit symbol test—DS, Rey–Osterrieth complex figure test—ROCF, Wisconsin Card Sorting Test—WCST, letter verbal fluency—LVF). Sociodemographic data and clinical parameters were acquired from an author questionnaire. Results: The one-year follow-up, after the performed CAS procedure, demonstrated a significant improvement of psychomotor speed, visuospatial episodic memory, and executive function. No changes in the area of verbal fluency or decline in any of cognitive functions under analysis were observed. Conclusions: Carotid artery stenting improves cognitive functioning, both in the area of basic and more complex cognitive functions in persons with carotid atherosclerosis.

Carotid revascularization improves cognitive function in patients with asymptomatic carotid artery stenosis

OBJECTIVE

To investigate cognitive changes after carotid revascularization in elderly patients with asymptomatic carotid artery stenosis. We also compared cognitive outcomes of carotid endarterectomy with stenting in asymptomatic patients.

METHODS

From April 2019 to December 2019, patients with ≥70% asymptomatic carotid stenosis who were treated with CEA or CAS were recruited for this study. The Montreal cognitive assessment (MoCA) instrument was used to evaluate cognitive function preoperatively and postoperatively at 3, 6, and 12 months. The incidence of ipsilateral ischemic cerebrovascular events and restenosis were analyzed within 12 months.

RESULTS

In 50 patients treated with CEA or CAS, baseline cognitive function was not different between CEA and CAS groups (P > 0.05). There was no difference in the incidence of ipsilateral ischemic cerebrovascular events and restenosis within the first 12 months between the two groups. There was a significant improvement in the total MoCA score, scores of attention, and delayed recall at 3, 6 and 12 months after revascularization compared with scores at baseline (all p<0.001). At 12 months, scores of cube copying and clock drawing were significantly improved (P=0.014, P=0.020). The clock drawing score was improved at 12 months after CAS compared with CEA (P=0.040).

CONCLUSIONS

Carotid revascularization has a beneficial effect on cognition in asymptomatic patients within 12 months of the procedure. Compared with CEA, CAS show improved test scores of executive functioning by 1 year.

Association between carotid revascularization for asymptomatic stenosis and cognitive functions

Summary: Asymptomatic carotid stenosis (ACS) can cause cognitive dysfunction, related to cerebral hypoperfusion and microemboli. These mechanisms could be treated by carotid revascularization, but the impact of carotid angioplasty stenting (CAS) or carotid endarterectomy (CEA) on cognitive functions remains unclear. The aim of this systematic review was to realize a report on the actual state of results about asymptomatic carotid stenosis revascularization and cognitive function. We performed a systematic literature review to analyze all studies assessing the impact of asymptomatic carotid stenosis revascularizations on cognitive functions. We reviewed all publications published in Medline database and Cochrane between January 2010 and January 2020 including subjects with a cognitive evaluation and receiving carotid revascularization for asymptomatic stenosis. We identified 567 records for review, and finally we included in the systematic review 20 studies about ACS revascularization and cognitive functions. Only observational studies analyzed the impact of CEA and CAS on cognitive functions. Thus, too heterogeneous data associated to the lack of randomized controlled trials with an evaluation of optimal medical treatment did not enable to affirm the interest of the revascularization management of ACS in cognitive domain. There was a lack of standardization and finally studies were too heterogeneous to conclude on the impact of carotid revascularization on cognitive functions. There is an urgent need to harmonize research in this domain in order to prevent and treat cognitive dysfunction related to ACS, especially in our society with an aging population.

A systematic review of cognitive function after carotid endarterectomy in asymptomatic patients

OBJECTIVE

Asymptomatic carotid stenosis has been associated with a progressive decline in neurocognitive function. However, the effect of carotid endarterectomy on this process is poorly understood. We aimed to evaluate pre and post-operative cognitive function changes in asymptomatic patients after carotid endarterectomy METHODS: A systematic review of the existing reports in PubMed/MEDLINE, Embase, and Cochran databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement recommendations. All original retrospective or prospective studies (including cohort, cross-sectional, case-control, pilot studies, etc.) and clinical trials that compared pre and post-operative neurocognitive function in asymptomatic patients with carotid stenosis after CEA, which were published from January 2000 to April 2021 were identified and considered eligible for inclusion in the study.

RESULTS

Thirteen studies (502 CEAs) comparing cognitive function changes before and after CEA were identified. In seven studies with a total number of 272 patients, a mean age range of 67.3 ± 4.8 to 76.35 years old and after follow-up ranging between 1 and 12 months, overall cognitive function improved after CEA. However, in six studies with a total sample of 230, a mean age range of 68.6 ± 6.9 to 74.4±6.1 years, and follow-up ranged from 24 hours to 3 years, showed no change or decline in overall cognitive function after procedures.

