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Kougias P, Collins R, Pastorek N, Sharath S, Barshes NR, McCulloch K, Pisimisis G, Berger DH. Comparison of domain-specific cognitive function after carotid endarterectomy and stenting. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.02.057] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fink HA, Hemmy LS, MacDonald R, Carlyle MH, Olson CM, Dysken MW, McCarten JR, Kane RL, Garcia SA, Rutks IR, Ouellette J, Wilt TJ. Intermediate- and Long-Term Cognitive Outcomes After Cardiovascular Procedures in Older Adults: A Systematic Review. Ann Intern Med 2015; 163:107-17. [PMID: 26192563 DOI: 10.7326/m14-2793] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Risks for intermediate- and long-term cognitive impairment after cardiovascular procedures in older adults are poorly understood. PURPOSE To summarize evidence about cognitive outcomes in adults aged 65 years or older at least 3 months after coronary or carotid revascularization, cardiac valve procedures, or ablation for atrial fibrillation. DATA SOURCES MEDLINE, Cochrane, and Scopus databases from 1990 to January 2015; ClinicalTrials.gov; and bibliographies of reviews and eligible studies. STUDY SELECTION English-language trials and prospective cohort studies. DATA EXTRACTION One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and strength of evidence (SOE). DATA SYNTHESIS 17 trials and 4 cohort studies were included; 80% of patients were men, and mean age was 68 years. Cognitive function did not differ after the procedure between on- and off-pump coronary artery bypass grafting (CABG) (n = 6; low SOE), hypothermic and normothermic CABG (n = 3; moderate to low SOE), or CABG and medical management (n = 1; insufficient SOE). One trial reported lower risk for incident cognitive impairment with minimal versus conventional extracorporeal CABG (risk ratio, 0.34 [95% CI, 0.16 to 0.73]; low SOE). Two trials found no difference between surgical carotid revascularization and carotid stenting or angioplasty (low and insufficient SOE, respectively). One cohort study reported increased cognitive decline after transcatheter versus surgical aortic valve replacement but had large selection and outcome measurement biases (insufficient SOE). LIMITATIONS Mostly low to insufficient SOE; no pertinent data for ablation; limited generalizability to the most elderly patients, women, and persons with substantial baseline cognitive impairment; and possible selective reporting and publication bias. CONCLUSION Intermediate- and long-term cognitive impairment in older adults attributable to the studied cardiovascular procedures may be uncommon. Nevertheless, clinicians counseling patients before these procedures should discuss the uncertainty in their risk for adverse cognitive outcomes. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Howard A. Fink
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Laura S. Hemmy
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Roderick MacDonald
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Maureen H. Carlyle
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Carin M. Olson
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Maurice W. Dysken
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - J. Riley McCarten
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Robert L. Kane
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Santiago A. Garcia
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Indulis R. Rutks
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Jeannine Ouellette
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Timothy J. Wilt
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
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Lobo M, Mourão J, Afonso G. Endarterectomia carotídea: revisão de 10 anos de prática de anestesia geral e locorregional num hospital terciário em Portugal. Braz J Anesthesiol 2015; 65:249-54. [DOI: 10.1016/j.bjan.2014.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/10/2014] [Indexed: 10/23/2022] Open
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Lobo M, Mourão J, Afonso G. Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal. Braz J Anesthesiol 2015; 65:249-54. [PMID: 26123143 DOI: 10.1016/j.bjane.2014.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/10/2014] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Retrospective and prospective randomized studies have compared general and locoregional anesthesia for carotid endarterectomy, but without definitive results. OBJECTIVES Evaluate the incidence of complications (medical, surgical, neurological, and hospital mortality) in a tertiary center in Portugal and review the literature. METHODS Retrospective analysis of patients undergoing endarterectomy between 2000 and 2011, using a software for hospital consultation. RESULTS A total of 750 patients were identified, and locoregional anesthesia had to be converted to general anesthesia in 13 patients. Thus, a total of 737 patients were included in this analysis: 74% underwent locoregional anesthesia and 26% underwent general anesthesia. There was no statistically significant difference between the two groups regarding per operative variables. The use of shunt was more common in patients undergoing general anesthesia, a statistically significant difference. The difference between groups of strokes and mortality was not statistically significant. The average length of stay was shorter in patients undergoing locoregional anesthesia with a statistically significant difference. CONCLUSIONS We found that our data are overlaid with the literature data. After reviewing the literature, we found that the number of studies comparing locoregional and general anesthesia and its impact on delirium, cognitive impairment, and decreased quality of life after surgery is still very small and can provide important data to compare the two techniques. Thus, some questions remain open, which indicates the need for randomized studies with larger number of patients and in new centers.
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Affiliation(s)
- Mercês Lobo
- Instituto Português de Oncologia do Porto, Hospital Francisco Gentil, Porto, Porto, Portugal.
| | - Joana Mourão
- Instituto Português de Oncologia do Porto, Hospital Francisco Gentil, Porto, Porto, Portugal
| | - Graça Afonso
- Instituto Português de Oncologia do Porto, Hospital Francisco Gentil, Porto, Porto, Portugal
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Xia ZY, Sun QJ, Yang H, Zhang MX, Ban R, Xu GL, Wu YP, Wang LX, Du YF. Effect of Carotid Artery Stenting on Cognitive Function in Patients with Internal Carotid Artery Stenosis and Cerebral Lacunar Infarction: A 3-Year Follow-Up Study in China. PLoS One 2015; 10:e0129917. [PMID: 26067432 PMCID: PMC4466228 DOI: 10.1371/journal.pone.0129917] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/14/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Carotid artery stenting (CAS) is an important therapeutic strategy for patients with carotid artery stenosis. However, the potential influence of CAS on cognitive function in patients with carotid artery stenosis and cerebral lacunar infarction has not been determined. This study investigated changes in cognitive function associated with CAS and the factors related to these changes. METHODS This prospective cohort study comprised 579 Chinese patients with cerebral lacunar infarction and carotid artery stenosis for whom CAS was indicated, and a matched control group of 552 healthy individuals. Cognitive function before CAS and at scheduled intervals from 6 months to 3 years was assessed with instruments that included the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scale. Potential factors that might affect cognitive function were analyzed via logistic regression. RESULTS The MMSE and MoCA scores of the patients before CAS were significantly lower than that of the control subjects. These scores were significantly higher 6 months after CAS and sustained or increased throughout the 3-year follow-up. Also significantly improved after CAS from baseline were scores for an alternating trail test, cube copying, clock-drawing, attention, and delayed recall in an auditory-verbal learning test. Logistic regression analyses showed that age greater than 65 y, little education, diabetes, and hypertension were independent risk factors for deteriorated MoCA scores 3 years after CAS. CONCLUSION CAS was associated with significantly improved cognitive function in cerebral lacunar infarction patients with severe stenosis.
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Affiliation(s)
- Zhang Yong Xia
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, PR China
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong, 252000, PR China
| | - Qin Jian Sun
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, PR China
| | - Hua Yang
- Department of Neurology, the Third People’s Hospital of Liaocheng, Liaocheng, Shandong, 252000, PR China
| | - Ming Xia Zhang
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong, 252000, PR China
| | - Ru Ban
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong, 252000, PR China
| | - Ge Lin Xu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, 210002, PR China
| | - Ya Ping Wu
- Department of Neurology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong, 252000, PR China
| | - Le Xin Wang
- School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia
| | - Yi Feng Du
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, PR China
- * E-mail:
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Scherr M, Kunz A, Doll A, Mutzenbach JS, Broussalis E, Bergmann HJ, Kirschner M, Trinka E, Killer-Oberpfalzer M. Ignoring floor and ceiling effects may underestimate the effect of carotid artery stenting on cognitive performance. J Neurointerv Surg 2015; 8:747-51. [DOI: 10.1136/neurintsurg-2014-011612] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 05/21/2015] [Indexed: 11/03/2022]
Abstract
IntroductionData on neuropsychological outcome after carotid artery stenting (CAS) remain inconsistent, furthermore cognitive outcome seems to be unpredictable in the individual case. Previous studies reporting improvement or decline might be due to ceiling and floor effects of the applied cognitive tests. We applied cognitive testing before and after CAS, avoiding the pitfall of ceiling and floor effects.MethodsIn our prospective database, we identified 72 patients free of clinical stroke with ≥70% carotid artery stenosis, who were treated with CAS. They were administered a neurocognitive test battery before and 3 months after CAS to compare cognitive performance before and after CAS. To avoid ceiling and floor effects of test performances, we additionally analysed subgroups of patients without baseline floor and ceiling cognitive performance.ResultsPre-interventional to post-interventional cognitive performance improved significantly in the subtests measuring verbal episodic memory; deterioration was observed in spatial memory. The subgroups of patients without baseline floor and ceiling cognitive performance improved in measures of global cognition, verbal episodic memory (patients with left-sided CAS) and divided attention (patients with right-sided CAS); we observed no significant effects in the other domains.ConclusionsIgnoring floor and ceiling effects may underestimate the impact of CAS on cognitive performance.
