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Relander K, Hietanen M, Ijäs P, Nuotio K, Vikatmaa P, Koskinen SM, Ala-Kauhaluoma M, Paajanen TI, Virkkala J, Lindsberg PJ, Soinne L. Long-term cognitive and neurovascular changes after carotid endarterectomy. J Neurol Sci 2024; 459:122981. [PMID: 38569375 DOI: 10.1016/j.jns.2024.122981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has been associated with both cognitive decline and improvement, but the underlying neurovascular mechanisms are unclear. The aim of this study was to investigate the relationship between neurovascular indices and cognitive changes after CEA. METHODS We studied 55 patients with severe (≥70%) symptomatic or asymptomatic carotid stenosis before and six months after CEA. A wide array of neuropsychological tests was arranged in eight cognitive domains and cognitive functions specific to hemisphere ipsilateral to operation. Differences in cognitive performance between patients and 38 matching healthy controls were studied with linear mixed models. Neurovascular functioning and microembolic signals were assessed with transcranial Doppler ultrasound of the middle cerebral artery. Associations between neurovascular indices and cognitive change were assessed with linear regression analyses. RESULTS On group level, the CEA patients improved more than controls in working memory, whereas no cognitive deterioration was detected. Also on individual level, improvement was most frequently observed in working memory. Worse preoperative cerebrovascular reactivity was related with improvement in cognitive functions of the ipsilateral hemisphere. Low preoperative pulsatility index was associated with improvement in executive functioning and ipsilateral cognitive functions. Poorer preoperative blood flow velocity associated with improvement in complex attention. Microembolic signals were rare. CONCLUSION The present findings suggest that CEA may have beneficial long-term effects on cognition. These effects may specifically involve patients with impaired preoperative circulatory adaptive mechanisms.
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Affiliation(s)
- Kristiina Relander
- Neuropsychology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland.
| | - Marja Hietanen
- Neuropsychology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Petra Ijäs
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Krista Nuotio
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Pirkka Vikatmaa
- Vascular Surgery, HUS Abdominal center, University of Helsinki and Helsinki University Hospital, Finland
| | - Suvi M Koskinen
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Marianne Ala-Kauhaluoma
- Ophthalmology, HUS Head and Neck Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Teemu I Paajanen
- Finnish Institute of Occupational Health, Work Ability and Working Careers Unit, Helsinki, Finland
| | - Jussi Virkkala
- Clinical Neurophysiology and Clinical Neurosciences, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Perttu J Lindsberg
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Lauri Soinne
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
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Václavík D, Pakizer D, Hrbáč T, Roubec M, Procházka V, Jonszta T, Herzig R, Školoudík D. Changes in Cognitive Functions after Carotid Endarterectomy and Carotid Stenting: A Decade-Apart Comparison. Biomedicines 2023; 12:13. [PMID: 38275374 PMCID: PMC10813376 DOI: 10.3390/biomedicines12010013] [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: 11/14/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND This study investigates changes in cognitive function in patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) and carotid stenting (CAS) over two decades. METHODS We compared cognitive function within 30 days after the procedure in 267 patients (first 100 each for CEA and CAS in two periods: 2008-2012 and 2018-2022) in a single institution. Assessments used Adenbrooke's Cognitive Examination-Revised (ACE-R), the Mini-Mental State Examination (MMSE), Speech Fluency Test (SFT), and Clock Drawing Test (CDT), conducted before and 30 ± 2 days after surgery. RESULTS Patients (mean age 67.2 years, 70%+ carotid stenosis) exhibited different cognitive changes over periods. In 2008-2012, significant declines in MMSE (CEA, p = 0.049) and CDT (CAS, p = 0.015) were observed among asymptomatic patients. On the contrary, in 2018-2022, improvements were observed in ACE-R and MMSE for symptomatic and asymptomatic patients undergoing CEA and CAS. CONCLUSION Over a decade, advances in interventional techniques and patient management have reduced risks of cognitive decline in patients with asymptomatic carotid stenosis and also have improved cognitive functions in both symptomatic and asymptomatic individuals.