CONCLUSIONS

The lack of standardization of specific cognitive tests and cognitive function assessment timing after CEA does not allow for definite conclusions to be made. However, improving the brain perfusion with combination of CEA and statin therapy may be a protective strategy against cognitive function decline.

ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES

OBJECTIVES

Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA).

METHODS

A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor.

RESULTS

Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71).

CONCLUSIONS

A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.

Cognitive Functions in Patients after Carotid Artery Revascularization-A Narrative Review

Carotid revascularization may lead to improved cognitive function beyond stroke prevention. This article summarizes the conclusions from available studies on the effects of carotid reperfusion procedures on cognitive function. The papers cited used different neuropsychological tests for cognitive assessment, resulting in different methodologies and the results obtained were not always convergent. However, most studies reported an improvement in neurocognitive abilities after both vascular interventions, but a more precise assessment of the specific benefits is still awaited. Clinical determinants to predict the effects of these treatments on cognitive function are still being sought, but results are not yet satisfactory. In view of these studies, carotid stenosis seems to be an independent risk factor for cognitive deterioration, and the main mechanisms responsible are embolism and cerebral hypoperfusion. The aim of this study is to order the knowledge about the effects of carotid artery stenting (CAS) and endarterectomy (CEA) on neurocognitive functions and to verify the usefulness of using these treatments.

Effect of Carotid Interventions on Cognitive Function in Patients With Asymptomatic Carotid Stenosis: A Systematic Review

OBJECTIVE

To determine the effect of carotid endarterectomy (CEA) and carotid artery stenting (CAS) on early (baseline vs. maximum three months) and late (baseline vs. at least five months) cognitive function in patients with exclusively asymptomatic carotid stenoses (ACS).

METHOD

Searches were conducted in PubMed/Medline, Embase, Scopus, and the Cochrane library. This systematic review includes 31 non-randomised studies.

RESULTS

Early post-operative period: In 24 CEA/CAS/CEA+CAS cohorts (n = 2 059), two cohorts (representing 91/2 059, 4.4% of the overall study population) reported significant improvement in cognitive function, while one (28/2 059, 1%) reported significant decline. Three cohorts (250/2 059, 12.5% reported "mixed findings" where some cognitive scores significantly improved, and a similar proportion declined. The majority (nine cohorts; 1 086/2 059, 53%) reported no change. Seven cohorts (250/2 059, 12.1%) were mostly unchanged but one to two individual test scores improved, while two cohorts (347/2 059, 16.8%) were mostly unchanged with one to two individual test scores worse. Late post-operative period: In 21 cohorts (n = 1 554), one (28/1 554, 1.8%) reported significantly worse cognitive function, one reported significant improvement (24/1 554, 1.5%), while a third (19/1 554, 1.2%) reported "mixed findings". The majority were unchanged (six cohorts; 1 073/1 554, 69%) or mostly unchanged, but with one to two cognitive tests showing significant improvement (11 cohorts; 386/1 554, 24.8%). Overall, there was a similar distribution of findings in small, medium, and large studies, in studies with controls vs. no controls, in studies comparing CEA vs. CAS, and in studies with shorter/longer late follow up.

CONCLUSION

Notwithstanding accepted limitations regarding heterogeneity within non-randomised studies, CEA/CAS rarely improved overall late cognitive function in ACS patients (< 2%) and the risk of significant cognitive decline was equally low (< 2%). In the long term, the majority were either unchanged (69%) or mostly unchanged with one to two test scores improved (24.8%). Until new research identifies vulnerable ACS subgroups (e.g., impaired cerebral vascular reserve) or provides evidence that silent embolisation from ACS causes cognitive impairment, evidence supporting intervention in ACS patients to prevent/reverse cognitive decline is lacking.

European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis

Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.

Changes in Cognition and Hemodynamics 1 Year after Carotid Endarterectomy for Asymptomatic Stenosis

OBJECTIVES

 The impact of a change in hemodynamics on cognitive skills in patients with asymptomatic carotid stenosis (ACS) after carotid endarterectomy (CEA) remains unclear. The aim of this study was to evaluate the results of CEA for ACS at 1 year by assessing the changes in anterior, middle, and posterior cerebral artery blood flow in tandem with changes in cognitive efficiency.

METHODS

 Flow volume in cerebral arteries using quantitative magnetic resonance angiography was measured in a group of 14 males and 5 females before and at 1 year after CEA for ACS. Cognitive efficiency was assessed by Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The values of flow volume were processed using simple ratio (SR) and were used for covariance analyses with changes in cognitive skills after CEA.

