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Oh EC, Sridharan ND, Avgerinos ED. Cognitive function after carotid endarterectomy in asymptomatic patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 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] [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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2
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Koueik J, Wesley UV, Dempsey RJ. Pathophysiology, cellular and molecular mechanisms of large and small vessel diseases. Neurochem Int 2023; 164:105499. [PMID: 36746322 DOI: 10.1016/j.neuint.2023.105499] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/07/2023]
Abstract
Cerebrovascular disease (CVD) is the second most common cause of cognitive impairment and dementia in aged population. CVD presents in a myriad number of clinical ways based on the functional location of pathology. While primary clinical emphasis has been placed on motor, speech and visual deficits, vascular cognitive decline is a vastly under recognized and devastating condition afflicting millions of Americans. CVD, a disease of the blood vessels that supply blood to brain involves an integration between small and large vessels. Cerebral large vessel diseases (LVD) are associated with atherosclerosis, artery-to-artery embolism, intracardiac embolism and a large vessel stroke leading to substantial functional disability. Cerebral small vessel disease (SVD) is critically involved in stroke, brain hemorrhages, cognitive decline and functional loss in elderly patients. An evolving understanding of cellular and molecular mechanisms emphasizes that inflammatory vascular changes contribute to systemic pathologic conditions of the central nervous systems (CNS), with specific clinical presentations including, cognitive decline. Advances in an understanding of pathophysiology of disease processes and therapeutic interventions may help improve outcomes. This review will focus on large and small vessels diseases and their relationship to vascular cognitive decline, atherosclerosis, stroke, and inflammatory neurodegeneration. We will also emphasize the molecular and cellular mechanisms, as well as genetic and epigenetic factors associated with LVD and SVD.
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Affiliation(s)
- Joyce Koueik
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53792, USA
| | - Umadevi V Wesley
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53792, USA
| | - Robert J Dempsey
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53792, USA.
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Culleton S, Baradaran H, Kim SE, Stoddard G, Roberts J, Treiman G, Parker D, Duff K, McNally JS. MRI Detection of Carotid Intraplaque Hemorrhage and Postintervention Cognition. AJNR Am J Neuroradiol 2022; 43:1762-1769. [PMID: 36357151 DOI: 10.3174/ajnr.a7701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/01/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND PURPOSE Cognitive improvement has been reported after carotid revascularization and attributed to treating stenosis and correcting hypoperfusion. This study investigated the effect of carotid intraplaque hemorrhage on postintervention cognition. MATERIALS AND METHODS In this institutional review board-approved single-center study, consecutive patients scheduled for carotid surgery were recruited for preoperative carotid MR imaging (MPRAGE) and pre- and postintervention cognitive testing using the Repeatable Battery for the Assessment of Neuropsychological Status. Pre- and postintervention scores were compared using t tests and multivariable linear regression. RESULTS Twenty-three participants were included, with endarterectomy performed in 20 (87%) and angioplasty/stent placement, in 3 (13%). Overall, statistically significant improvements occurred in the pre- versus postintervention mean Total Scale score (92.1 [SD, 15.5] versus 96.1 [SD, 15.8], P = .04), immediate memory index (89.4 [SD, 18.2] versus 97.7 [SD, 14.9], P < .001), and verbal index (96.1 [SD, 14.1] versus 103.0 [SD, 12.0], P = .002). Intraplaque hemorrhage (+) participants (n = 11) had no significant improvement in any category, and the attention index significantly decreased (99.4 [SD, 18.0] versus 93.5 [SD, 19.4], P = .045). Intraplaque hemorrhage (-) participants (n = 12) significantly improved in the Total Scale score (86.4 [SD, 11.8] versus 95.5 [SD, 12.4], P = .004), immediate memory index (82.3 [SD, 14.6] versus 96.2 [SD, 14.1], P = .002), delayed memory index (94.3 [SD, 14.9] versus 102.4 [SD, 8.0], P = .03), and verbal index (94.3 [SD, 13.2] versus 101.5 [SD, 107.4], P = .009). Postintervention minus preintervention scores for intraplaque hemorrhage (+) versus (-) groups showed statistically significant differences in the Total Scale score (-0.4 [SD, 6.8] versus 8.0 [SD, 8.5], P = .02), attention index (-5.9 [SD, 8.5] versus 4.3 [SD, 11.9], P = .03), and immediate memory index (4.2 [SD, 6.7] versus 12.2 [SD, 10.2], P = .04). CONCLUSIONS Cognitive improvement was observed after carotid intervention, and this was attributable to intraplaque hemorrhage (-) plaque. MR imaging detection of intraplaque hemorrhage status may be an important determinant of cognitive change after intervention.
