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Lengyel B, Magyar-Stang R, Pál H, Debreczeni R, Sándor ÁD, Székely A, Gyürki D, Csippa B, István L, Kovács I, Sótonyi P, Mihály Z. Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis. J Clin Med 2024; 13:2487. [PMID: 38731014 PMCID: PMC11084304 DOI: 10.3390/jcm13092487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.
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Affiliation(s)
- Balázs Lengyel
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Hanga Pál
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Róbert Debreczeni
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Ágnes Dóra Sándor
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Dániel Gyürki
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Lilla István
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
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Relander K, Hietanen M, Ijäs P, Nuotio K, Vikatmaa P, Koskinen SM, Ala-Kauhaluoma M, Paajanen TI, Virkkala J, Lindsberg PJ, Soinne L. Long-term cognitive and neurovascular changes after carotid endarterectomy. J Neurol Sci 2024; 459:122981. [PMID: 38569375 DOI: 10.1016/j.jns.2024.122981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
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.
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Affiliation(s)
- Kristiina Relander
- Neuropsychology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland.
| | - Marja Hietanen
- Neuropsychology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Petra Ijäs
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Krista Nuotio
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Pirkka Vikatmaa
- Vascular Surgery, HUS Abdominal center, University of Helsinki and Helsinki University Hospital, Finland
| | - Suvi M Koskinen
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Marianne Ala-Kauhaluoma
- Ophthalmology, HUS Head and Neck Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Teemu I Paajanen
- Finnish Institute of Occupational Health, Work Ability and Working Careers Unit, Helsinki, Finland
| | - Jussi Virkkala
- Clinical Neurophysiology and Clinical Neurosciences, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Perttu J Lindsberg
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Lauri Soinne
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
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Tang Y, Yang Y, Feng J, Geng Y, Wang Y, Wang R, Zhang D, Zhao J. Hybrid surgery can improve neurocognitive function in patients with internal carotid artery occlusion. Sci Rep 2023; 13:22793. [PMID: 38129543 PMCID: PMC10739823 DOI: 10.1038/s41598-023-50270-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
Internal carotid artery occlusion (ICAO) is a relatively uncommon but important cause of transient ischaemic attack and cerebral infarction. Hybrid surgery (HS) improves cerebral perfusion, but its impact on neurocognitive function has been controversial. Patients with symptomatic chronic ICAO treated by hybrid surgery or medical treatment from 2016 to 2019 were included. We recorded and analysed the clinical characteristics, angiographic data, outcomes and cognitive status. Functional assessments, including the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index, and a battery of neuropsychological tests, including the Mini-Mental State Examination (MMSE), Alzheimer Disease Assessment Scale-Cognitive Subtest (ADAS-cog), verbal fluency, and Colour Trail test Parts 1 and 2, were administered. Significant improvements in the ADAS (before, 7.5 ± 6.2 versus after, 5.2 ± 5.7; P = 0.022), MMSE (before, 25.5 ± 2.8 versus after, 28.1 ± 2.3; P = 0.013), and Colour Trail test Part 1 (before, 118.3 ± 26.5 versus after, 96.2 ± 23.1; P = 0.016) were observed six months after HS. Moreover, the abovementioned postprocedure scales were ameliorated in the HS group. This study found that in patients with multiple symptomatic ICAO and objective ipsilateral ischaemia, successful HS leads to improvement in the scores of three cognitive tests.
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Affiliation(s)
- Yudi Tang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yunna Yang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
| | - Junqiang Feng
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yibo Geng
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Hospital, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Elshikhawoda MSM, Jararaa S, Tan SHS, Mohamed AHA, Abdalaziz DAS, Roble AA, Okaz M, Ahmad W, Elsanosi A, Jararah H. Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience. Cureus 2023; 15:e50930. [PMID: 38249276 PMCID: PMC10800008 DOI: 10.7759/cureus.50930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA). In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEA at Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who are physically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.