RESULTS

 A significant improvement in cognitive efficiency indexes of immediate memory and visuospatial perception at 1 year after CEA for ACS was observed. Simultaneously, a significant deterioration of speech index was noted. During the analysis of association between flow and cognition, the highest correlation could be seen between the middle cerebral artery (MCA) flow and the visuospatial perception. A change in posterior cerebral artery (PCA) flow was associated with an increase in immediate memory index and anterior cerebral artery (ACA) flow change with the speech index.

CONCLUSION

 Convergence of data supporting the association between revascularization and cognitive improvement were added in a small, single-center cohort of ACS patients undergoing CEA. No significant differences in cognition were seen between preoperative findings and at 1 year after CEA. Visuospatial perception improvement was linked to flow change in MCA, immediate memory improvement to flow change in PCA, and speech index change to flow change in ACA. Methodical limitations of this small study preclude formulating larger generalizations. Hemodynamic factors in CEA should be assessed in a larger-scale study.

Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment

BACKGROUND

Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT).

METHODS

Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months followup periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only.

RESULTS

Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period.

CONCLUSION

Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.

Role of Carotid Artery Stenting in Prevention of Stroke for Asymptomatic Carotid Stenosis: Bayesian Cross-Design and Network Meta-Analyses

Background and Objectives

There is insufficient evidence regarding the optimal treatment for asymptomatic carotid stenosis.

Methods

Bayesian cross-design and network meta-analyses were performed to compare the safety and efficacy among carotid artery stenting (CAS), carotid endarterectomy (CEA), and medical treatment (MT). We identified 18 studies (4 randomized controlled trials [RCTs] and 14 nonrandomized, comparative studies [NRCSs]) comparing CAS with CEA, and 4 RCTs comparing CEA with MT from MEDLINE, Cochrane Library, and Embase databases.

Results

The risk for periprocedural stroke tended to increase in CAS, compared to CEA (odds ratio [OR], 1.86; 95% credible interval [CrI], 0.62–4.54). However, estimates for periprocedural myocardial infarction (MI) were quite heterogeneous in RCTs and NRCSs. Despite a trend of decreased risk with CAS in RCTs (OR, 0.70; 95% CrI, 0.27–1.24), the risk was similar in NRCSs (OR, 1.02; 95% CrI, 0.87–1.18). In indirect comparisons of MT and CAS, MT showed a tendency to have a higher risk for the composite of periprocedural death, stroke, MI, or nonperiprocedural ipsilateral stroke (OR, 1.30; 95% CrI, 0.74–2.73). Analyses of study characteristics showed that CEA-versus-MT studies took place about 10-year earlier than CEA-versus-CAS studies.

Conclusions

A similar risk for periprocedural MI between CEA and CAS in NRCSs suggested that concerns about periprocedural MI accompanied by CEA might not matter in real-world practice when preoperative evaluation and management are working. Maybe the benefits of CAS over MT have been overestimated considering advances in medical therapy within10-year gap between CEA-versus-MT and CEA-versus-CAS studies.

Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis

BACKGROUND

Carotid artery stenting is an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004, 2007, and 2012.

OBJECTIVES

To assess the benefits and risks of stenting compared with endarterectomy in people with symptomatic or asymptomatic carotid stenosis.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched August 2018) and the following databases: CENTRAL, MEDLINE, Embase, and Science Citation Index to August 2018. We also searched ongoing trials registers (August 2018) and reference lists, and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing stenting with endarterectomy for symptomatic or asymptomatic atherosclerotic carotid stenosis. In addition, we included RCTs comparing carotid artery stenting with medical therapy alone.

DATA COLLECTION AND ANALYSIS

One review author selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endarterectomy as the reference group. We quantified heterogeneity using the I² statistic and used GRADE to assess the overall certainty of evidence.