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Affiliation(s)
- S Culleton
- From the Department of Radiology (S.C., H.B., S.-E.K., J.R., D.P., J.S.M.)
| | - H Baradaran
- From the Department of Radiology (S.C., H.B., S.-E.K., J.R., D.P., J.S.M.)
| | - S-E Kim
- From the Department of Radiology (S.C., H.B., S.-E.K., J.R., D.P., J.S.M.)
| | - G Stoddard
- Utah Center for Advanced Imaging Research, Division of Epidemiology (G.S.)
| | - J Roberts
- From the Department of Radiology (S.C., H.B., S.-E.K., J.R., D.P., J.S.M.)
| | - G Treiman
- Department of Internal Medicine, Department of Surgery (G.T.)
| | - D Parker
- From the Department of Radiology (S.C., H.B., S.-E.K., J.R., D.P., J.S.M.)
| | - K Duff
- Center for Alzheimer's Care, Imaging and Research (K.D.), University of Utah, Salt Lake City, Utah
| | - J S McNally
- From the Department of Radiology (S.C., H.B., S.-E.K., J.R., D.P., J.S.M.)
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A systematic review of cognitive function after carotid endarterectomy in asymptomatic patients. J Vasc Surg 2022; 75:2074-2085. [PMID: 34995717 DOI: 10.1016/j.jvs.2021.12.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/04/2021] [Indexed: 11/21/2022]
Abstract
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.
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Ancetti S, Paraskevas KI, Faggioli G, Naylor AR. Effect of Carotid Interventions on Cognitive Function in Patients With Asymptomatic Carotid Stenosis: A Systematic Review. Eur J Vasc Endovasc Surg 2021; 62:684-694. [PMID: 34474964 DOI: 10.1016/j.ejvs.2021.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/05/2021] [Accepted: 07/11/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Stefano Ancetti
- Vascular Surgery, Department of Experimental, Diagnostic and Specialist Medicine - DIMES University of Bologna "Alma Mater Studiorum", Bologna, Italy.
| | - Kosmas I Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialist Medicine - DIMES University of Bologna "Alma Mater Studiorum", Bologna, Italy
| | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
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Migdalski A, Jawien A. New insight into biology, molecular diagnostics and treatment options of unstable carotid atherosclerotic plaque: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1207. [PMID: 34430648 PMCID: PMC8350668 DOI: 10.21037/atm-20-7197] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/24/2021] [Indexed: 12/23/2022]
Abstract
Indications for intervention in hemodynamically relevant carotid artery stenosis (carotid endarterectomy or stenting) are primarily based on a degree of stenosis and symptomatology. To date the plaque vulnerability is rarely taken into account in clinical decision making although development of molecular imaging allows a better understanding of plaque biology and provides new techniques detecting potentially vulnerable plaque at risk. A significant number of reports describing the mechanisms of unstable plaque formation suggest that it is a multifactorial process. Inflammation, lipid accumulation, apoptosis, proteolysis, the thrombotic process and angiogenesis are among the main factors of carotid plaque destabilization. Although inflammation is a key process in development of plaque vulnerability, the hemostasis and neoangiogenesis should be regarded as equally important. Only a small group of asymptomatic patients may benefit from the invasive treatment and it remains a challenge to determine whether initially asymptomatic carotid plaque become unstable or vulnerable. Currently, the main task of research on atherosclerotic lesion imaging is focused on functional state of the plaque. The presence of one or more features such as stenosis progression, large plaque area, large juxta-luminal black area, plaque echolucency, intra-plaque hemorrhage, impaired cerebral vascular reserve and spontaneous embolization may indicate patients at higher risk for stroke suitable for revascularization. Treatment of carotid stenosis as one of the manifestations of generalized atherosclerosis requires a broad approach. Nowadays pharmacological treatment options for the atherosclerotic process are largely aimed at stimulating the plaque stabilization, but in symptomatic patients and selected asymptomatic patients, carotid plaque should be removed as a potential source of embolism.