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Yoon BA, Sohn SW, Cheon SM, Kim DH, Cha JK, Yi S, Park KW. Effect of carotid artery stenting on cognitive function in patients with carotid artery stenosis: a prospective, 3-month-follow-up study. J Clin Neurol 2015; 11:149-56. [PMID: 25851893 PMCID: PMC4387480 DOI: 10.3988/jcn.2015.11.2.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose Carotid artery stenting (CAS) is emerging as an alternative to carotid endarterectomy for the treatment of carotid artery stenosis (CS), but the effect of CAS on the cognitive function of patients with severe CS has not been fully investigated. The aim of this study was to use comprehensive neuropsychological tests to determine the effect of CAS on cognitive function from baseline to 3 months postprocedure in patients with severe CS. Methods Thirty-one patients due to undergo CAS due to high-grade CS (≥70%) and 11 control subjects who were diagnosed with CS, but who did not undergo CAS, and who visited the clinic or emergency room between February 2009 and February 2012 were recruited consecutively at baseline (i.e., pre-CAS). Follow-up neuropsychological evaluations after 3 months were completed by 23 of the 31 patients who underwent CAS, and by 10 of the 11 control subjects. The primary cognitive outcome was assessed using a neuropsychological test containing subcategories designed to test general cognitive function, attention, visuospatial function, language and related functions, memory, and frontal lobe/executive function. Results Of the 23 patients undergoing CAS who completed the 3-month follow-up tests, 12 had asymptomatic CS. During the 3-month follow-up period, the patients who underwent CAS and those with asymptomatic CS achieved similar results to the control group on all cognitive tests. However, symptomatic CS patients (n=11) who underwent CAS exhibited improvements in visuospatial function (p=0.046) and total Seoul Neuropsychological Screening Battery-Dementia Version scores (p=0.010) in comparison with both the asymptomatic CS patients and the control group. Conclusions The findings of this study suggest that CAS has a positive effect on cognitive function in patients with symptomatic CS over a 3-month follow-up period. A long-term, multicenter, prospective case-control study would be helpful to predict quality of life and prognoses for patients undergoing CAS.
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Affiliation(s)
- Byeol A Yoon
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Sang Wuk Sohn
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Sang Myung Cheon
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Dae Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea.; Busan-Ulsan Regional Cardio-Cerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea.; Busan-Ulsan Regional Cardio-Cerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Sojeong Yi
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Won Park
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea.; Dong-A Anti-aging Research Institute, Dong-A University College of Medicine, Busan, Korea.
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Heyer EJ, Mallon KA, Mergeche JL, Stern Y, Connolly ES. Deficits of hand coordination and laterality of carotid endarterectomy. J Neurosurg 2015; 122:101-6. [DOI: 10.3171/2014.8.jns1459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Neurocognitive performance is used to assess multiple cognitive domains, including motor coordination, before and after carotid endarterectomy (CEA). Although gross motor strength is impaired with ischemia of large cortical areas or of the internal capsule, the authors hypothesize that patients undergoing CEA demonstrate significant motor deficits of hand coordination contralateral to the operative side, which is more clearly manifest in the nondominant hand than in the dominant hand with ischemia of smaller cortical areas.
METHODS
The neurocognitive performance of 374 patients was evaluated with a battery of neuropsychometric tests. Both asymptomatic and symptomatic patients undergoing CEA were included. The authors evaluated the patients' dominant and nondominant hand performance on the Grooved Pegboard test, a test of hand coordination, to demonstrate their functional laterality. Neurocognitive dysfunction was evaluated as the difference in performance before and after CEA according to group-rate and event-rate analyses. The z scores were generated for all tests using a reference group of patients who were having simple spine surgery. Dominant and nondominant motor coordination functions were evaluated as raw scores and as calculated z scores.
RESULTS
According to event-rate analysis, significantly more patients undergoing CEA of the opposite carotid artery demonstrated nondominant than dominant hand deficits of coordination (41.2% vs 26.4%, respectively, p = 0.02). Similarly, according to group-rate analysis, in patients undergoing CEA of the opposite carotid artery, raw difference scores from the Grooved Pegboard test reflected greater nondominant than dominant hand deficits of coordination (21.0 ± 54.4 vs 9.7 ± 37.0, respectively, p = 0.02).
CONCLUSIONS
Patients undergoing CEA of the opposite carotid artery are more likely to demonstrate nondominant than dominant hand deficits of coordination because of greater dexterity in the dominant hand before surgery.
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Affiliation(s)
| | | | | | | | - E. Sander Connolly
- 2Neurology and
- 3Neurological Surgery, Columbia University, New York, New York
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Abstract
Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.
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Yan Y, Yuan Y, Liang L, Chen T, Shen Y, Zhong C. Influence of carotid artery stenting on cognition of elderly patients with severe stenosis of the internal carotid artery. Med Sci Monit 2014; 20:1461-8. [PMID: 25129549 PMCID: PMC4144945 DOI: 10.12659/msm.890847] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The aim of this study was to investigate the influence of carotid artery stenting (CAS) on the cognition and quality of life of elderly patients with severe stenosis of the internal carotid artery. Material/Methods 65 elderly patients with symptomatic severe stenosis of internal carotid artery were recruited into 2 groups: the pharmacotherapy group (n=29) and the CAS group (n=36). Before surgery and 1, 3, 6, and 12 months after surgery, Montreal cognitive assessment (MoCA) was used for the evaluation of cognition and WHOQOL-BREF was used for the assessment of quality of life. Results At 12 months after surgery, total MoCA score and WHOQOL-BREF score in the pharmacotherapy group was significantly reduced when compared with those before surgery (P<0.05). In the CAS group, the total MoCA score, scores of attention and delayed recall, and WHOQOL-BREF score increased significantly at different time points after surgery when compared with those before surgery (P<0.05). Moreover, in CAS group, the MoCA score and WHOQOL-BREF markedly increased gradually over time (P<0.05). Compared with the pharmacotherapy group, cognition and quality of life in the CAS group were improved dramatically during the follow-up period (P<0.05). Conclusions Severe stenosis of the internal carotid artery is a cause of cognition impairment, and CAS may improve cognition and quality of life.
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Affiliation(s)
- Yongxing Yan
- Department of Neurology, Third People's Hospital of Hangzhou, Hangzhou, China (mainland)
| | - Yanrong Yuan
- Department of Neurology, Third People's Hospital of Hangzhou, Hangzhou, China (mainland)
| | - Lizhen Liang
- Department of Neurology, Third People's Hospital of Hangzhou, Hangzhou, China (mainland)
| | - Tao Chen
- Department of Neurology, Third People's Hospital of Hangzhou, Hangzhou, China (mainland)
| | - Yonghui Shen
- Department of Neurology, Third People's Hospital of Hangzhou, Hangzhou, China (mainland)
| | - Changyang Zhong
- Department of Neurology, Third People's Hospital of Hangzhou, Hangzhou, China (mainland)
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Asymptomatic Carotid Stenosis and Cognitive Improvement using Transcervical Stenting with Protective Flow Reversal Technique. Eur J Vasc Endovasc Surg 2014; 47:585-92. [DOI: 10.1016/j.ejvs.2014.02.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 02/28/2014] [Indexed: 11/19/2022]
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Altinbas A, Hendrikse J, Algra A, van Zandvoort MJE, Brown MM, Bonati LH, de Borst GJ, Kappelle LJ, van der Worp HB. Ipsilateral foetal-type posterior cerebral artery is associated with cognitive decline after carotid revascularisation. BMC Neurol 2014; 14:84. [PMID: 24739135 PMCID: PMC4021499 DOI: 10.1186/1471-2377-14-84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 02/24/2014] [Indexed: 11/12/2022] Open
Abstract
Background Stenosis of the internal carotid artery has been associated with cognitive impairment and decline. However, studies testing the effect of carotid revascularisation on cognition have had conflicting results. This may in part be explained by variation in the flow territory of the carotid artery. In 12 to 36% of the patients, the posterior cerebral artery is mainly or exclusively supplied by the internal carotid artery via a foetal-type posterior cerebral artery. In these patients, ipsilateral carotid artery stenosis is likely to result in a larger area with hypoperfusion than in case of a normal posterior cerebral artery. Patients with a foetal-type posterior cerebral artery could therefore benefit more from revascularisation. We compared the effects of carotid revascularisation on cognition between patients with a foetal-type and those with a normal posterior cerebral artery. Methods Patients with symptomatic internal carotid artery stenosis ≥ 50%, enrolled in the International Carotid Stenting Study (ICSS) at a single centre, underwent detailed neuropsychological examinations before and 6 months after revascularisation. Cognitive test results were standardized into z-scores, from which a cognitive sumscore was calculated. The primary outcome was the change in cognitive sumscore between baseline and follow-up. Changes in cognitive sumscore were compared between patients with an ipsilateral foetal-type and those with a normal posterior cerebral artery, as assessed with CT or MR angiography. Results Of 145 patients enrolled in ICSS at the centre during the study period, 98 had both angiography at baseline and neuropsychological examination at baseline and at 6-months follow-up. The cognitive sum score decreased by 0.28 (95% confidence interval, 0.10 to 0.45) in 13 patients with an ipsilateral foetal-type posterior cerebral artery and by 0.07 (95% CI, 0.002 to 0.15) in 85 patients with a normal posterior cerebral artery (mean difference, -0.20; 95% CI, -0.40 to -0.01). This did not change essentially after adjustment for baseline factors. Conclusion An ipsilateral foetal-type posterior cerebral artery appears to increase cognitive decline after carotid revascularisation. Our findings have to be reproduced in an independent study before further implications can be made.