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Affiliation(s)
- Daniel Václavík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
- Stroke Centre, Department of Neurology, Hospital Agel Ostrava Vitkovice, 703 00 Ostrava, Czech Republic
| | - David Pakizer
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Tomáš Hrbáč
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic;
- Department of Neuroscience, Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Václav Procházka
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Tomáš Jonszta
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Roman Herzig
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
| | - David Školoudík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
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Foret T, Guillaumin M, Desmarets M, Costa P, Rinckenbach S, du Mont LS. Association between carotid revascularization for asymptomatic stenosis and cognitive functions. VASA 2022; 51:138-149. [DOI: 10.1024/0301-1526/a000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Asymptomatic carotid stenosis (ACS) can cause cognitive dysfunction, related to cerebral hypoperfusion and microemboli. These mechanisms could be treated by carotid revascularization, but the impact of carotid angioplasty stenting (CAS) or carotid endarterectomy (CEA) on cognitive functions remains unclear. The aim of this systematic review was to realize a report on the actual state of results about asymptomatic carotid stenosis revascularization and cognitive function. We performed a systematic literature review to analyze all studies assessing the impact of asymptomatic carotid stenosis revascularizations on cognitive functions. We reviewed all publications published in Medline database and Cochrane between January 2010 and January 2020 including subjects with a cognitive evaluation and receiving carotid revascularization for asymptomatic stenosis. We identified 567 records for review, and finally we included in the systematic review 20 studies about ACS revascularization and cognitive functions. Only observational studies analyzed the impact of CEA and CAS on cognitive functions. Thus, too heterogeneous data associated to the lack of randomized controlled trials with an evaluation of optimal medical treatment did not enable to affirm the interest of the revascularization management of ACS in cognitive domain. There was a lack of standardization and finally studies were too heterogeneous to conclude on the impact of carotid revascularization on cognitive functions. There is an urgent need to harmonize research in this domain in order to prevent and treat cognitive dysfunction related to ACS, especially in our society with an aging population.
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Affiliation(s)
- Thomas Foret
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHRU Besançon, France
| | | | - Maxime Desmarets
- Unité de méthodologie (uMETh), Centre d’investigation Clinique 1431, Centre Hospitalier Universitaire de Besançon, France
- Unité mixte de recherche Right (UMR1098), Inserm, Établissement Français du Sang BFC, Université Bourgogne Franche-Comté, Besançon, France
| | - Patricia Costa
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHRU Besançon, France
| | - Simon Rinckenbach
- Vascular and Endovascular Surgery Department, CHRU Besançon, France
- EA3920, Université de Bourgogne Franche-Comté, Besançon, France
| | - Lucie Salomon du Mont
- Vascular and Endovascular Surgery Department, CHRU Besançon, France
- EA3920, Université de Bourgogne Franche-Comté, Besançon, France
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Halliday A, Sneade M, Björck M, Pendlebury ST, Bulbulia R, Parish S, Llewellyn-Bennett R, Pan H, Whiteley W, Pan H, Gottsäter A. Editor's Choice - Effect of Carotid Endarterectomy on 20 Year Incidence of Recorded Dementia: A Randomised Trial. Eur J Vasc Endovasc Surg 2022; 63:535-545. [PMID: 35272949 DOI: 10.1016/j.ejvs.2021.12.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Stroke and carotid atherosclerosis are associated with dementia. Carotid endarterectomy (CEA) reduces stroke risk, although its effect on later dementia is uncertain. Participants in the Asymptomatic Carotid Surgery Trial (ACST-1), randomly allocated to immediate vs. deferral of CEA (i.e., no intervention unless or until triggered by ipsilateral transient ischaemic attack or stroke), were followed, to study effects on dementia. METHODS From 1993 to 2003, ACST-1 included 3 120 participants with asymptomatic tight carotid stenosis. All UK and Swedish patients (n = 1 601; 796 immediate vs. 805 deferral) were followed with trial records, national electronic health record linkage, and (UK only) by post and telephone. Cumulative incidence and competing risk analyses were used to measure the effects of risk factors and CEA on dementia risk. Intention to treat analyses yielded hazard ratios (HRs; immediate vs. deferral) of dementia. RESULTS The median follow up was 19.4 years (interquartile range 16.9 - 21.7). Dementia was recorded in 107 immediate CEA patients and 115 allocated delayed surgery; 1 290 patients died (1 091 [538 vs. 536] before any dementia diagnosis). Dementia incidence rose with age and with female sex (men: 8.3% aged < 70 years at trial entry vs. 15.1% aged ≥ 70; women: 15.1% aged < 70 years at trial entry vs. 22.4% aged ≥ 70 years) and was higher in those with pre-existing cerebral infarction (silent or with prior symptoms; 20.2% vs. 13.6%). Dementia risk was similar in both randomised groups: 6.7% vs. 6.6% at 10 years and 14.3% vs. 15.5% at 20 years, respectively. The dementia HR was 0.98 (95% confidence interval [CI] 0.75 - 1.28; p = .89), with no heterogeneity in the neutral effect of immediate CEA on dementia related to age, carotid stenosis, blood pressure, diabetes, country of residence, or medical treatments at trial entry (heterogeneity values p > .05). CONCLUSION CEA was not associated with significant reductions in the long term hazards of dementia, but the CI did not exclude a proportional benefit or hazard of about 25%.