MAIN RESULTS

We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy stenting was associated with a higher risk of periprocedural death or stroke (the primary safety outcome; OR 1.70, 95% CI 1.31 to 2.19; P < 0.0001, I² = 5%; 10 trials, 5396 participants; high-certainty evidence); and periprocedural death, stroke, or myocardial infarction (OR 1.43, 95% CI 1.14 to 1.80; P = 0.002, I² = 0%; 6 trials, 4861 participants; high-certainty evidence). The OR for the primary safety outcome was 1.11 (95% CI 0.74 to 1.64) in participants under 70 years old and 2.23 (95% CI 1.61 to 3.08) in participants 70 years old or more (interaction P = 0.007). There was a non-significant increase in periprocedural death or major or disabling stroke with stenting (OR 1.36, 95% CI 0.97 to 1.91; P = 0.08, I² = 0%; 7 trials, 4983 participants; high-certainty evidence). Compared with endarterectomy, stenting was associated with lower risks of myocardial infarction (OR 0.47, 95% CI 0.24 to 0.94; P = 0.03, I² = 0%), cranial nerve palsy (OR 0.09, 95% CI 0.06 to 0.16; P < 0.00001, I² = 0%), and access site haematoma (OR 0.32, 95% CI 0.15 to 0.68; P = 0.003, I² = 27%). The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.51, 95% CI 1.24 to 1.85; P < 0.0001, I² = 0%; 8 trials, 5080 participants; high-certainty evidence). The rate of ipsilateral stroke after the periprocedural period did not differ between treatments (OR 1.05, 95% CI 0.75 to 1.47; P = 0.77, I² = 0%). In participants with asymptomatic carotid stenosis, there was a non-significant increase in periprocedural death or stroke with stenting compared with endarterectomy (OR 1.72, 95% CI 1.00 to 2.97; P = 0.05, I² = 0%; 7 trials, 3378 participants; moderate-certainty evidence). The risk of periprocedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR 1.27, 95% CI 0.87 to 1.84; P = 0.22, I² = 0%; 6 trials, 3315 participants; moderate-certainty evidence). Moderate or higher carotid artery restenosis (50% or greater) or occlusion during follow-up was more common after stenting (OR 2.00, 95% CI 1.12 to 3.60; P = 0.02, I² = 44%), but the difference in risk of severe restenosis was not significant (70% or greater; OR 1.26, 95% CI 0.79 to 2.00; P = 0.33, I² = 58%; low-certainty evidence).

AUTHORS' CONCLUSIONS

Stenting for symptomatic carotid stenosis is associated with a higher risk of periprocedural stroke or death than endarterectomy. This extra risk is mostly attributed to an increase in minor, non-disabling strokes occurring in people older than 70 years. Beyond the periprocedural period, carotid stenting is as effective in preventing recurrent stroke as endarterectomy. However, combining procedural safety and long-term efficacy in preventing recurrent stroke still favours endarterectomy. In people with asymptomatic carotid stenosis, there may be a small increase in the risk of periprocedural stroke or death with stenting compared with endarterectomy. However, CIs of treatment effects were wide and further data from randomised trials in people with asymptomatic stenosis are needed.

eGFR and deep white matter hyperintensity as predictors of cognitive decline long after carotid endarterectomy

Chronic kidney disease and white matter hyperintensity (WMH) are associated with cognitive decline. The aim of this study was to assess the correlations between estimated glomerular filtration rate (eGFR) or WMH and cognitive function in patients who have undergone carotid endarterectomy (CEA). Cognitive functions were investigated using the Neurobehavioral Cognitive Status Examination (Cognistat) in 83 patients who had undergone CEA. The eGFR at 5 years prior to examination was significantly associated with severe cognitive impairment (odds ratio, 0.89 per 1-mL/min/1.73 m² increase, 95% confidence interval 0.82–0.97, p = 0.0004). Receiver operating characteristic analysis revealed that a cutoff eGFR of 46.8 mL/min/1.73 m² at 5 years prior to examination offered the most reliable predictor of severe cognitive impairment (sensitivity 88.9%, specificity 76.5%, area under the curve 0.848). The eGFR at 5 years prior to examination showed a significant linear association with total Cognistat score (r² = 0.11035, p = 0.0032) compared to eGFR at 3 years prior to examination (r² = 0.06455, p = 0.0230) or at examination (r² = 0.0210, p = 0.0210). Spearman’s correlation coefficient revealed that orientation, comprehension, repetition, construction, memory, and similarity correlated with eGFR at 5 years prior to examination. Conversely, Fazekas grade for deep WMH at examination was associated with total Cognistat score (p = 0.0016), unlike that at 3 years (p = 0.0100) or 5 years prior to examination (p = 0.0172). While eGFR correlates with future cognitive function, deep WMH associates with present cognitive function in patients who have undergone CEA.