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Affiliation(s)
- Aysun Altinbas
- Utrecht Stroke Center, Departments of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands.
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Murao K, Bombois S, Cordonnier C, Hénon H, Bordet R, Pasquier F, Leys D. Influence of cognitive impairment on the management of ischaemic stroke. Rev Neurol (Paris) 2014; 170:177-86. [PMID: 24613474 DOI: 10.1016/j.neurol.2014.01.665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 01/03/2014] [Accepted: 01/30/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Because of ageing of the population, it is more and more frequent to treat ischaemic stroke patients with pre-stroke cognitive impairment (PSCI). Currently, there is no specific recommendation on ischaemic stroke management in these patients, both at the acute stage and in secondary prevention. However, these patients are less likely to receive treatments proven effective in randomised controlled trials, even in the absence of contra-indication. OBJECTIVE To review the literature to assess efficacy and safety of validated therapies for acute ischaemic stroke and secondary prevention in PSCI patients. RESULTS Most randomised trials did not take into account the pre-stroke cognitive status. The few observational studies conducted at the acute stage or in secondary prevention, did not provide any information that the benefit could be either lost or replaced by harm in the presence of PSCI. CONCLUSIONS There is no reason not to treat ischaemic stroke patients with PSCI according to the currently available recommendations for acute management and secondary prevention. Further observational studies are needed and pre-stroke cognition should be taken into account in future stroke trials.
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Affiliation(s)
- K Murao
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France
| | - S Bombois
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France; Departments of Neurology, Memory Centre, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France.
| | - C Cordonnier
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France; Departments of Neurology, Stroke centre, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France
| | - H Hénon
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France; Departments of Neurology, Stroke centre, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France
| | - R Bordet
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France; Department, of Pharmacology. Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France
| | - F Pasquier
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France; Departments of Neurology, Memory Centre, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France
| | - D Leys
- EA 1046, Departments of Neurology, University Lille North of France, UDSL, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France; Departments of Neurology, Stroke centre, Lille University Hospital, 1, place de Verdun, 59045 Lille cedex, France
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Heyer EJ, Mergeche JL, Anastasian ZH, Kim M, Mallon KA, Connolly ES. Arterial blood pressure management during carotid endarterectomy and early cognitive dysfunction. Neurosurgery 2014; 74:245-51; discussion 251-3. [PMID: 24335822 PMCID: PMC4038378 DOI: 10.1227/neu.0000000000000256] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A common practice during cross-clamp of carotid endarterectomy (CEA) is to manage mean arterial pressure (MAP) above baseline to optimize the collateral cerebral blood flow and reduce the risk of ischemic stroke. OBJECTIVE To determine whether MAP management ≥20% above baseline during cross-clamp is associated with lower risk of early cognitive dysfunction, a subtler form of neurological injury than stroke. METHODS One hundred eighty-three patients undergoing CEA were enrolled in this ad hoc study. All patients had radial arterial catheters placed before the induction of general anesthesia. MAP was managed at the discretion of the anesthesiologist. All patients were evaluated with a battery of neuropsychometric tests preoperatively and 24 hours postoperatively. RESULTS Overall, 28.4% of CEA patients exhibited early cognitive dysfunction (eCD). Significantly fewer patients with MAP ≥20% above baseline during cross-clamp exhibited eCD than those managed <20% above (11.6% vs 38.6%, P < .001). In a multivariate logistic regression model, MAP ≥20% above baseline during the cross-clamp period was associated with significantly lower risk of eCD (odds ratio [OR], 0.18 [0.07-0.40], P < .001), whereas diabetes mellitus (OR, 2.73 [1.14-6.61], P = .03) and each additional year of education (OR, 1.19 [1.06-1.34], P = .003) were associated with significantly higher risk of eCD. CONCLUSION The observations of this study suggest that MAP management ≥20% above baseline during cross-clamp of the carotid artery may be associated with lower risk of eCD after CEA. More prospective work is necessary to determine whether MAP ≥20% above baseline during cross-clamp can improve the safety of this commonly performed procedure.
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Affiliation(s)
- Eric J. Heyer
- Department of Anesthesiology, Columbia University, New York, NY
- Department of Neurology, Columbia University, New York, NY
| | | | | | - Minjae Kim
- Department of Anesthesiology, Columbia University, New York, NY
| | | | - E. Sander Connolly
- Department of Neurology, Columbia University, New York, NY
- Department of Neurological Surgery, Columbia University, New York, NY
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Paraskevas K, Lazaridis C, Andrews C, Veith F, Giannoukas A. Comparison of Cognitive Function after Carotid Artery Stenting versus Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2014; 47:221-31. [DOI: 10.1016/j.ejvs.2013.11.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/14/2013] [Indexed: 10/26/2022]
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Nadelson M, Sanders R, Avidan M. Perioperative cognitive trajectory in adults. Br J Anaesth 2014; 112:440-51. [DOI: 10.1093/bja/aet420] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Terlecki P, Pawlik P, Iwaniuk A, Kocki T, Przywara S, Ilzecki M, Zubilewicz T, Kowalczyk M, Parada-Turska J, Dąbrowski W. Carotid surgery affects plasma kynurenic acid concentration: a pilot study. Med Sci Monit 2014; 20:303-10. [PMID: 24561546 PMCID: PMC3937007 DOI: 10.12659/msm.890212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/06/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND An increase in plasma kynurenic acid (KYNA) concentration has been observed following surgery, inflammation, and cerebral pathologies. The aim of the present study was to analyze the changes in plasma KYNA concentration in patients undergoing carotid surgery (CS). MATERIAL AND METHODS Adult patients undergoing elective carotid endarterectomy (CEA) or carotid angioplasty with stent placement (CAS) were studied. Plasma KYNA concentrations were analyzed before surgery and at 4 time points after CS. The amount of inflammation was measured as neutrophil-lymphocyte ratio (NLR). RESULTS Forty patients (10 female and 30 male) aged 55-86 years of age were evaluated in this study. In patients with unstable carotid plaque, the plasma KYNA concentration was higher than in patients with stable carotid plaque. Moreover, the NLR was significantly higher in patients with unstable carotid plaque undergoing CEA than in patients undergoing CAS. Plasma KYNA concentration increased after surgery in patients undergoing CEA and CAS. There was a strong correlation between plasma KYNA concentration and NLR in patients with postoperative neurological disorders. CONCLUSIONS CS increases plasma KYNA concentration, and changes in plasma KYNA concentration can indicate neurologic outcomes in patients undergoing CS.