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Affiliation(s)
- Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | - Mary Sneade
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Martin Björck
- Department of Surgical Sciences, University of Uppsala, Uppsala, Sweden
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Parish
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Holly Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - William Whiteley
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Huang KL, Ho MY, Chang YJ, Chang CH, Liu CH, Wu HC, Chang TY, Lee TH. Cognitive Sequelae of Silent Ischemic Lesions Following Carotid Artery Stenting: Possible Role of Age-Related Moderation. Front Aging Neurosci 2022; 13:732617. [PMID: 35095463 PMCID: PMC8789655 DOI: 10.3389/fnagi.2021.732617] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/14/2021] [Indexed: 12/03/2022] Open
Abstract
Background: The occurrence of ischemic lesions is common in patients receiving carotid artery stenting (CAS), and most of them are clinically silent. However, few studies have directly addressed the cognitive sequelae of these procedure-related silent ischemic lesions (SILs). Objective: In this study, we attempted to investigate the effects of SILs on cognition using a comprehensive battery of neuropsychological tests. Method: Eighty-five patients with unilateral carotid stenosis and 25 age-matched healthy volunteers participated in this study. Brain MRI was performed within 1 week before and 1 week after CAS to monitor the occurrence of post-CAS SILs. A comprehensive battery tapping reading ability, verbal and non-verbal memory, visuospatial function, manual dexterity, executive function, and processing speed was administered 1 week before and 6 months after CAS. To control for practice effects on repeated cognitive testing, the reliable change index (RCI) derived from the healthy volunteers was used to determine the cognitive changes in patients with carotid stenosis. Results: Among the 85 patients with carotid stenosis, 21 patients received medical treatment (MED group), and procedure-related SILs were noted in 17 patients (SIL+ group) but not observed in 47 patients (SIL– group) after undergoing CAS. Two-way (group × phase) ANOVA revealed that the volunteer group showed improved scores in most cognitive tests while only limited improvement was noted in the SIL– group. The MED and control groups tended to show improvement in the follow-up cognitive testing than the SIL+ group. However, most of the cognitive changes for each patient group did not exceed the upper or lower limits (z = ±1.0) of the RCI. Conclusions: Although the occurrence of procedure-related SILs is common in patients undergoing CAS, their impacts on cognitive changes after CAS may be limited. The practice effect should be taken into consideration when interpreting cognitive changes following CAS.