Beneficial Effect of Carotid Artery Stenting on Cerebral Hemodynamic Impairment and Cognitive Function

The aim of this study was to evaluate the effects of the carotid artery stenting (CAS) procedure on cerebral hemodynamics and cognitive performance in patients with internal carotid artery stenosis. In this prospective observational study, 16 consecutive patients in a single institute were treated with CAS from 2010 to 2011 (71.7 ± 7.3 years old, 12 males, and six left-sided procedures). Before and after the CAS procedure, all patients were evaluated with single photon emission computed tomography using ¹²³ I-iodoamphetamine and acetazolamide as well as the Weschler Adult Intelligent Scale (WAIS) to assess three intelligent quotients and four indexes. Patients with decreased preprocedural cerebral blood flow (CBF) and cerebrovascular reserve (CVR) experienced significant increases in CBF and CVR (P = 0.01 and 0.03). Twelve (75%) patients experienced a significant increase in one or more WAIS scores, while two (13%) showed a significant decrease. The most frequently improved scores were the Working Memory Index and Processing Speed Index (seven patients/44%). Preprocedural CBF was significantly correlated with the Full-scale and Performance Intelligent Quotients (r = 0.51–0.56, P = 0.02–0.04), and patients who experienced a significant increase in these scores had larger increases in CVR than patients with unchanged scores (P = 0.0097–0.019). These results indicate that the CAS procedure improved impaired cerebral hemodynamics and might benefit the cognitive function of patients with internal carotid artery stenosis related to impaired cerebral hemodynamics.

Cognitive improvement after carotid artery stenting in patients with symptomatic internal carotid artery near-occlusion

BACKGROUND AND PURPOSE

To investigate the influence of carotid artery stenting (CAS) with embolic protection device (EPD) on the cognitive function of patients with near-occlusion of the cervical internal carotid artery (ICA).

METHODS

From February 2014 to December 2017, a total of 79 symptomatic patients were recruited in this study. Of these patients, 31 patients refused to receive CAS therapy. They were divided into the CAS group (48 patients) and the medical treatment group (31 patients). Montreal cognitive assessment (MoCA) instrument was used for the evaluation of cognitive function. The analyzed endpoints included cumulative 12 month incidence of ipsilateral ischemic cerebrovascular events and MoCA scores at 1 month and 12 months after treatment.

RESULTS

Cumulative 12 months incidence of ipsilateral ischemic cerebrovascular events was lower in patients who underwent CAS than in patients on medical treatment (P < 0.05). In CAS group, the total MoCA score, scores of attention and delayed recall at months 1 and 12 increased when compared with those at baseline (P < 0.05). In medical treatment group, the total MoCA score and attention score at month 12 decreased when compared with those at baseline (P < 0.05). In CAS group, the total MoCA score, scores of line connection test, drawing clock, attention and delayed recall were improved at 1 and 12 months when compared with medical treatment at the same time points (P < 0.05).

CONCLUSIONS

CAS with EPD not only decreases the risk of ipsilateral TIA and stroke but also may improve the cognitive function of symptomatic patients with ICA near-occlusion.

Influence of collateral circulation on cerebral blood flow and frontal lobe cognitive function in patients with severe internal carotid artery stenosis

Background

This study aimed to investigate the cerebral blood flow (CBF) and frontal lobe cognitive function in severe internal carotid artery (ICA) stenosis patients with different types of collateral circulation.

Methods

One hundred twenty-six patients with severe unilateral ICA stenosis were enrolled. Digital subtraction angiography (DSA) was performed to recruit patients with one of three common types of collateral circulation: anterior communicating artery (AcoA), posterior communicating artery (PcoA) and ophthalmic artery (OA). The hemodynamic parameters of the middle cerebral artery (MCA) were measured using transcranial Doppler (TCD), and the individual frontal lobe cognitive attention functions were evaluated using Word Fluency Test, Trail-Making Test (TMT), Digit Span, and Stroop Color Word Test (SCWT). The correlation between hemodynamic changes and the scores of all tasks was analyzed.

Results

On the side of arterial stenosis, the CBF velocities were highest in AcoA group and lowest in the OA group. All patients performed worse in TMT and Digit Span than the matched normal controls. The AcoA group exhibited a lower pulsatility index (PI) and a longer response time in the Stroop task, but had a higher accuracy rate in the Stroop task and higher scores in Word Fluency Test than the PcoA and OA groups. In all the three groups, PI was positively correlated with the accuracy rate for Stroop interference effects.

Conclusions

Our findings suggested that the frontal lobe cognitive function of patients with ICA was impaired, and AcoA collaterals may be beneficial for selective attention functions, whereas OA collaterals may be associated with impairment of selective attention functions. Additionally, a high PI may be an indicator for identifying impaired selective attention in patients with severe ICA stenosis.

Dynamics of brain perfusion and cognitive performance in revascularization of carotid artery stenosis

INTRODUCTION

There is evidence suggesting a detrimental effect of asymptomatic carotid artery stenosis on cognitive function even in the absence of ischemic cerebral lesions. Hypoperfusion has been suggested as pathophysiological mechanism causing cognitive impairment. We aimed to assess cognitive performance and cerebral perfusion changes in patients with carotid artery stenosis without ischemic lesions by arterial spin labeling (ASL) and contrast enhanced (CE) perfusion MRI before and after revascularization therapy.