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Affiliation(s)
- Arkadiusz Migdalski
- Department of Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
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Yan J, Li Z, Wills M, Rajah G, Wang X, Bai Y, Dong P, Zhao X. Intracranial microembolic signals might be a potential risk factor for cognitive impairment. Neurol Res 2021; 43:867-873. [PMID: 34409926 DOI: 10.1080/01616412.2021.1939488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: We aimed to explore the relationship between microembolic signals (MES) and cognitive impairment in patients with neurological disorders using a 30-minute MES monitoring test.Methods: We retrospectively reviewed patients who visited outpatient departments and underwent a 30-minute MES monitoring session using dual-channel transcranial doppler (TCD) at Beijing Tiantan hospital between July 2016 and December 2018. All patients completed the Montreal Cognitive Assessment (MoCA) and underwent magnetic resonance imaging (MRI). Cognitive impairment was defined as a MoCA score of less than 26. MES were identified according to the criteria of the International Consensus Group on Microembolus Detection.Results: Of the 1356 subjects who underwent MES monitoring, 159 patients (including 50 cases of MES positive and 109 cases of MES negative) had both analyzable MES monitoring recording and cognition evaluation data, of which 72 had cognitive impairment. Compared with the group with no deficits in cognitive function, the proportion of MES positive was significantly higher in patients with impaired cognitive function - that is, 47% (34/72) versus 18.4% (16/87), respectively, with p < 0.05. In multivariate logistic regression analysis, MES were independently associated with lower MoCA score (odd ratios (OR), 7.36; 95% confidence intervals (CI), 2.72-19.85, P < 0.0001).Conclusions: In this retrospective study, we found a possible correlation and relationship between MES and cognitive impairment. Further studies are required to determine whether continuous cerebral microembolization to the brain will lead to progressive cognitive impairment.
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Affiliation(s)
- Jing Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhaoxia Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Melissa Wills
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gary Rajah
- Department of Neurosurgery, Munson Medical Center, Traverse City, MI, USA
| | - Xin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yaqiu Bai
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Pei Dong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Meshram NH, Jackson D, Mitchell CC, Wilbrand SM, Dempsey RJ, Hermann BP, Varghese T. Study of the Relationship Between Ultrasound Strain Indices and Cognitive Decline for Vulnerable Carotid Plaque. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:2088-2091. [PMID: 33018417 DOI: 10.1109/embc44109.2020.9175911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A relationship between ultrasound strain indices in carotid plaque to cognitive domains of executive and language function are studied in 42 symptomatic and 34 asymptomatic patients. The mean and standard deviation of the percentage stenosis were 72.10 ± 15.19 and 77.41 ± 11.20 for symptomatic and asymptomatic patients respectively. Pearson's correlation between axial, lateral and shear strain indices versus executive and language composite scores was performed.. A significant inverse correlation for both executive and language function for symptomatic patients to strain indices was found. On the other hand, for asymptomatic patients only executive function was inversely correlated with the corresponding strain indices. Our hypothesis that microemboli from vulnerable plaque and possible 'silent strokes' may be responsible for decline in executive function for both symptomatic and asymptomatic patients'. Strokes and transient ischemic attacks may be responsible for further cognitive decline in language function for symptomatic patients.