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Affiliation(s)
- Kuo-Lun Huang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Meng-Yang Ho
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Clinical Psychology Program, c/o Department of Occupational Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Yeu-Jhy Chang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiu-Chuan Wu
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ting-Yu Chang
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Ting-Yu Chang
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
- *Correspondence: Tsong-Hai Lee
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Carotid revascularization and cognitive impairment: the neglected role of cerebral small vessel disease. Neurol Sci 2021; 43:139-152. [PMID: 34596778 DOI: 10.1007/s10072-021-05629-w] [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: 07/01/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
Carotid atherosclerosis is a pathological process that leads to narrowing of the vessel lumen and a consequent risk of stroke. Revascularization procedures such as carotid endarterectomy (CEA) and carotid stenting aim to reduce occurrence of stroke in selected patients. Due to the proven benefit and low intraoperative risk, CEA is currently the preferred choice in candidates for carotid revascularization. However, the risk of cognitive impairment subsequent to CEA has not been fully elucidated and is unclear whether certain conditions, such as frailty, may increase this risk. There is consistent evidence that shows that frail patients have higher risk of cognitive impairment after surgical procedure. Moreover, brain pre-existing conditions may play a role in cognitive impairment after CEA. Cerebral small vessel disease (SVD) is a pathology that involves microcirculation and is detectable with computed tomography or magnetic resonance. SVD shares common vascular risk factors with carotid atherosclerosis, is a major contributor to vascular cognitive impairment and vascular dementia, and has been proposed as a marker of brain frailty. In this review, we discuss the current evidence about the link between carotid revascularization and cognitive impairment and advance the hypothesis that SVD may play a relevant role in development of cognitive impairment after carotid revascularization.
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7
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Ancetti S, Paraskevas KI, Faggioli G, Naylor AR. Effect of Carotid Interventions on Cognitive Function in Patients With Asymptomatic Carotid Stenosis: A Systematic Review. Eur J Vasc Endovasc Surg 2021; 62:684-694. [PMID: 34474964 DOI: 10.1016/j.ejvs.2021.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/05/2021] [Accepted: 07/11/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the effect of carotid endarterectomy (CEA) and carotid artery stenting (CAS) on early (baseline vs. maximum three months) and late (baseline vs. at least five months) cognitive function in patients with exclusively asymptomatic carotid stenoses (ACS). METHOD Searches were conducted in PubMed/Medline, Embase, Scopus, and the Cochrane library. This systematic review includes 31 non-randomised studies. RESULTS Early post-operative period: In 24 CEA/CAS/CEA+CAS cohorts (n = 2 059), two cohorts (representing 91/2 059, 4.4% of the overall study population) reported significant improvement in cognitive function, while one (28/2 059, 1%) reported significant decline. Three cohorts (250/2 059, 12.5% reported "mixed findings" where some cognitive scores significantly improved, and a similar proportion declined. The majority (nine cohorts; 1 086/2 059, 53%) reported no change. Seven cohorts (250/2 059, 12.1%) were mostly unchanged but one to two individual test scores improved, while two cohorts (347/2 059, 16.8%) were mostly unchanged with one to two individual test scores worse. Late post-operative period: In 21 cohorts (n = 1 554), one (28/1 554, 1.8%) reported significantly worse cognitive function, one reported significant improvement (24/1 554, 1.5%), while a third (19/1 554, 1.2%) reported "mixed findings". The majority were unchanged (six cohorts; 1 073/1 554, 69%) or mostly unchanged, but with one to two cognitive tests showing significant improvement (11 cohorts; 386/1 554, 24.8%). Overall, there was a similar distribution of findings in small, medium, and large studies, in studies with controls vs. no controls, in studies comparing CEA vs. CAS, and in studies with shorter/longer late follow up. CONCLUSION Notwithstanding accepted limitations regarding heterogeneity within non-randomised studies, CEA/CAS rarely improved overall late cognitive function in ACS patients (< 2%) and the risk of significant cognitive decline was equally low (< 2%). In the long term, the majority were either unchanged (69%) or mostly unchanged with one to two test scores improved (24.8%). Until new research identifies vulnerable ACS subgroups (e.g., impaired cerebral vascular reserve) or provides evidence that silent embolisation from ACS causes cognitive impairment, evidence supporting intervention in ACS patients to prevent/reverse cognitive decline is lacking.