METHODS

17 asymptomatic patients with unilateral high-grade (≥70%) carotid artery stenosis without evidence of structural brain lesions underwent ASL and CE perfusion MRI and cognitive testing (MMSE, DemTect, Clock-Drawing Test, Trail-Making Test, Stroop Test) before and 6-8 weeks after revascularization therapy by endarterectomy or stenting. Multiparametric perfusion maps (ASL: cerebral blood flow (ASL-CBF), bolus arrival time (ASL-BAT); CE: cerebral blood flow (CE-CBF), mean transit time (CE-MTT), cerebral blood volume (CE-CBV)) were calculated and analyzed by vascular territory. Relative perfusion values were calculated.

RESULTS

Multivariate analysis revealed a significant impact of revascularization therapy on all perfusion measures analyzed. At baseline post-hoc testing showed significant hypoperfusion in MCA borderzones as assessed by ASL-CBF, ASL-BAT, CE-MTT and CE-CBV. All perfusion alterations normalized after revascularization. We did not observe any significant correlation of cognitive test results with perfusion parameters. There was no significant change in cognitive performance after revascularization.

CONCLUSION

We found evidence of traceable perfusion alterations in patients with high grade carotid artery stenosis in the absence of structural brain lesions, which proved fully reversible after revascularization therapy. In this cohort of asymptomatic patients we did not observe an association of hypoperfusion with cognitive performance.

Is Hemispheric Hypoperfusion a Treatable Cause of Cognitive Impairment?

PURPOSE OF REVIEW

To review the current literature that supports the notion that cerebral hemodynamic compromise from internal carotid artery stenosis may be a cause of vascular cognitive impairment that is amenable to treatment by revascularization.

RECENT FINDINGS

Converging evidence suggests that successful carotid endarterectomy and carotid artery stenting are associated with reversal of cognitive decline in many patients with severe but asymptomatic carotid artery stenosis. Most of these findings have been derived from cohort studies and comparisons with either normal or surgical controls. Failure to find treatment benefit in a number of studies appears to have been the result of patient heterogeneity or confounding from concomitant conditions independently associated with cognitive decline, such as heart failure and other cardiovascular risk factors, or failure to establish pre-procedure hemodynamic failure. Patients with severe carotid artery stenosis causing cerebral hemodynamic impairment may have a reversible cause of cognitive decline. None of the prior studies, however, were done in the context of a randomized clinical trial with large numbers of participants. The ongoing CREST-2 trial comparing revascularization with medical therapy versus medical therapy alone, and its associated CREST-H study determining whether cognitive decline is reversible among those with hemodynamic compromise may address this question.

Convergence Analysis of Micro-Lesions (CAML): An approach to mapping of diffuse lesions from carotid revascularization

Carotid revascularization (endarterectomy, stenting) prevents stroke; however, procedure-related embolization is common and results in small brain lesions easily identified by diffusion weighted magnetic resonance imaging (DWI). A crucial barrier to understanding the clinical significance of these lesions has been the lack of a statistical approach to identify vulnerable brain areas. The problem is that the lesions are small, numerous, and non-overlapping. Here we address this problem with a new method, the Convergence Analysis of Micro-Lesions (CAML) technique, an extension of the Anatomic Likelihood Analysis (ALE). The method combines manual lesion tracing, constraints based on known lesion patterns, and convergence analysis to represent regions vulnerable to lesions as probabilistic brain atlases. Two studies were conducted over the course of 12 years in an active, vascular surgery clinic. An analysis in an initial group of 126 patients at 1.5 T MRI was cross-validated in a second group of 80 patients at 3T MRI. In CAML, lesions were manually defined and center points identified. Brains were aligned according to side of surgery since this factor powerfully determines lesion distribution. A convergence based analysis, was performed on each of these groups. Results indicated the most consistent region of vulnerability was in motor and premotor cortex regions. Smaller regions common to both groups included the dorsolateral prefrontal cortex and medial parietal regions. Vulnerability of motor cortex is consistent with previous work showing changes in hand dexterity associated with these procedures. The consistency of CAML also demonstrates the feasibility of this new approach to characterize small, diffuse, non-overlapping lesions in patients with multifocal pathologies.

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Convergence Analysis of Micro-Lesions technique finds patterns in diffuse lesions.

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Lesions from carotid revascularization affect consistent brain targets.

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Motor cortex is the most vulnerable brain region to these lesions.