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Mitchell CC, Wilbrand SM, Cook TD, Meshram NH, Steffel CN, Nye R, Varghese T, Hermann BP, Dempsey RJ. Carotid Plaque Strain Indices Were Correlated With Cognitive Performance in a Cohort With Advanced Atherosclerosis, and Traditional Doppler Measures Showed no Association. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:2033-2042. [PMID: 32395885 PMCID: PMC7531894 DOI: 10.1002/jum.15311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/20/2020] [Accepted: 04/06/2020] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Traditional Doppler measures have been used to predict cognitive performance in patients with carotid atherosclerosis. Novel measures, such as carotid plaque strain indices (CPSIs), have shown associations with cognitive performance. We hypothesized that lower mean middle cerebral artery (MCA) velocities, higher bulb-internal carotid artery (ICA) velocities, the MCA pulsatility index (PI), and CPSIs would be associated with poorer cognitive performance in individuals with advanced atherosclerosis. METHODS Neurocognitive testing, carotid ultrasound imaging, transcranial Doppler imaging, and carotid strain imaging were performed on 40 patients scheduled for carotid endarterectomy. Kendall tau correlations were used to examine relationships between cognitive tests and the surgical-side maximum peak systolic velocity (PSV; from the bulb, proximal, mid, or distal ICA), mean MCA velocity and PI, and maximum CPSIs (axial, lateral, and shear strain indices used to characterize plaque deformations with arterial pulsation). Cognitive measures included age-adjusted indices of verbal fluency, verbal and visual learning/memory, psychomotor speed, auditory attention/working memory, visuospatial construction, and mental flexibility. RESULTS Participants had a median age of 71.0 (interquartile range, 9.75) years; 26 were male (65%), and 14 were female (35%). Traditional Doppler parameters, PSV, mean MCA velocity, and MCA PI did not predict cognitive performance (all P > .05). Maximum CPSIs were significantly associated with cognitive performance (P < .05). CONCLUSIONS Traditional velocity measurements of the maximum bulb-ICA PSV, mean MCA velocity, and PI were not associated with cognitive performance in patients with advanced atherosclerotic disease; however, maximum CPSIs were associated with cognitive performance. These findings suggest that cognition may be associated with unstable plaque rather than blood flow.
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Affiliation(s)
- Carol C. Mitchell
- Department of Medicine, Division of Cardiovascular
Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland
Avenue, Madison, WI, USA 53792
| | - Stephanie M. Wilbrand
- Department of Neurological Surgery, University of Wisconsin
School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, USA
53792
| | - Thomas D. Cook
- Department of Biostatistics and Medical Informatics,
University of Wisconsin School of Medicine and Public Health, 610 Walnut Street,
Madison WI, USA 53726
| | - Nirvedh H. Meshram
- Department of Medical Physics, University of Wisconsin
School of Medicine and Public Health, University of Wisconsin-Madison, 1111 Highland
Avenue, Madison, WI, USA 53705
- Department of Electrical and Computer Engineering,
University of Wisconsin-Madison, University of Wisconsin-Madison, 1415 Engineering
Drive, Madison, WI, USA 53706
- Corresponding Author: Carol C. Mitchell,
PhD, 600 Highland Avenue, Madison, WI, USA 53792, 608-262-0680,
| | - Catherine N. Steffel
- Department of Medical Physics, University of Wisconsin
School of Medicine and Public Health, University of Wisconsin-Madison, 1111 Highland
Avenue, Madison, WI, USA 53705
| | - Rebecca Nye
- Department of Medicine, Division of Cardiovascular
Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland
Avenue, Madison, WI, USA 53792
| | - Tomy Varghese
- Department of Medical Physics, University of Wisconsin
School of Medicine and Public Health, University of Wisconsin-Madison, 1111 Highland
Avenue, Madison, WI, USA 53705
- Department of Electrical and Computer Engineering,
University of Wisconsin-Madison, University of Wisconsin-Madison, 1415 Engineering
Drive, Madison, WI, USA 53706
| | - Bruce P. Hermann
- Department of Neurology, University of Wisconsin School of
Medicine and Public Health, 600 Highland Avenue, Madison, WI USA 53792
| | - Robert J. Dempsey
- Department of Neurological Surgery, University of Wisconsin
School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, USA
53792
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10