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Affiliation(s)
- Piotr Terlecki
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Paulina Pawlik
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Adam Iwaniuk
- Department of Clinical and Experimental Pharmacology Medical University of Lublin, Lublin, Poland
| | - Tomasz Kocki
- Department of Clinical and Experimental Pharmacology Medical University of Lublin, Lublin, Poland
| | - Stanisław Przywara
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Marek Ilzecki
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Tomasz Zubilewicz
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Michał Kowalczyk
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Jolanta Parada-Turska
- Department of Rheumatology and Connective Tissue Diseases Medical University of Lublin, Lublin, Poland
| | - Wojciech Dąbrowski
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
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Plessers M, Van Herzeele I, Vermassen F, Vingerhoets G. Neurocognitive functioning after carotid revascularization: a systematic review. Cerebrovasc Dis Extra 2014; 4:132-48. [PMID: 25076958 PMCID: PMC4105952 DOI: 10.1159/000362921] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/15/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The objective of this study was to review the recent literature regarding the neurocognitive consequences of carotid endarterectomy (CEA) and carotid stenting (CAS). METHODS AND RESULTS A PubMed and Web of Science search was conducted using the key words 'carotid' in combination with 'cognitive', 'cognition', 'neurocognition', 'neurocognitive', 'neuropsychology', and 'neuropsychological'. Bibliographies of relevant articles were cross-referenced. We included 37 studies published since 2007 of which 18 examined CEA, 12 CAS, and 7 compared CEA to CAS. There is a wide variability in the reported neurocognitive outcome following CEA and CAS. Nonetheless, none of the included studies unveiled significant differences between CEA and CAS on postoperative neurocognitive functioning. Postoperative changes observed for CEA and CAS separately seem limited to a small percentage (around 10-15%) of patients and can either present as an improvement or impairment. KEY MESSAGES The available data seem to suggest that no obvious cognitive differences between CAS and CEA can be observed after intervention. Both improvement and deterioration in cognitive functioning can be observed following CAS or CEA. Methodological differences such as patient heterogeneity, implementation and type of control groups, type of psychometric tests used, statistical analyses, or timing of the assessments play an important role in explaining the sometimes divergent results of the included studies. Large-scale and methodologically solid studies comparing CEA and CAS on neurocognitive outcome remain warranted. Future studies should implement adequate control groups to correct for practice effects in the target groups.
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Affiliation(s)
- Maarten Plessers
- Department of Experimental Psychology, Ghent University, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Guy Vingerhoets
- Department of Experimental Psychology, Ghent University, Ghent, Belgium
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Cognitive Performance following Carotid Endarterectomy or Stenting in Asymptomatic Patients with Severe ICA Stenosis. Cardiovasc Psychiatry Neurol 2013; 2013:342571. [PMID: 24455200 PMCID: PMC3880731 DOI: 10.1155/2013/342571] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 09/30/2013] [Accepted: 11/08/2013] [Indexed: 11/25/2022] Open
Abstract
Background. Endarterectomy (CEA) or stenting (CAS) of a stenotic carotid artery is currently undertaken to reduce stroke risk. In addition removal of the arterial narrowing has been hypothesized to improve cerebral hemodynamics and provide benefits in cognitive functions, by supposedly resolving a “hypoperfusion” condition. Methods. In this study we sought to test whether resolution of a carotid stenosis is followed by measurable changes in cognitive functions in 22 subjects with “asymptomatic” stenosis. Results. A main finding of the study was the statistically significant pre-post difference observed in the performance of phonological verbal fluency and Rey's 15-word immediate recall. Remarkably, there was a significant interaction between phonological verbal fluency performance and side of the carotid intervention, as the improvement in the verbal performance, a typical “lateralized” skill, was associated with resolution of the left carotid stenosis. Conclusion. The results reflect a substantial equivalence of the overall performance at the before- and after- CEA or CAS tests. In two domains, however, the postintervention performance resulted improved. The findings support the hypothesis that recanalization of a stenotic carotid could improve brain functions by resolving hypothetical “hypoperfusion” states, associated with the narrowing of the vessels.
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The effect of white matter lesions on cognition after carotid revascularization. J Neurol Sci 2013; 334:77-82. [DOI: 10.1016/j.jns.2013.07.2512] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 06/21/2013] [Accepted: 07/25/2013] [Indexed: 11/22/2022]
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Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use. Acta Neurochir (Wien) 2013; 155:2085-96. [PMID: 23996165 DOI: 10.1007/s00701-013-1858-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Routine shunting to minimize ischemia during carotid endarterectomy (CEA) is controversial. The aim of this study was to stratify the ischemic parameters associated with CEA and evaluate the effect of routine shunting in attempting to mitigate those ischemia. METHOD Data from 248 CEAs with routine shunting were retrospectively evaluated. Our assessment included somatosensory evoked potential (SSEP) amplitude reduction more than 50 % and longer than 5 min (SSEP<50%, >5 min), new postoperative diffusion-weighted imaging lesions (new DWI lesions), and severe stenosis as indicated by reduced ipsilateral middle cerebral artery (MCA) signal on preoperative magnetic resonance angiography (MRA asymmetry), as surrogates of hypoperfusion, microembli, and hemodynamic impairment, respectively. RESULTS SSEP<50%, >5 min occurred in 15 % of CEAs during cross-clamping, and shunting reversed the SSEP changes. New DWI lesions were observed in 4.1 %. Pre-clamping the common and external carotid artery during dissection (pre-clamp method) decreased the rate of new DWI lesions compared to without pre-clamping (3.5 % vs. 7.5 %, P = 0.22). Occlusion time was significantly longer in the pre-clamp method than without pre-clamping (P < 0.0001). However, the incidence of SSEP<50%, >5 min was not increased with the pre-clamp method (p = 1.0) when using information regarding SSEP and collaterals to modify the speed of shunt manipulation. MRA asymmetry was identified in 39 CEAs (15.8 %) with correction of asymmetry postoperatively. MRA asymmetry correlated with symptomatic hyperperfusion (P = 0.0034). Only three CEAs had symptomatic hyperperfusion (1.2 %) with minimal symptoms. Ten CEAs sustained transient ischemia, symptomatic hyperperfusion, or 30-day-stroke (composite postoperative ischemic symptoms). Logistic regression analysis confirmed that SSEP<50%, >5 min (p = 0.009), new DWI lesions (p = 0.004) and MRA asymmetry (p = 0.042) were independent predictors of composite postoperative ischemic symptoms. CONCLUSIONS SSEP<50%, >5 min, new DWI lesions, and MRA asymmetry were able to stratify the ischemic impacts in CEA. Meticulous routine shunting could mitigate those appropriately.
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Yoshida K, Ogasawara K, Kobayashi M, Yoshida K, Kubo Y, Otawara Y, Ogawa A. Improvement and impairment in cognitive function after carotid endarterectomy: comparison of objective and subjective assessments. Neurol Med Chir (Tokyo) 2013; 52:154-60. [PMID: 22450480 DOI: 10.2176/nmc.52.154] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective and subjective assessments of postoperative improvement and impairment in cognition were prospectively compared in patients who underwent carotid endarterectomy (CEA). Each patient underwent subjective cognitive assessment by a neurosurgeon and the patient's next of kin, and neuropsychological testing consisting of five test scores within 7 days before surgery and between 1 and 2 months after surgery. Of 213 patients studied, 24 (11%), 166 (78%), and 23 (11%) patients were defined as having subjectively improved, unchanged, and impaired cognition, respectively, following surgery. In all neuropsychological tests, differences in test scores between the two tests (postoperative test score - preoperative test score) significantly differentiated patients with subjectively improved, unchanged, and impaired cognition after surgery. Receiver operating characteristic analysis showed that the cut-off point for the differences in neuropsychological test scores in detecting subjective improvement and impairment in cognition after surgery was identical to mean +2 standard deviations (SDs) and mean -2 SDs, respectively, of the control value obtained from normal subjects. Of 27 patients with differences in neuropsychological test scores more than the upper cut-off point and 26 patients with differences in neuropsychological test scores less than the lower cut-off point in one or more neuropsychological tests, 24 (89%) and 23 (88%) exhibited subjectively improved and impaired cognition, respectively, after surgery. The present study indicates that neuropsychological test scores reflect the subjective assessment of postoperative change in cognition, and can detect subjective improvement and impairment in cognition after CEA using the optimal cut-off points for the test scores.
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Affiliation(s)
- Koji Yoshida
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate
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Huang CC, Chen YH, Lin MS, Lin CH, Li HY, Chiu MJ, Chao CC, Wu YW, Chen YF, Lee JK, Wang MJ, Chen MF, Kao HL. Association of the Recovery of Objective Abnormal Cerebral Perfusion With Neurocognitive Improvement After Carotid Revascularization. J Am Coll Cardiol 2013; 61:2503-9. [DOI: 10.1016/j.jacc.2013.02.059] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 01/01/2013] [Accepted: 02/14/2013] [Indexed: 11/30/2022]
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Neurocognitive changes after eversion carotid endarterectomy under local anesthesia. Ann Vasc Surg 2013; 27:727-35. [PMID: 23706182 DOI: 10.1016/j.avsg.2012.06.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/07/2012] [Accepted: 06/12/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND The effects of carotid endarterectomy (CEA) on cognitive function have yet to be fully elucidated. The aim of our study was to administer a battery of cognitive tests to identify any cognitive changes occurring in a consecutive series of patients who underwent CEA using the eversion technique under local anesthesia. METHODS This prospective study was designed to analyze a consecutive series of patients undergoing eversion CEA under local anesthesia for significant carotid stenosis at our vascular surgery unit over a period of 6 months. Patients underwent tests to rule-out those who already had cognitive impairments or states of depression/anxiety capable of interfering with cognitive testing outcomes. Patients then completed a battery of 10 neurocognitive tests preoperatively and again 30 days and 4 months after surgery to assess the functions of both cerebral hemispheres as thoroughly as possible. RESULTS Of the 48 patients initially considered for our study, 39 completed the follow-up. They were 71.4 ± 8.2 (mean ± SD) years of age; 30 were men and 9 were women. Six were symptomatic for carotid stenosis and 33 were asymptomatic. All patients were examined by a neurologist and underwent pre- and postoperative nuclear MRI or CT scan of the brain to identify any cerebral ischemia potentially correlated with the surgical procedure. In all cases, the cognitive test findings tended to improve postoperatively; this improvement was statistically significant in 7 tests. Post-hoc analysis confirmed an improvement between the pre- and postoperative test results. Among the different variables considered, only age <75 years seems to have influenced cognitive improvement. CONCLUSIONS The effects on cognitive function of carotid stenosis, particularly CEA, is still a much debated issue. The data reported in the literature vary considerably, preventing any final conclusions from being drawn. The mechanisms capable of inducing changes in cognitive status after CEA have yet to be precisely clarified. In our study, a suitable battery of tests were used to analyze the trend of cognitive function correlating with eversion CEA under local anesthesia. Our results demonstrate substantially improved cognitive function after CEA, which was statistically significant in 7 of 10 tests. We surmise that the CEA procedure, per se, can help to protect patients against cognitive deterioration, especially in those <75 years of age.