Carotid stenosis - basing treatment on individual patients' needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

Though carotid artery stenosis is a known origin of stroke, risk assessment and treatment modality are not yet satisfactorily established. Guideline updates according to latest evidence are expected shortly. Current clinical weakness concerns in particular the identification of "at-risk" patients. Beside the symptomatic status and the degree of stenosis, further signs of unstable plaque on carotid and cerebral imaging should be considered. Moreover, medical and endovascular therapy are continuously improving. Randomized trials and meta-analyses have shown similar long-term results for protected carotid artery stenting and endarterectomy. However, endovascular revascularization was associated with an increased 30-day rate of minor strokes. Newly developed embolic protection devices could possibly compensate for this disadvantage. Furthermore, high-level optimal medical therapy alone is currently being evaluated comparatively. We assume that a comprehensive evaluation of plaque vulnerability, serious consideration of advanced embolic protection, and more space for optimal medical therapy alone according to latest evidence, will benefit patients with carotid stenosis.

Effective collateral circulation may indicate improved perfusion territory restoration after carotid endarterectomy

OBJECTIVES

To investigate the relationship between the level of collateral circulation and perfusion territory normalisation after carotid endarterectomy (CEA).

METHODS

This study enrolled 22 patients with severe carotid stenosis that underwent CEA and 54 volunteers without significant carotid stenosis. All patients were scanned with ASL and t-ASL within 1 month before and 1 week after CEA. Collateral circulation was assessed on preoperative ASL images based on the presence of ATA. The postoperative flow territories were considered as back to normal if they conformed to the perfusion territory map in a healthy population. Neuropsychological tests were performed on patients before and within 7 days after surgery.

RESULTS

ATA-based collateral score assessed on preoperative ASL was significantly higher in the flow territory normalisation group (n=11, 50 %) after CEA (P < 0.0001). The MMSE (mean change=1.36±0.96) and MOCA (mean change=1.18±0.95) test scores showed a significant postoperative (7 days after CEA) improvement in the flow territory normalisation group [>mean differences+2SD among control (MMSE=1.35, MOCA=1.02)].

CONCLUSIONS

This study demonstrated that effective collateral flow in carotid stenosis patients was associated with normalisation of t-ASL perfusion territory after CEA. The perfusion territory normalisation group tends to have more cognitive improvement after CEA.

KEY POINTS

• Evaluation of collaterals before CEA is helpful for avoiding ischaemia during clamping. • There was good agreement on ATA-based ASL collateral grading. • Perfusion territories in carotid stenosis patients are altered. • Patients have better collateral circulation with perfusion territory back to normal. • MMSE and MOCA test scores improved more in the territory normalisation group.

Carotid Stenosis and Impaired Cognition: The Effect of Intervention

There is a clear association between carotid artery stenosis and cognitive impairment. However, there is no consensus as to how to interpret this association, and what, if any, impact this connection should have on the management of carotid stenosis. A review of the relevant literature suggests that although an intervention to relieve carotid stenosis in patients without clinically significant cognitive impairment does not improve cognition, there may be a cognitive benefit with intervention for carotid stenosis in those patients with clinically significant cognitive disorders.

Influence of Severe Carotid Stenosis on Cognition, Depressive Symptoms and Quality of Life

BACKGROUND

Carotid artery disease is not just a causal risk factor of ischemic stroke, but may predispose patients to depressive symptoms and low health related quality of life (HRQoL).

OBJECTIVES

The objectives of the present study were to assess the association between severe carotid artery stenosis (CAS) and cognitive impairment, frequency of depressive symptoms and status of HRQoL.

METHODS

Cross - sectional study involved 55 patients with severe CAS and 54 patients with lower extremity peripheral artery disease (PAD). Cognitive impairment was assessed using Montreal Cognitive Assessment Scale (MoCA), depressive symptoms - PHQ-9 scale. HRQoL was measured using Medical Outcome Survey Short Form version 2 (SF-36v2).

RESULTS

Median MoCA score 24 [23;26] was significantly lower in patients with severe CAS than in patients with PAD - 26 [25-28],(p=0.005; effect size r=0.3). There was no statistically significant difference of median PHQ-9 scores the in CAS group (median PHQ-9 score 4.0 [5]) and in the PAD group (median PHQ-9 score 5.5 [7]), (p=0.08, effect size r=0.18). Mean SF-36v2 scores were similar in CAS and PAD groups except for bodily pain (p=0.001, Cohen's d value = 0.77) and vitality (p=0.02, Cohen's d value = 0.49).

CONCLUSION

In summary, our findings indicate that severe CAS could play a role in cognitive decline. Further studies should be conducted using larger patient cohorts without ischemic brain lesions and with balanced vascular risk profiles to investigate impact of CAS on cognition. There was no association between severe CAS and depressive symptoms in the present study. As patients with severe CAS did not exhibit physical symptoms, HRQoL was better for those patients than for patients with lower extremity PAD.