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Affiliation(s)
- Stefano Ancetti
- Vascular Surgery, Department of Experimental, Diagnostic and Specialist Medicine - DIMES University of Bologna "Alma Mater Studiorum", Bologna, Italy.
| | - Kosmas I Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialist Medicine - DIMES University of Bologna "Alma Mater Studiorum", Bologna, Italy
| | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
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Matsumoto T, Hoshi H, Hirata Y, Ichikawa S, Fukasawa K, Gonda T, Poza J, Rodríguez-González V, Gómez C, Shigihara Y. The association between carotid blood flow and resting-state brain activity in patients with cerebrovascular diseases. Sci Rep 2021; 11:15225. [PMID: 34315975 PMCID: PMC8316461 DOI: 10.1038/s41598-021-94717-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/15/2021] [Indexed: 11/09/2022] Open
Abstract
Cerebral hypoperfusion impairs brain activity and leads to cognitive impairment. Left and right common carotid arteries (CCA) are the major source of cerebral blood supply. It remains unclear whether blood flow in both CCA contributes equally to brain activity. Here, CCA blood flow was evaluated using ultrasonography in 23 patients with cerebrovascular diseases. Resting-state brain activity and cognitive status were also assessed using magnetoencephalography and a cognitive subscale of the Functional Independence Measure, respectively, to explore the relationships between blood flow, functional brain activity, and cognitive status. Our findings indicated that there was an association between blood flow and resting-state brain activity, and between resting-state brain activity and cognitive status. However, blood flow was not significantly associated with cognitive status directly. Furthermore, blood velocity in the right CCA correlated with resting-state brain activity, but not with the resistance index. In contrast, the resistance index in the left CCA correlated with resting-state brain activity, but not with blood velocity. Our findings suggest that hypoperfusion is important in the right CCA, whereas cerebral microcirculation is important in the left CCA for brain activity. Hence, this asymmetry should be considered when designing appropriate therapeutic strategies.
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Affiliation(s)
- Takahiro Matsumoto
- Department of Neurosurgery, Kumagaya General Hospital, Kumagaya, 360-8567, Japan
| | - Hideyuki Hoshi
- Precision Medicine Centre, Hokuto Hospital, Kisen-7-5 Inadacho, Obihiro, Hokkaido, 080-0833, Japan
| | - Yoko Hirata
- Department of Neurosurgery, Kumagaya General Hospital, Kumagaya, 360-8567, Japan
| | - Sayuri Ichikawa
- Clinical Laboratory, Kumagaya General Hospital, Kumagaya, 360-8567, Japan
| | - Keisuke Fukasawa
- Clinical Laboratory, Kumagaya General Hospital, Kumagaya, 360-8567, Japan
| | - Tomoyuki Gonda
- Department of Rehabilitation, Kumagaya General Hospital, Kumagaya, 360-8567, Japan
| | - Jesús Poza
- Biomedical Engineering Group, Higher Technical School of Telecommunications Engineering, University of Valladolid, Castilla y León, 47011, Valladolid, Spain.,Centro de Investigación Biomédica en Red en Bioingeniería, (CIBER-BBN), Biomateriales y Nanomedicina, Castilla y León, 47011, Valladolid, Spain.,Instituto de Investigación en Matemáticas (IMUVA), University of Valladolid, Castilla y León, 47011, Valladolid, Spain
| | - Víctor Rodríguez-González
- Biomedical Engineering Group, Higher Technical School of Telecommunications Engineering, University of Valladolid, Castilla y León, 47011, Valladolid, Spain
| | - Carlos Gómez
- Biomedical Engineering Group, Higher Technical School of Telecommunications Engineering, University of Valladolid, Castilla y León, 47011, Valladolid, Spain.,Centro de Investigación Biomédica en Red en Bioingeniería, (CIBER-BBN), Biomateriales y Nanomedicina, Castilla y León, 47011, Valladolid, Spain
| | - Yoshihito Shigihara
- Precision Medicine Centre, Hokuto Hospital, Kisen-7-5 Inadacho, Obihiro, Hokkaido, 080-0833, Japan. .,Precision Medicine Centre, Kumagaya General Hospital, Kumagaya, 360-8567, Japan.