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Nakamizo A, Amano T, Matsuo S, Kuwashiro T, Yasaka M, Okada Y. Common carotid flow velocity is associated with cognitive function after carotid endarterectomy. J Clin Neurosci 2020; 76:53-57. [PMID: 32307301 DOI: 10.1016/j.jocn.2020.04.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/09/2020] [Indexed: 11/24/2022]
Abstract
The relationship between ultrasonographic flow parameters and cognitive function has not been well studied. This study aimed to clarify associations between carotid flow velocity (FV) and cognitive function in patients with a history of carotid endarterectomy (CEA). Ninety-four patients who previously underwent CEA participated in this study. The Neurobehavioral Cognitive Status Examination (Cognistat) and Frontal Assessment Battery (FAB) were adopted to assess cognitive functions at a mean of 6.5 ± 3.2 years after CEA. End-diastolic flow velocity (EDV) of the left and right common carotid artery (CCA) was significantly associated with total Cognistat score (p < 0.001) and total FAB score (p < 0.05). Pulsatility index (PI) of the left CCA was significantly associated with total Cognistat score and total FAB score (p < 0.01). A cut-off right CCA EDV of 14.5 cm/s offered the most reliable predictor of the bottom 25th percentile of total Cognistat score (sensitivity 83.3%, specificity 61.0%, area under the curve (AUC) 0.731, p = 0.0060), while a cut-off left CCA PI of 1.83 was the most reliable predictor of the bottom 25th percentile of total FAB score (sensitivity 73.3%, specificity 60.0%, AUC 0.679, p = 0.0179). Left and right CCA EDV correlated with sub-components of comprehension, construction, judgment, programming (p < 0.01), and conceptualization (p < 0.05). Right CCA EDV correlated with similarity (p < 0.01), repetition, naming, and memory (p < 0.05). Left CCA PI correlated with attention, conceptualization (p < 0.01), repetition, construction, similarity, and mental flexibility (p < 0.05), while right CCA PI correlated with construction (p < 0.05). CCA FV may offer useful markers of cognitive functions in patients with a history of CEA.
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Affiliation(s)
- Akira Nakamizo
- Departments of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan.
| | - Toshiyuki Amano
- Departments of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan
| | - Satoshi Matsuo
- Departments of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan
| | - Takahiro Kuwashiro
- Departments of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan
| | - Masahiro Yasaka
- Departments of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan
| | - Yasushi Okada
- Departments of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1, Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan
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11
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Dempsey RJ, Bowman K. The past, present, and future of neurosurgery's role in stroke. J Neurosurg 2020; 133:260-266. [PMID: 32244210 DOI: 10.3171/2020.1.jns193043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Pucite E, Krievina I, Miglane E, Erts R, Krievins D, Millers A. Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment. Curr Neurovasc Res 2020; 16:47-62. [PMID: 30706811 PMCID: PMC6696820 DOI: 10.2174/1567202616666190129153409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Elina Pucite
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
| | - Ildze Krievina
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Evija Miglane
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
| | - Renars Erts
- Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Dainis Krievins
- Faculty of Medicine, University of Latvia, Riga, Latvia.,Vascular Surgery Centre, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrejs Millers
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
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Nakamizo A, Amano T, Kuwashiro T, Yasaka M, Okada Y. eGFR and deep white matter hyperintensity as predictors of cognitive decline long after carotid endarterectomy. Sci Rep 2019; 9:17855. [PMID: 31780807 PMCID: PMC6883058 DOI: 10.1038/s41598-019-54459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/14/2019] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Akira Nakamizo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
| | - Toshiyuki Amano
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Takahiro Kuwashiro
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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14