Transcatheter aortic valve replacement: perioperative stroke and beyond

INTRODUCTION

The definition of stroke has changed over time, from a clinical only-based diagnosis to a more complex classification, including both clinical and imaging-based criteria, in part due to widespread use of magnetic resonance imaging (MRI). The increasing number of transcatheter aortic valve replacement (TAVR) procedures in patients with severe aortic valvular stenosis who are considered high-risk surgical candidates has influenced our view on the diagnosis, interpretation, and significance of perioperative stroke during these procedures. Areas covered: In this perspective, we summarize changes in the definition and diagnostic criteria for stroke and transient ischemic attacks. We examine how the introduction of MRI and standardized cognitive tests has affected our understanding of the safety of TAVR procedures. Finally, we review the growing evidence regarding the role of cerebral protection technology during TAVR procedures on cognitive function. Expert commentary: Standardized MRI-based protocols and prospective evaluation of neurologic deficits with a battery of cognitive assessment tests are needed to ensure accurate recognition of postprocedural clinical events in patients undergoing TAVR procedures and to confirm the effectiveness of embolic protection technology.

Cognitive Outcomes of Cardiovascular Surgical Procedures in the Old: An Important but Neglected Area

Older individuals can now undergo invasive cardiovascular procedures without serious concern about mortality, and the numbers and proportions of the over 65s and 85s doing so in Australia has been increasing over the last 20 years. There is overwhelming evidence linking cardiovascular conditions to late-life (65 years and over) cognitive impairment and dementia including Alzheimer's Disease, primarily due to impaired cerebrovascularisation and cascading neuropathological processes. Somewhat paradoxically, these cardiovascular interventions, carried out with the primary aim of revascularisation, are not usually associated with short- or long-term improvements in cognitive function in older adults. We discuss factors associated with cognitive outcomes post-cardiovascular surgeries in patients over 65 years of age. There are many opportunities for future research: we know almost nothing about cognitive outcomes following invasive cardiac procedures in the oldest old (85 years and over) nor how to predict the cognitive/delirium outcome using pre-surgical data, and lastly, intervention opportunities exist both pre and postoperatively that have not been tested. As our population ages with increased cardiovascular burden and rates of cardiovascular interventions and surgeries, it is critical that we understand the cognitive consequences of these procedures, who is at greatest risk, and ways to optimise cognition.

Microembolization is associated with transient cognitive decline in patients undergoing carotid interventions

OBJECTIVE

Carotid interventions are important in helping to reduce the risk of stroke for patients with high-grade carotid artery stenosis; however, subclinical cerebral microemboli can occur during these procedures. Associations have been found between the incidence of microemboli and postoperative decline in memory. We therefore sought to determine whether this decline persisted long-term and to assess changes in other cognitive domains.

METHODS

Patients were prospectively recruited under an Institutional Review Board-approved protocol at a single academic center. Neuropsychological testing was administered preoperatively and at 1-month and 6-month intervals postoperatively. Cognitive domains that were evaluated included verbal memory, visual memory, psychomotor speed, dexterity, and executive function. Diffusion-weighted magnetic resonance imaging sequencing was performed preoperatively and ≤48 hours postoperatively to identify procedure-related microemboli. Univariate and multivariate regression models were used to identify relationships among microembolization, demographics, and cognition.

RESULTS

Included were 80 male patients with an average age of 69 years. Forty patients underwent carotid artery stenting and 40 underwent carotid endarterectomy. Comorbidities included diabetes in 45%, coronary artery disease in 50%, and prior neurologic symptoms in 41%. New postoperative microemboli were found in 45 patients (56%). Microembolization was significantly more common in the carotid artery stenting cohort (P < .005). Univariate analysis demonstrated that patients with procedurally related embolization showed decline 1 month postoperatively in verbal memory and Trail Making A measures. Multivariate analysis demonstrated that procedurally related embolization (odds ratio [OR], 2.8; P = .04) and preoperative symptomatic stenosis (OR, 3.2; P = .026) were independent predictors of decline for the Rey Auditory Verbal Learning Test Short Delay measure at 1 month. At 6 months, no significant relationship was found between emboli and decline on Rey Auditory Verbal Learning Test Short Delay, but age (OR, 1.1, P = .005) and chronic obstructive pulmonary disease (OR, 7.1, P = .018) were significantly associated with decline at 6 months after the intervention.

CONCLUSIONS

Microembolization that is associated with carotid artery intervention predicts short-term cognitive decline. However, some of these cognitive deficits persist at 6 months after the intervention, and further investigation is warranted to determine individual patient risk factors that may affect recovery.