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Mendoza JFW, Latorraca CDOC, Oliveira RDÁ, Pachito DV, Martimbianco ALC, Pacheco RL, Riera R. Methodological quality and redundancy of systematic reviews that compare endarterectomy versus stenting for carotid stenosis. BMJ Evid Based Med 2021; 26:14-18. [PMID: 31266765 DOI: 10.1136/bmjebm-2018-111151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 12/14/2022]
Abstract
A review of systematic reviews (SRs) and a critical appraisal study was conducted at Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). The objectives of this review are (1) to identify all published SRs comparing the effectiveness and safety of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) for carotid artery stenosis, (2) to assess their methodological quality and (3) to compare the primary studies contained in each SR. We included 17 SRs published between 2005 and 2017. None of the SRs fulfilled all items of AMSTAR-2. The overall confidence in the results was graded as critically low for 16 SRs (94%) and low for 1 SR (6%). Five items were judged inadequate in all SRs: reference to a published protocol, explanation to the selection of study design, comprehensive search of the literature, methods for statistical combination of findings and consideration of the risk of bias on the results of meta-analysis. In total, 15 randomised clinical trials (RCTs) were included at least in one SR. The number of included RCTs in each SR was inconsistent (4 to 15) and was not related to the year of publication of the SR. Our study found redundant and low methodological quality SR comparing CAS versus CEA for carotid stenosis.
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Affiliation(s)
- Juan Fulgencio Welko Mendoza
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
| | | | - Ricardo de Ávila Oliveira
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Department of Surgery, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Daniela Vianna Pachito
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
| | - Ana Luiza Cabrera Martimbianco
- Postgraduate of Health and Environment, Universidade Metropolitana de Santos, Santos, São Paulo, Brazil
- Medical Research Center, Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Rafael Leite Pacheco
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Medical Research Center, Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Rachel Riera
- Discipline of Evidence-Based Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, São Paulo, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
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10
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Reply to: cognitive function after carotid endarterectomy. Eur J Anaesthesiol 2021; 38:85-86. [PMID: 33273380 DOI: 10.1097/eja.0000000000001280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pucite E, Krievina I, Miglane E, Erts R, Krievins D, Millers A. Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment. Curr Neurovasc Res 2020; 16:47-62. [PMID: 30706811 PMCID: PMC6696820 DOI: 10.2174/1567202616666190129153409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT). METHODS Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months followup periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only. RESULTS Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period. CONCLUSION Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.
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Affiliation(s)
- Elina Pucite
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
| | - Ildze Krievina
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Evija Miglane
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
| | - Renars Erts
- Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Dainis Krievins
- Faculty of Medicine, University of Latvia, Riga, Latvia.,Vascular Surgery Centre, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrejs Millers
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
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Ge Y, Li Q, Nie Y, Gao J, Luo K, Fang X, Wang C. Dexmedetomidine improves cognition after carotid endarterectomy by inhibiting cerebral inflammation and enhancing brain-derived neurotrophic factor expression. J Int Med Res 2019; 47:2471-2482. [PMID: 31014147 PMCID: PMC6567697 DOI: 10.1177/0300060519843738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives Carotid endarterectomy (CEA) is efficient in preventing stroke for patients with significant carotid stenosis, but results in mild cognitive dysfunction. Dexmedetomidine is neuroprotective in stroke models. We hypothesized that dexmedetomidine may improve cognition after CEA. Methods Forty-nine patients scheduled for elective CEA were randomly assigned to intravenous dexmedetomidine treatment group (n = 25) and control group C (normal saline, n = 24). Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA), as well as lactate, TNF-α, IL-6, and BDNF levels in blood, were assessed before, during, and after surgery. Results MMSE and MOCA scores showed subtle decline in both groups at 24 hours postoperatively; this decline remained at 48 hours postoperatively in group C. Both scores were higher in group D than in group C at 48 and 72 hours postoperatively. TNF-α and IL-6 were lower from 5 minutes post-clamping through 24 hours postoperatively in group D; lactate was lower at 5 minutes post-clamping in group D. BDNF was higher from 5 minutes post-clamping through 1 hour postoperatively in both groups, and remained high in group D at 24 hours postoperatively. Conclusions Dexmedetomidine improved recovery of cognition after CEA, potentially due to reduced inflammation and enhanced BDNF expression.