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Varghese T, Meshram NH, Mitchell CC, Wilbrand SM, Hermann BP, Dempsey RJ. Lagrangian carotid strain imaging indices normalized to blood pressure for vulnerable plaque. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:477-485. [PMID: 31168787 PMCID: PMC6760247 DOI: 10.1002/jcu.22739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/10/2019] [Accepted: 05/22/2019] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Ultrasound Lagrangian carotid strain imaging (LCSI) utilizes physiological deformation caused by arterial pressure variations to generate strain tensor maps of the vessel walls and plaques. LCSI has been criticized for the lack of normalization of magnitude-based strain indices to physiological stimuli, namely blood pressure. We evaluated the impact of normalization of magnitude-based strain indices to blood pressure measured immediately after the acquisition of radiofrequency (RF) data loops for LCSI. MATERIALS AND METHODS A complete clinical ultrasound examination along with RF data loops for LCSI was performed on 50 patients (30 males and 20 females) who presented with >60% carotid stenosis and were scheduled for carotid endarterectomy. Cognition was assessed using the 60-minute neuropsychological test protocol. RESULTS For axial strains correlation of maximum accumulated strain indices (MASI), cognition scores were -0.46 for non-normalized and -0.45, -0.49, -0.37, and -0.48 for systolic, diastolic, pulse pressure, and mean arterial pressure normalized data, respectively. The corresponding area under the curve (AUC) values for classifiers designed using maximum likelihood estimation of a binormal distribution with a median-split of the executive function cognition scores were 0.73, 0.70, 0.71, 0.70, and 0.71, respectively. CONCLUSIONS No significant differences in the AUC estimates were obtained between normalized and non-normalized magnitude-based strain indices.
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Affiliation(s)
- Tomy Varghese
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Electrical and Computer Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nirvedh H Meshram
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Electrical and Computer Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Carol C Mitchell
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stephanie M Wilbrand
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bruce P Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert J Dempsey
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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15
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Kolb B, Fadel H, Rajah G, Saber H, Luqman A, Rangel-Castilla L. Effect of revascularization on cognitive outcomes in intracranial steno-occlusive disease: a systematic review. Neurosurg Focus 2019; 46:E14. [PMID: 30717064 DOI: 10.3171/2018.11.focus18517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVESteno-occlusive diseases of the cerebral vasculature have been associated with cognitive decline. The authors performed a systematic review of the existing literature on intracranial steno-occlusive disease, including intracranial atherosclerosis and moyamoya disease (MMD), to determine the extent and quality of evidence for the effect of revascularization on cognitive performance.METHODSA systematic search of PubMed/MEDLINE, the Thomson Reuters Web of Science Core Collection, and the KCI Korean Journal Database was performed to identify randomized controlled trials (RCTs) in the English-language literature and observational studies that compared cognitive outcomes before and after revascularization in patients with steno-occlusive disease of the intracranial vasculature, from which data were extracted and analyzed.RESULTSNine papers were included, consisting of 2 RCTs and 7 observational cohort studies. Results from 2 randomized trials including 142 patients with symptomatic intracranial atherosclerotic steno-occlusion found no additional benefit to revascularization when added to maximal medical therapy. The certainty in the results of these trials was limited by concerns for bias and indirectness. Results from 7 observational trials including 282 patients found some cognitive benefit for revascularization for symptomatic atherosclerotic steno-occlusion and for steno-occlusion related to MMD in children. The certainty of these conclusions was low to very low, due to both inherent limitations in observational studies for inferring causality and concerns for added risk of bias and indirectness in some studies.CONCLUSIONSThe effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.