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Maggio P, Altamura C, Landi D, Migliore S, Lupoi D, Moffa F, Quintiliani L, Vollaro S, Palazzo P, Altavilla R, Pasqualetti P, Errante Y, Quattrocchi CC, Tibuzzi F, Passarelli F, Arpesani R, di Giambattista G, Grasso FR, Luppi G, Vernieri F. Diffusion-weighted lesions after carotid artery stenting are associated with cognitive impairment. J Neurol Sci 2013; 328:58-63. [DOI: 10.1016/j.jns.2013.02.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 01/24/2013] [Accepted: 02/21/2013] [Indexed: 10/27/2022]
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Saito H, Ogasawara K, Nishimoto H, Yoshioka Y, Murakami T, Fujiwara S, Sasaki M, Kobayashi M, Yoshida K, Kubo Y, Beppu T, Ogawa A. Postoperative changes in cerebral metabolites associated with cognitive improvement and impairment after carotid endarterectomy: a 3T proton MR spectroscopy study. AJNR Am J Neuroradiol 2013; 34:976-82. [PMID: 23124640 DOI: 10.3174/ajnr.a3344] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cognitive function can improve or decline after carotid endarterectomy. Proton MR spectroscopy can be used evaluate cerebral metabolites, such as N-acetylaspartate, choline, and creatine, in vivo. The purpose of the present study was to determine whether postoperative changes in cerebral metabolites measured by using 3T proton MR spectroscopy were associated with changes in cognitive function after CEA. MATERIALS AND METHODS In 100 patients undergoing CEA for ipsilateral cervical internal carotid artery stenosis (≥70%), brain proton MR spectroscopy was performed before and after surgery. NAA/Cr and Cho/Cr ratios were measured in regions of interest placed in the centrum semiovale of both cerebral hemispheres. Neuropsychological testing was also performed preoperatively and 1 month postoperatively. Multivariate statistical analysis of factors related to postoperatively changed cognition was performed, and odds ratios with 95% confidence intervals were calculated. RESULTS On the basis of the neuropsychological assessments, 10 (10%), 80 (80%), and 10 (10%) patients were defined as having postoperatively improved, unchanged, and impaired cognition, respectively. A positive and high ΔNAA/Cr ratio (postoperative value-preoperative value) in the cerebral hemisphere ipsilateral to the operative site was significantly associated with postoperatively improved cognition (95% CI, 13.3-21.3; P = .0016). Negative and high absolute values of the ΔNAA/Cr ratio (95% CI, 0.018-0.101; P = .0039) and ΔCho/Cr ratio (95% CI, 0.042-0.135; P = .0046) in the ipsilateral cerebral hemisphere were significantly associated with postoperatively impaired cognition. CONCLUSIONS Postoperative changes in cerebral metabolites measured by using proton MR spectroscopy were associated with changes in cognitive function after CEA.
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Affiliation(s)
- H Saito
- Department of Neurosurgery, Iwate Medical University, Uchimaru, 19-1, Morioka 020-8505, Japan.
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CHENG YONG, WANG YANJIANG, YAN JIACHUAN, ZHOU RUI, ZHOU HUADONG. Effects of carotid artery stenting on cognitive function in patients with mild cognitive impairment and carotid stenosis. Exp Ther Med 2013; 5:1019-1024. [PMID: 23596467 PMCID: PMC3627448 DOI: 10.3892/etm.2013.954] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/24/2013] [Indexed: 11/06/2022] Open
Abstract
Carotid stenosis is known to be an independent risk factor in the transformation process of mild cognitive impairment (MCI) to dementia and is treated by carotid artery stenting (CAS); however, the effects of CAS on cognitive function are unclear. In this study, 240 patients were prospectively assigned to a CAS or control group according to patient preference and underwent detailed neuropsychological examinations (NPEs) before and 6 months after treatment. Cerebral perfusion was assessed with computed tomography perfusion (CTP). Among the 240 patients included in the study, 208 patients completed NPEs at baseline and 6 months after therapy. The patients in the two groups did not differ with regard to baseline characteristics, educational level, vascular risk factors (VRFs) and NPEs prior to therapy. Significant improvements in the Mini-Mental State Examination (MMSE; before, 24.6±1.7 vs. after, 24.8±1.9; P=0.016), Montreal Cognitive Assessment (MOCA; before, 23.7±1.7 vs. after, 24.1±2.0; P=0.006), Fuld Object Memory Evaluation (FOME; before, 13.8±2.2 vs. after, 14.0±2.3; P=0.031) and Wechsler Adult Intelligence Scale-digital span (WAIS-DS; before, 6.7±2.1 vs. after, 6.9±2.3; P=0.040) were observed in the CAS group; however, improvements were not observed in the control group. Of the 84 patients in the CAS group who received CTP follow-up, 72 (86%) presented improvements in ipsilateral brain perfusion 6 months after the procedure; however, no improvement was observed in the control group. Close correlations were identified between the change in perfusion and the change in MMSE (r=0.575) and MOCA (r=0.574). CAS improves global cognitive function in patients with carotid stenosis and MCI and the improvement of cognition is closely related to the improvement of cerebral perfusion.
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Affiliation(s)
| | | | | | | | - HUA DONG ZHOU
- Correspondence to: Professor Hua Dong Zhou, Department of Neurology and Center for Clinical Neuroscience, Daping Hospital, Third Military Medical University, No. 10 Chang Jiang Branch Road, Daping, Chongqing 400042, P.R. China, E-mail:
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Takaiwa A, Kuwayama N, Akioka N, Kurosaki K, Hayashi N, Endo S, Kuroda S. Effect of carotid endarterectomy on cognitive function in patients with asymptomatic carotid artery stenosis. Acta Neurochir (Wien) 2013; 155:627-33. [PMID: 23361637 DOI: 10.1007/s00701-013-1625-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/10/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study was conducted to determine if patients with asymptomatic carotid artery stenosis show cognitive function decline, and if they experience any changes in cognitive function after carotid endarterectomy (CEA). METHOD Cognitive function was examined in 15 patients (12 males and three females, 70.0 ± 6.5 years) with asymptomatic carotid artery stenosis before and 3 months after CEA. Cognitive function was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), two subtests of the Wechsler Adult Intelligence Scale-Revised (WAIS-R 2 subtests), and the Japanese version of National Adult Reading Test (JART). The patients' average scores were compared with the normal average by one-sample t-tests, and the before and after scores were compared with paired t-tests. Changes in each patient were calculated from difference before and after CEA using 95 % confidence intervals. RESULTS Before surgery, patients showed significant cognitive decline in RBANS total scale and immediate memory, language, and attention. At 3 months after CEA, the total scale and the immediate memory were not significantly different from the normal average. The average total scale score, the immediate memory and attention, and the WAIS-R 2 subtests scores were increased after treatment. Changes in each patient were calculated from the scores before and after CEA. At 3 months after CEA, the rate of increase in RBANS scores were 60.0 % of the patients for immediate memory, 26.7 % for visuospatial/constructional, 33.3 % for language and attention, 26.7 % for delayed memory, 47.7 % for total scale and 26.7 % for WAIS-R 2 subtests. Thus, so-called asymptomatic patients exhibit mild cognitive impairment before surgery, but after CEA, patients recover normal memory abilities. CONCLUSIONS Our findings of mild cognitive dysfunction in asymptomatic patients suggest that they might be symptomatic after all.