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Affiliation(s)
- Yali Ge
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
| | - Qian Li
- 2 Department of Anesthesiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yuyan Nie
- 2 Department of Anesthesiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Ju Gao
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
| | - Ke Luo
- 3 Department of Anesthesiology, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiangzhi Fang
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
| | - Cunjing Wang
- 1 Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou City, Jiangsu Province, China
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Tanashyan MM, Antonova KV, Medvedev RB, Skrylev SI, Krotenkova MV, Romantsova TI. Symptomatic and silent cerebral ischemia (detected on MRI) in patients with type 2 diabetes mellitus after carotid revascularization procedures. DIABETES MELLITUS 2019. [DOI: 10.14341/dm9633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Type 2 diabetes mellitus (T2DM) is a significant independent risk factor for ischaemic stroke. Carotid revascularisation procedures are an effective method of primary and secondary stroke prevention. However, patients developed postoperative acute ischaemic lesions (AILs), which were identified via magnetic resonance imaging (MRI) of the brains. Most of the patients with these AILs lack clinically overt symptoms.
Aims: To assess the risk of ischaemic brain damage in patients with T2DM in the setting of carotid angioplasty with stenting (CAS) or carotid endarterectomy (CAE).
Materials and methods: This open prospective study comprised of 164 patients with carotid atherosclerosis, who have undergone either CAS or CAE. Patients with T2DM were included in Group 1: 38 patients and 28 patients with CAE. Group 2 included patients without T2DM: 62 patients with CAS and 36 patients with CAE. All patients underwent a thorough neurological examination and diffusion-weighted brain MRI. In patients with T2DM, plasma glucose levels and glycated haemoglobin (HbA1c) were determined and their relationships to brain damage were evaluated.
Results: In CAS, there were no statistically significant differences in the AIL frequency in patients with and without T2DM. AILs were found in 15 patients with T2DM (39.8%) and 29 patients without T2DM (46.8%, р = 0.24); three patients without T2DM were diagnosed with stroke. Of the 28 patients with T2DM who underwent CAE, 13 had AIL (46.4%); three had stroke (10.7%). In patients without T2DM, AILs were less prevalent in seven cases (19.4%, р = 0.012) and appeared asymptomatic. Following CAS, the baseline HbA1c levels were higher in patients with T2DM who developed AILs compared to those who did not develop AIL, 7.8% 1.4% vs 7.1 1.1% (р = 0.0469). Negative impact of hyperglycaemia on the risk of cerebral ischaemia was observed in patients who underwent CAE, the baseline fasting plasma glucose level was 8.5 1.9 mmol/l vs 7.0 1.5 mmol/l in patients without AIL (р = 0.014). The baseline HbA1c levels in patients with and without AILs were 8.0% 1.7% and 6.9% 0.9% respectively (р = 0.023).
Conclusions: Carotid revascularisation procedure for patients with carotid atherosclerosis may be associated with risk of stroke and asymptomatic acute cerebral ischaemic lesions, which are more prevalent in patients with T2DM. Also, increased HbA1c levels is a risk factor for AIL.