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Meshram NH, Jackson D, Varghese T, Mitchell CC, Wilbrand SM, Dempsey RJ, Hermann BP. A Cross-Sectional Investigation of Cognition and Ultrasound-Based Vascular Strain Indices. Arch Clin Neuropsychol 2019; 35:46-55. [PMID: 30805597 PMCID: PMC7014973 DOI: 10.1093/arclin/acz006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/19/2018] [Accepted: 01/30/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE We examine the relationship between variability in the plaque strain distribution estimated using ultrasound with multiple cognitive domains including executive, language, visuospatial reasoning, and memory function. METHOD Asymptomatic (n = 42) and symptomatic (n = 34) patients with significant (>60%) carotid artery stenosis were studied for plaque instability using ultrasound strain imaging and multiple cognitive domains including executive, language, visuospatial reasoning, and memory function. Correlation and ROC analyses were performed between ultrasound strain indices and cognitive function. Strain indices and cognition scores were also compared between symptomatic and asymptomatic patients to determine whether there are significant group differences. RESULTS Association of high-strain distributions with dysexecutive function was observed in both asymptomatic and symptomatic patients. For memory, visuospatial, and language functions, the correlations between strain and cognition were weaker for the asymptomatic compared to symptomatic group. CONCLUSIONS Both asymptomatic and symptomatic patients demonstrate a relationship between vessel strain indices and executive function indicating that silent strokes and micro-emboli could initially contribute to a decline in executive function, whereas strokes and transient ischemic attacks may cause the further decline in other cognitive functions.
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Affiliation(s)
- N H Meshram
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Electrical and Computer Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - D Jackson
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - T Varghese
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Electrical and Computer Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - C C Mitchell
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - S M Wilbrand
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - R J Dempsey
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - B P Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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17
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Nagm A, Horiuchi T, Hongo K. Letter to the Editor. Carotid atherosclerotic plaque instability and cognition: collecting additional data. J Neurosurg 2018; 129:1373-1374. [DOI: 10.3171/2018.5.jns181177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alhusain Nagm
- Shinshu University School of Medicine, Matsumoto, Nagano, Japan; and
- Al-Azhar University Faculty of Medicine, Nasr City, Cairo, Egypt
| | | | - Kazuhiro Hongo
- Shinshu University School of Medicine, Matsumoto, Nagano, Japan; and
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18
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Dempsey RJ, Jackson DC, Wilbrand SM, Mitchell CC, Berman SE, Johnson SC, Meshram NH, Varghese T, Hermann BP. In Reply: The Preservation of Cognition 1 Year After Carotid Endarterectomy in Patients With Prior Cognitive Decline. Neurosurgery 2018; 83:E181. [PMID: 31222269 DOI: 10.1093/neuros/nyy325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert J Dempsey
- Department of Neurological Surgery University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Daren C Jackson
- Wisconsin Surgical Outcomes Center Research Program Department of Surgery University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Stephanie M Wilbrand
- Department of Neurological Surgery University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Carol C Mitchell
- Department of Medicine Cardiovascular Medicine Division University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Sara E Berman
- Alzheimer's Disease Research Center University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Sterling C Johnson
- Alzheimer's Disease Research Center University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Nirvedh H Meshram
- Department of Medical Physics University of Wisconsin School of Medicine and Public Health Madison, Wisconsin.,Department of Electrical and Computer Engineering University of Wisconsin-Madison Madison, Wisconsin
| | - Tomy Varghese
- Department of Medical Physics University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| | - Bruce P Hermann
- Department of Neurology University Wisconsin School of Medicine and Public Health Madison, Wisconsin
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19
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Nagm A, Horiuchi T, Hongo K. Letter: The Preservation of Cognition 1 Year After Carotid Endarterectomy in Patients With Prior Cognitive Decline. Neurosurgery 2018; 83:E179-E180. [PMID: 31222268 DOI: 10.1093/neuros/nyy323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alhusain Nagm
- Department of Neurosurgery Shinshu University School of Medicine Matsumoto, Japan.,Department of Neurosurgery Al-Azhar University Faculty of Medicine-Nasr City Cairo, Egypt
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery Shinshu University School of Medicine Matsumoto, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery Shinshu University School of Medicine Matsumoto, Japan
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20
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Paraskevas KI, Veith FJ, Ricco JB. Best medical treatment alone may not be adequate for all patients with asymptomatic carotid artery stenosis. J Vasc Surg 2018; 68:572-575. [DOI: 10.1016/j.jvs.2018.02.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/27/2018] [Indexed: 12/20/2022]
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