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Affiliation(s)
- Akiko Takaiwa
- Department of Neurosurgery, Faculty of Medicine, University of Toyama, Sugitani 2630, Toyama, Toyama, 930-0194, Japan
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Microemboli detection in patients with carotid artery stenting — A potential marker for future cognitive impairment? J Neurol Sci 2013; 326:96-9. [DOI: 10.1016/j.jns.2013.01.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 09/11/2012] [Accepted: 01/17/2013] [Indexed: 11/30/2022]
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Inoue T, Ohwaki K, Tamura A, Tsutsumi K, Saito I, Saito N. Subclinical ischemia verified by somatosensory evoked potential amplitude reduction during carotid endarterectomy: negative effects on cognitive performance. J Neurosurg 2013; 118:1023-9. [PMID: 23451902 DOI: 10.3171/2013.1.jns121668] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although the mechanisms underlying neurocognitive changes after carotid endarterectomy (CEA) are poorly understood, intraoperative ischemia and postoperative hemodynamic changes may play a role. METHODS Data from 81 patients who underwent unilateral CEA with routine shunt use for carotid artery stenosis were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised before and 6 months after CEA. results of NPEs were converted into z scores, from which pre- and postoperative cognitive composite scores (CSpre and CSpost) were obtained. The association between the change of CS between pre- and postoperative NPEs (that is, CSpost - CSpre [CSpost - pre]) and various variables was assessed. These latter variables included ischemic or hemodynamic parameters such as 1) intraoperative hypoperfusion detected by somatosensory evoked potential (SSEP) change-that is, an SSEP amplitude reduction more than 50% and longer than 5 minutes (SSEP< 50%, > 5 min); 2) new lesions on postoperative diffusion-weighted imaging studies; and 3) preexisting hemodynamic impairment. Paired t-tests of the NPE scores were performed to determine the net effect of these factors on neurocognitive function at 6 months. RESULTS A significant CSpost - pre decrease was observed in patients with SSEP< 50%, > 5 min when compared with those without SSEP< 50%, > 5 min (-0.225 vs 0.018; p = 0.012). Multiple regression analysis demonstrated that SSEP< 50%, > 5 min independently and negatively correlated with CSpost - pre (p = 0.0020). In the group-rate analysis, postoperative NPE scores were significantly improved relative to preoperative scores. CONCLUSIONS Hypoperfusion during cross-clamping, as verified by SSEP amplitude reduction, plays a significant role in the subtle decline in cognition following CEA. However, this detrimental effect was small, and various confounding factors were present. Based on these observations and the group-rate analysis, the authors conclude that successful unilateral CEA with routine shunt use does not adversely affect postoperative cognitive function.
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Affiliation(s)
- Tomohiro Inoue
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Shizuoka, Japan.
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81
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Ishihara H, Oka F, Shirao S, Kato S, Sadahiro H, Osaki M, Suzuki M. Cognitive outcome differences on the side of carotid artery stenting. J Vasc Surg 2013; 57:125-30. [DOI: 10.1016/j.jvs.2012.07.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 07/25/2012] [Accepted: 07/25/2012] [Indexed: 10/27/2022]
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82
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Ortega G, Álvarez B, Quintana M, Ribó M, Matas M, Álvarez-Sabin J. Cognitive Improvement in Patients with Severe Carotid Artery Stenosis after Transcervical Stenting with Protective Flow Reversal. Cerebrovasc Dis 2013; 35:124-30. [DOI: 10.1159/000346102] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 11/22/2012] [Indexed: 11/19/2022] Open
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83
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TAKAHASHI Y, OGASAWARA K, MATSUMOTO Y, KOBAYASHI M, YOSHIDA K, KUBO Y, BEPPU T, MURAKAMI T, NANBA T, OGAWA A. Changes in Cognitive Function After Carotid Endarterectomy in Older Patients: Comparison With Younger Patients. Neurol Med Chir (Tokyo) 2013; 53:353-9. [DOI: 10.2176/nmc.53.353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Kenji YOSHIDA
- Department of Neurosurgery, Iwate Medical University
| | | | - Takaaki BEPPU
- Department of Neurosurgery, Iwate Medical University
| | | | | | - Akira OGAWA
- Department of Neurosurgery, Iwate Medical University
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84
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Wu Y, Bian L, Ni X, Ning M, Zhao Y, Ling R. A mechanistic investigation into non-infarcted brain injury induced by cerebral artery microemboli. Mol Biol Rep 2012; 40:1283-90. [PMID: 23129315 DOI: 10.1007/s11033-012-2171-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 10/08/2012] [Indexed: 11/24/2022]
Abstract
To establish a rat brain injury by non-infarction process model induced by cerebral artery microemboli which would be used to further explore the neural injury mechanisms of cerebral artery microemboli. Seventy-two Sprague-Dawley rats were randomly divided into the microemboli group and the sham group; 100 25-50 μm microemboli in 300 μl or the same amount of saline were injected into the left carotid artery, respectively. The severity of neuron damage was assessed 3 and 7 days after the operation, using haematoxylin-eosin (HE) staining and immunohistochemical staining for caspase-3. Immunohistochemical staining for CD11b and GFAP were used to quantitatively analyse hyperplasia and the activation of microglia and astrocytes. TNF-α expression was detected by using ELISA and the NF-κB expression was detected by employing Western blotting. The results of HE staining had shown that ischaemic infarct foci were not detected in either the microemboli group or sham group. Only a few apoptotic cells and a few cells with the positive expression of CD11b and GFAP were detected in the sham group. And compared with that of the sham group, the number of apoptotic cells and the positive expression of CD11b and GFAP in the microemboli group were significantly increased (P < 0.001). These parameters were also significantly increased 7 days after the operation compared to rats 3 days after surgery (P < 0.001). The expressions of TNF-α and NF-κB were significantly increased in the microemboli group (P < 0.001), and the increase of the expression of TNF-α and NF-κB on the 3 days was more significant compared to that of TNF-α and NF-κB on 7 days (P < 0.001). Injection of 25-50 μm microemboli at a dose of 100 microemboli in 300 μl into the carotid artery of rats did not result in cerebral infarction, but led to neuronal apoptosis, hyperplasia and activation of microglia and astrocytes. This leads us to conclude that TNF-α and NF-κB may play important roles in the pathogenesis of neuronal apoptosis induced by microemboli in the cerebral arteries.
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Affiliation(s)
- Yiying Wu
- Department of Geriatrics, Shanghai First People's Hospital, Shanghai Jiaotong University, No. 100 Haining Road, Shanghai, 200080, China
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85
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Casas-Hernanz L, Garolera M, Badenes-Guia D, Cejudo-Bolivar JC, Royo J, Aguilar M. The effect of carotid occlusion in cognition before endarterectomy. Arch Clin Neuropsychol 2012; 27:879-90. [PMID: 23070315 DOI: 10.1093/arclin/acs075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The role of carotid stenosis on cognition remains to be determined. To study whether people with stenosis of the carotid artery have increased cognitive impairments, we studied 53 patients with moderate or severe carotid stenosis (with no symptoms of stroke or dementia) and 53 controls. We describe which cognitive functions were impaired in the patients and whether there were differences based on the side, the severity of the stenosis or the presence of neurological symptoms. Using the Repeatable Battery for the Assessment of Neuropsychological Status, we found that the patients with carotid stenosis had lower cognitive performances in attention, verbal memory, visuospatial capacity and verbal fluency. Patients with lesser degrees of stenosis than healthy control patients had better scores in learning and memory. The results from this study suggest that patients with severe carotid stenosis have a lower cognitive status than healthy control patients, which is associated with the degree of total carotid stenosis.
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Affiliation(s)
- Laura Casas-Hernanz
- Servei de Neurologia, Hospital Universitari Mutua Terrassa, Terrassa, Spain.
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86
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Abstract
Stroke is a known cause of cognitive impairment but the relationship between
asymptomatic carotid artery stenosis and cognitive function is not clear. The
main risk factors for vascular disease are also related to carotid stenosis and
cognitive impairment. The association of high-grade stenosis of the internal
carotid artery with cognitive impairment is related to silent embolization and
hypoperfusion, but it may also be present without evidence of infarction on
magnetic resonance imaging. Carotid stenosis treatment may lead to a decline in
cognitive function due to complications related to the procedures
(endarterectomy or stenting). On the other hand, reperfusion may improve
cognitive impairment. The best treatment choice is unclear, considering possible
deterioration of cognitive function related to carotid artery stenosis. There is
insufficient evidence to consider cognitive impairment an important factor in
determining the therapy for carotid stenosis.