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Affiliation(s)
| | | | | | | | | | | | - Mahmoud Okaz
- Vascular Surgery, Glan Clwyd Hospital, Rhyl, GBR
| | - Waseem Ahmad
- Vascular Surgery, Glan Clwyd Hospital, Rhyl, GBR
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Tomić Mahečić T, Malojčić B, Tonković D, Mažar M, Baronica R, Juren Meaški S, Crkvenac Gregorek A, Meier J, Dünser MW. Near-Infrared Spectroscopy-Guided, Individualized Arterial Blood Pressure Management for Carotid Endarterectomy under General Anesthesia: A Randomized, Controlled Trial. J Clin Med 2023; 12:4885. [PMID: 37568287 PMCID: PMC10420278 DOI: 10.3390/jcm12154885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 08/13/2023] Open
Abstract
Background: Differences in blood pressure can influence the risk of brain ischemia, perioperative complications, and postoperative neurocognitive function in patients undergoing carotid endarterectomy (CEA). Methods: In this single-center trial, patients scheduled for CEA under general anesthesia were randomized into an intervention group receiving near-infrared spectroscopy (NIRS)-guided blood pressure management during carotid cross-clamping and a control group receiving standard care. The primary endpoint was postoperative neurocognitive function assessed before surgery, on postoperative days 1 and 7, and eight weeks after surgery. Perioperative complications and cerebral autoregulatory capacity were secondary endpoints. Results: Systolic blood pressure (p < 0.001) and norepinephrine doses (89 (54-122) vs. 147 (116-242) µg; p < 0.001) during carotid cross-clamping were lower in the intervention group. No group differences in postoperative neurocognitive function were observed. The rate of perioperative complications was lower in the intervention group than in the control group (3.3 vs. 26.7%, p = 0.03). The breath-holding index did not differ between groups. Conclusions: Postoperative neurocognitive function was comparable between CEA patients undergoing general anesthesia in whom arterial blood pressure during carotid cross-clamping was guided using NIRS and subjects receiving standard care. NIRS-guided, individualized arterial blood pressure management resulted in less vasopressor exposition and a lower rate of perioperative complications.
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Affiliation(s)
- Tina Tomić Mahečić
- Department of Anesthesiology and Intensive Care Medicine, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Branko Malojčić
- Department of Neurology, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Dinko Tonković
- Department of Anesthesiology and Intensive Care Medicine, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Mirabel Mažar
- Department of Anesthesiology and Intensive Care Medicine, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Robert Baronica
- Department of Anesthesiology and Intensive Care Medicine, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | | | | | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4040 Linz, Austria
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4040 Linz, Austria
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Oh EC, Sridharan ND, Avgerinos ED. Cognitive function after carotid endarterectomy in asymptomatic patients. J Cardiovasc Surg (Torino) 2023; 64:317-321. [PMID: 36897209 PMCID: PMC10957150 DOI: 10.23736/s0021-9509.23.12632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
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.
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Affiliation(s)
- Edward C Oh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA -
| | - Natalie D Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Efthymios D Avgerinos
- Clinic of Vascular and Endovascular Surgery, Athens Medical Group, Athens, Greece
- Department of Vascular Surgery, Attikon Hospital, University of Athens, Athens, Greece
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Erben Y, Brott TG. The Challenge of Preventing Carotid Artery Stroke in Properly Medically Managed Patients: Lessons From SPACE-2. J Vasc Surg 2023; 77:1575-1577. [PMID: 36893947 DOI: 10.1016/j.jvs.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
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Paraskevas KI. Cognitive function in patients with asymptomatic carotid stenosis after carotid endarterectomy. J Vasc Surg 2022; 76:849-850. [PMID: 35995488 DOI: 10.1016/j.jvs.2022.04.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 10/15/2022]
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Sridharan N, Asaadi S, Thirumala P, Avgerinos ED. Reply. J Vasc Surg 2022; 76:851. [PMID: 35995489 DOI: 10.1016/j.jvs.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/26/2022] [Indexed: 11/22/2022]
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Porcu M, Cocco L, Cau R, Suri JS, Mannelli L, Puig J, Qi Y, Paraskevas KI, Saba L. Mid-term effects of carotid endarterectomy on cognition and white matter status evaluated by whole brain diffusion tensor imaging metrics: a preliminary analysis. Eur J Radiol 2022; 151:110314. [DOI: 10.1016/j.ejrad.2022.110314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/03/2022] [Accepted: 04/08/2022] [Indexed: 12/24/2022]
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