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Affiliation(s)
- Aurélio Pimenta Dutra
- Médico Neurologista. Assessor Médico da Neurologia Vascular Fleury Medicina Diagnóstica
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87
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Mohan IV, Naylor AR. Carotid artery stenting: where are we up to with evidence-based practice? ANZ J Surg 2012; 82:486-8. [PMID: 22863221 DOI: 10.1111/j.1445-2197.2012.06131.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Irwin V Mohan
- Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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88
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Amyloid deposition after cerebral hypoperfusion: Evidenced on [18F]AV-45 positron emission tomography. J Neurol Sci 2012; 319:124-9. [DOI: 10.1016/j.jns.2012.04.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 03/21/2012] [Accepted: 04/13/2012] [Indexed: 11/24/2022]
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89
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Age-dependent effects of carotid endarterectomy or stenting on cognitive performance. J Neurol 2012; 259:2309-18. [PMID: 22527231 PMCID: PMC3484278 DOI: 10.1007/s00415-012-6491-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/20/2012] [Accepted: 03/21/2012] [Indexed: 11/09/2022]
Abstract
Although evidence is accumulating that age modifies the risk of carotid angioplasty and stenting (CAS) versus endarterectomy (CEA) for patients with significant carotid stenosis, the impact of age on cognition after either CEA or CAS remains unclear. In this study, we analyzed the effects of age on cognitive performance after either CEA or CAS using a comprehensive neuropsychological test battery with parallel test forms and a control group to exclude a learning effect. The neuropsychological outcomes after revascularization were determined in 19 CAS and 27 CEA patients with severe carotid stenosis. The patients were subdivided according to their median age (<68 years and ≥68 years); 27 healthy subjects served as a control group. In all patients clinical examinations, MRI scans and a neuropsychological test battery that assessed four major cognitive domains were performed immediately before, within 72 h, and 3 months after CEA or CAS. While patients <68 years of age showed no significant cognitive alteration after either CEA or CAS, a significant cognitive decline was observed in patients ≥68 years in both treatment groups (p = 0.001). Notably, this cognitive deterioration persisted in patients after CEA, whereas it was only transient in patients treated with CAS. These results demonstrate an age-dependent effect of CEA and CAS on cognitive functions. In contrast to the recently observed increased clinical complication rates in older subjects after CAS compared with CEA, CEA appears to be associated with a greater, persistent decline in cognitive performance than CAS in this subgroup of patients.
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90
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Mendiz OA, Sposato LA, Fabbro N, Lev GA, Calle A, Valdivieso LR, Fava CM, Klein FR, Torralva T, Gleichgerrcht E, Manes F. Improvement in executive function after unilateral carotid artery stenting for severe asymptomatic stenosis. J Neurosurg 2012; 116:179-84. [DOI: 10.3171/2011.9.jns11532] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Executive functions are crucial for organizing and integrating cognitive processes. While some studies have assessed the effect of carotid artery stenting (CAS) on cognitive functioning, results have been conflicting. The object of this study was to assess the effect of CAS on cognitive status, with special interest on executive functions, among patients with severe asymptomatic internal carotid artery (ICA) stenosis.
Methods
The authors prospectively assessed the neuropsychological status of 20 patients with unilateral asymptomatic extracranial ICA stenosis of 60% or more by using a comprehensive assessment battery focused on executive functions before and after CAS. Individual raw scores on neuropsychological tests were converted into z scores by normalizing for age, sex, and years of education. The authors compared baseline and 3-month postoperative neuropsychological scores by using Wilcoxon signed-rank tests.
Results
The mean preoperative cognitive performance was within normal ranges on all variables. All patients underwent a successful CAS procedure. Executive function scores improved after CAS, relative to baseline performance as follows: set shifting (Trail-Making Test Part B: −0.75 ± 1.43 vs −1.2 ± 1.48, p = 0.003) and processing speed (digit symbol coding: −0.66 ± 0.85 vs −0.97 ± 0.82, p = 0.035; and symbol search: −0.24 ± 1.32 vs −0.56 ± 0.77, p = 0.049). The benefit of CAS for working memory was marginally significant (digit span backward: −0.41 ± 0.61 vs −0.58 ± 0.76, p = 0.052). Both verbal (immediate Rey Auditory Verbal Learning Test: 0.35 ± 1.04 vs −0.22 ± 0.82, p = 0.011) and visual (delayed Rey-Osterrieth Complex Figure: 0.27 ± 1.26 vs −0.22 ± 1.01, p = 0.024) memory improved after CAS.
Conclusions
The authors found a beneficial effect on executive function and memory 3 months after CAS among their prospective cohort of consecutive patients with unilateral and asymptomatic ICA stenosis of 60% or more.
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Affiliation(s)
| | - Luciano A. Sposato
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
- 4Laboratory of Neuroscience, Universidad Diego Portales, Santiago, Chile
| | - Nicolás Fabbro
- 3Institute of Neurosciences, Favaloro University Hospital
| | | | - Analía Calle
- 3Institute of Neurosciences, Favaloro University Hospital
| | | | | | | | - Teresa Torralva
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
| | - Ezequiel Gleichgerrcht
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
| | - Facundo Manes
- 2INECO and INECO Foundation, Buenos Aires, Argentina; and
- 3Institute of Neurosciences, Favaloro University Hospital
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91
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Lin MS, Chiu MJ, Li HY, Kao HL. Response to Letter Regarding Article “Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion and Cerebral Ischemia”. Stroke 2012. [DOI: 10.1161/strokeaha.111.639047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mao-Shin Lin
- Department of Internal Medicine
National Taiwan University Hospital
Taipei, Taiwan
Graduate Institute of Clinical Medicine
Medical College
National Taiwan University
Taipei, Taiwan (Lin)
| | - Ming-Jang Chiu
- Department of Neurology
National Taiwan University Hospital
Taipei, Taiwan
Department of Psychology
National Taiwan University
Taipei, Taiwan (Chiu)
| | | | - Hsien-Li Kao
- Department of Internal Medicine
National Taiwan University Hospital
Taipei, Taiwan (Li, Kao)
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92
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Huang KL, Ho MY, Chang CH, Ryu SJ, Wong HF, Hsieh IC, Chang TY, Wu TC, Lee TH, Chang YJ. Impact of silent ischemic lesions on cognition following carotid artery stenting. Eur Neurol 2011; 66:351-8. [PMID: 22123044 DOI: 10.1159/000332614] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 08/20/2011] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The occurrence of silent ischemic lesions (SILs) is a common finding after carotid artery stenting (CAS). This study aimed to evaluate the impact of SILs on cognitive functioning following CAS. METHODS The retrospective study separated 131 patients with unilateral carotid stenosis into three groups: medication only, MRI-evaluated CAS and CT-evaluated CAS, and compared the sociodemographic factors, post-CAS images and Mini-Mental State Examination scores performed before and 6-12 months after enrollment. RESULTS Seven minor strokes occurred in the 99 patients receiving CAS. SILs were detected in 12 of 55 patients with diffusion-weighted MR imaging (DWI) and in 3 of 37 patients with CT 1 week after CAS. In patients with DWI follow-up, the frequency of SILs was 8, 24, 43 and 60% in patients with 0-, 1-, 2- and 3-vessel coronary artery disease (p = 0.006). The frequency of SILs on DWI was 0, 32 and 33% in patients with improved, unchanged, or deteriorated cognitive functioning (p = 0.02). Such an association was not observed if based on SILs on CT or manifesting stroke. CONCLUSION The presence of coronary artery disease increases the risk for having post-CAS SILs, and the occurrence of SILs may be associated with cognitive changes after CAS.
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Affiliation(s)
- Kuo-Lun Huang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, ROC
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93
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Scarcello E, Morrone F, Piro P, Tarsitano S, Intrieri F, Vaccarella S, Guerra E, Serra R, de Franciscis S. Protein S-100B as Biochemical Marker of Brain Ischemic Damage After Treatment of Carotid Stenosis. Ann Vasc Surg 2011; 25:975-8. [DOI: 10.1016/j.avsg.2011.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 03/10/2011] [Indexed: 11/29/2022]
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94
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Mark DB, Patel MR, Anstrom KJ. Trade-Offs and Toss-Ups. J Am Coll Cardiol 2011; 58:1566-8. [DOI: 10.1016/j.jacc.2011.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 07/12/2011] [Indexed: 10/17/2022]
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95
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Brucki SMD, Ferraz AC, de Freitas GR, Massaro AR, Radanovic M, Schultz RR. Treatment of vascular dementia. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Dement Neuropsychol 2011; 5:275-287. [PMID: 29213754 PMCID: PMC5619040 DOI: 10.1590/s1980-57642011dn05040005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/20/2011] [Indexed: 11/22/2022] Open
Abstract
Scientific Department of Cognitive Neurology and Aging of ABN had a consensus meeting to write recommendations on treatment of vascular dementia, there was no previous issue. This disease has numerous particularities and can be considered a preventable dementia. Prevention treatment is primary care of vascular risk factors or a secondary prevention of factors that could cause recurrence of ischemic or hemorrhagic brain modifications. In these guidelines we suggested only symptomatic treatment, pharmacologic or non-pharmacologic. We have reviewed current publications on MEDLINE (PubMed), LILACS e Cochrane Library databases. Recommendations are concern to the following factors and their prevention evidences, association, or treatment of vascular dementia: physical activity, tobacco use, diet and food supplements, arterial hypertension, diabetes mellitus, obesity, statins, cardiac failure, atrial fibrillation, antithrombotics, sleep apnea, carotid revascularization, symptomatic pharmacological treatment.
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Affiliation(s)
- Sonia Maria Dozzi Brucki
- Neurology Service, Hospital Santa Marcelina, Cognitive
and Behavioral Neurology Group of Clínicas Hospital of the University of
São Paulo School of Medicine (FMUSP), Referral Center for Cognitive Disorders
(CEREDIC) of the FMUSP, São Paulo SP, Brazil
- D'Or Institute of Research and Teaching, University
Federal Fluminense, Rio de Janeiro RJ, Brazil
| | - Ana Cláudia Ferraz
- D'Or Institute of Research and Teaching, University
Federal Fluminense, Rio de Janeiro RJ, Brazil
| | | | - Ayrton Roberto Massaro
- Medical Investigation Laboratory 27 (LIM 27), Institute
of Psychiatry, School of Medicine, University of Sao Paulo, São Paulo SP,
Brazil
| | - Márcia Radanovic
- Sector of Behavioral Neurology of the Department of
Neurology and Neurosurgery of the Federal University of São Paulo (UNIFESP),
Center for Brain Aging (NUDEC) - Institute of Memory (UNIFESP), São Paulo SP,
Brazil
| | - Rodrigo Rizek Schultz
- Sector of Behavioral Neurology of the Department of
Neurology and Neurosurgery of the Federal University of São Paulo (UNIFESP),
Center for Brain Aging (NUDEC) - Institute of Memory (UNIFESP), São Paulo SP,
Brazil
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96
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Lin MS, Chiu MJ, Wu YW, Huang CC, Chao CC, Chen YH, Lin HJ, Li HY, Chen YF, Lin LC, Liu YB, Chao CL, Tseng WYI, Chen MF, Kao HL. Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion and Cerebral Ischemia. Stroke 2011; 42:2850-4. [DOI: 10.1161/strokeaha.111.613133] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mao-Shin Lin
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Ming-Jang Chiu
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Yen-Wen Wu
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Ching-Chang Huang
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Chi-Chao Chao
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Ying-Hsien Chen
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Hung-Ju Lin
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Hung-Yuan Li
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Ya-Fang Chen
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Lung-Chun Lin
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Yen-Bin Liu
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Chia-Lun Chao
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Wen-Yih Isaac Tseng
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Ming-Fong Chen
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
| | - Hsien-Li Kao
- From the Department of Internal Medicine (M.-S.L., Y.-W.W., C.-C.H., Y.-H.C., H.-J.L., H.-Y.L., L.-C.L., Y.-B.L., M.-F.C., H.-L.K.), National Taiwan University Hospital, Taipei; Graduate Institute of Clinical Medicine (M.-S.L.), Medical College, National Taiwan University, Taipei; Department of Neurology (M.-J.C., C.-C.C.), National Taiwan University Hospital, Taipei; Department of Psychology (M.-J.C.), National Taiwan University, Taipei; Department of Nuclear Medicine (Y.-W.W.), National Taiwan
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97
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Murata K, Fujiki M, Ooba H, Kubo T, Morishige M, Abe T, Ishii K, Kobayashi H, Kiyosue H, Mori H. Cognitive alteration after carotid revascularization is correlated with cortical GABAB-ergic modulations. Neurosci Lett 2011; 500:151-6. [DOI: 10.1016/j.neulet.2011.04.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/08/2011] [Accepted: 04/20/2011] [Indexed: 11/16/2022]
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98
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Balucani C, Silvestrini M. Carotid Atherosclerotic Disease and Cognitive Function: Mechanisms Identifying New Therapeutic Targets. Int J Stroke 2011; 6:368-9. [DOI: 10.1111/j.1747-4949.2011.00628.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The treatment of carotid atherosclerotic disease lies primarily in decreasing the risk of stroke. Many investigations have suggested carotid atherosclerotic disease as being independently associated with cognitive dysfunction, also supporting the notion that in sub-clinical stages, carotid atherosclerotic disease may not be truly silent. An improvement in cognitive function following revascularization approaches may be expected from the reduced embolism and the improved hemodynamics achieved. However, there are no strong data indicating a cognitive change after carotid angioplasty and stenting or carotid endarterectomy in patients who do not experience stroke complications and there is no evidence to support the performance of prophylactic revascularization procedures with the aim of preventing a cognitive decline in otherwise asymptomatic patients. Given the burden of dementia and its tragic implications for individuals and societies, the identification and treatment of such a preventable condition as carotid atherosclerotic disease should be considered. Therefore, it would be desirable in the design of future comparative studies of treatment strategies for carotid atherosclerotic disease to consider cognitive outcome as an endpoint.
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Affiliation(s)
- Clotilde Balucani
- Neurology Department, University of Perugia, Perugia, Italy
- Comprehensive Stroke Center, University of Alabama, Birmingham, AL, USA
| | - Mauro Silvestrini
- Department of Neuroscience, Polytechnic University of Marche, Ancona, Italy
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99
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Levine DA, Langa KM. Vascular cognitive impairment: disease mechanisms and therapeutic implications. Neurotherapeutics 2011; 8:361-73. [PMID: 21556678 PMCID: PMC3167237 DOI: 10.1007/s13311-011-0047-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The prevalence of vascular cognitive impairment (VCI) is likely to increase as the population ages and cardiovascular disease survival improves. We provide an overview of the definition and disease mechanisms of VCI and present a systematic literature review of the current evidence for the pharmacologic and nonpharmacologic therapies used to treat the VCI symptoms of cognitive dysfunction or to modify VCI through primary and secondary prevention. The Cochrane Database of Systematic Reviews was searched from 2005 to October 2010 using the keywords "vascular dementia" or "vascular cognitive impairment and therapy." MEDLINE was searched for English-language articles published within the last 10 years using the combined Medical Subject Headings (MeSH) "therapeutics and dementia," "vascular" or "vascular cognitive impairment." Although cholinesterase inhibitors and memantine produce small cognitive improvements in patients with VCI, these drugs do not improve global clinical outcomes and have adverse effects and costs. Selective serotonin reuptake inhibitors and dihydropyridine calcium channel blockers may improve short-term cognitive function in patients with VCI. Anti-hypertensive therapy with an ACE inhibitor-based regimen and statins may prevent the major subtype of VCI known as poststroke cognitive decline. Clinical and effectiveness studies with long-term follow-up are needed to determine the benefits and risks of pharmacologic and nonpharmacologic therapies to prevent and treat VCI. Given its growing health, social, and economic burden, the prevention and treatment of VCI are critical priorities for clinical care and research.
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Affiliation(s)
- Deborah A Levine
- Division of General Medicine, University of Michigan Health System, and Ann Arbor VA Healthcare System, Ann Arbor, MI 48109, USA.
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100
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Nedeltchev K, Pattynama PM, Biaminoo G, Diehm N, Jaff MR, Hopkins LN, Ramee S, van Sambeek M, Talen A, Vermassen F, Cremonesi A. Standardized definitions and clinical endpoints in carotid artery and supra-aortic trunk revascularization trials. Catheter Cardiovasc Interv 2011; 76:333-44. [PMID: 20506555 DOI: 10.1002/ccd.22560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Endovascular therapy has emerged as a promising alternative to open surgery for stroke prevention in patients with obstructive disease of the supra-aortic arteries. Although most previous studies have used similar safety and efficacy endpoints, differences in definitions, timing of assessments, and standards of reporting have hampered direct comparisons across various trials. METHODS AND RESULTS The DEFINE group, an informal collaboration of multidisciplinary physicians, involved in the therapy of patients with obstructive disease of the supra-aortic arteries in Europe and the United States reviewed the current literature and, after extensive correspondence and meetings, proposed the definitions outlined in the present manuscript. Three meetings including all authors of the manuscript, along with representatives of the United States Food and Drug Administration (FDA) and commercial device manufacturers were held in Barcelona, Spain, in May 2008, in Munich, Germany, in July 2008, and in New York in November 2008. The proposed definitions encompass baseline clinical and anatomic characteristics, clinical and radiologic outcomes, complications, standards of reporting, and timing of assessment. CONCLUSIONS Considering the broad consensus between the multidisciplinary scientific members and the regulatory authorities, the proposed definitions are expected to find adoption in future clinical investigations. These definitions can be applied to both endovascular and open surgery trials and will allow reliable comparisons between these two revascularization methods.
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