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15
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Lu T, Liang J, Wei N, Pan L, Yang H, Weng B, Zeng J. Extracranial Artery Stenosis Is Associated With Total MRI Burden of Cerebral Small Vessel Disease in Ischemic Stroke Patients of Suspected Small or Large Artery Origins. Front Neurol 2019; 10:243. [PMID: 30949118 PMCID: PMC6437037 DOI: 10.3389/fneur.2019.00243] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 02/25/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose: Extracranial artery stenosis (ECAS) is related to individual imaging markers of cerebral small vessel disease (cSVD). However, little has been reported on the association between ECAS and the total burden of cSVD as assessed by magnetic resonance imaging (MRI). The purpose of this study was to investigate the relationship between ECAS and cSVD burden in patients with ischemic stroke of suspected small or large artery origin. Methods: We reviewed consecutive patients with ischemic stroke of suspected small or large artery origin who underwent color Doppler ultrasonography and brain MRI. Bilateral extracranial cerebral arteries including common carotid artery, internal carotid artery (ICA), and proximal vertebral artery (VA, ostium, V2–3 segments) were assessed using color Doppler ultrasonography. ECAS severity was classified as no/mild stenosis, moderate stenosis, severe stenosis, or occlusion. The total cSVD score was assessed by awarding one point according to the load of each of these cSVD markers as determined using MRI; lacunar infarction, white matter hyperintensities, cerebral microbleeds, and enlarged perivascular spaces. The relationship between ECAS severity and cSVD burden according to MRI was examined. Results: Two hundred and twenty one patients were included in this study (mean age 61 ± 12 years, 75.6% male). Hypertension, current smoking, hyperlipidaemia, and diabetic mellitus were frequent among the patients (67.4, 45.7, 43.9, and 36.7%, respectively), while the other vascular risk factors including previous stroke or TIA and alcohol excess were less frequent (19.0 and 15.4%, respectively). Patients with higher total cSVD burden was significantly older and had severer ECAS. The frequency of hypertension was significantly higher in patients with higher total cSVD burden. This analysis indicated that that increasing ECAS severity (from no stenosis through to 100%) was independently associated with increasing total cSVD score after adjusting for other vascular risk factors (odds ratio 1.76, 95% CI [1.16–2.69]). Conclusions: In this study, high levels of ECAS from ultrasound evidence were associated with coexisting advanced cerebral cSVD in ischemic stroke patients of suspected small or large artery origin. Further studies are required to determine if and how extracranial arterial imaging helps reduce cSVD burden or improves cognitive function.
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Affiliation(s)
- Tao Lu
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China.,Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jiahui Liang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ninglin Wei
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Liya Pan
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Hong Yang
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Baohui Weng
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Jinsheng Zeng
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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16
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Paraskevas KI, Veith FJ, Ricco JB. Best medical treatment alone may not be adequate for all patients with asymptomatic carotid artery stenosis. J Vasc Surg 2018; 68:572-575. [DOI: 10.1016/j.jvs.2018.02.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/27/2018] [Indexed: 12/20/2022]
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Marley CJ, Sinnott A, Hall JE, Morris-Stiff G, Woodsford PV, Lewis MH, Bailey DM. Failure to account for practice effects leads to clinical misinterpretation of cognitive outcome following carotid endarterectomy. Physiol Rep 2018; 5:5/11/e13264. [PMID: 28611148 PMCID: PMC5471430 DOI: 10.14814/phy2.13264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 03/31/2017] [Indexed: 11/24/2022] Open
Abstract
Carotid endarterectomy (CEA) is a surgical procedure to remove stenotic atherosclerotic plaque from the origin of the carotid artery to reduce the risk of major stroke. Its impact on postoperative cognitive function (POCF) remains controversial; complicated, in part, by a traditional failure to account for practice effects incurred during consecutive psychometric testing. To address this for the first time, we performed psychometric testing (learning and memory, working memory, attention and information processing, and visuomotor coordination) in 15 male patients aged 68 ± 8 years with symptomatic carotid stenosis the day before and 24 h following elective CEA (two consecutive tests, 48 h apart). Multiple baselining was also performed in a separate cohort of 13 educationally, anthropometrically and age‐matched controls (63 ± 9 years) not undergoing revascularization at identical time points with additional measures performed over a further 96 h (four consecutive tests, each 48 h apart). A single consecutive test in the control group resulted in progressive improvements in learning and memory, working memory, and attention and information (P < 0.05 vs. Test 1), with three tests required before cognitive performance stabilized. Following correction for practice effects in the patient group, CEA was associated with a deterioration rather than an improvement in learning and memory as originally observed (P < 0.05). These findings highlight the potential for the clinical misinterpretation of POCF unless practice effects are taken into account and provide practical recommendations for implementation within the clinical setting.
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Affiliation(s)
- Christopher J Marley
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, United Kingdom
| | - Andrew Sinnott
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, United Kingdom
| | - Judith E Hall
- Department of Anaesthetics and Intensive Care Medicine, Cardiff University, Wales, United Kingdom
| | - Gareth Morris-Stiff
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paul V Woodsford
- Department of Surgery, Royal Glamorgan Hospital, Wales, United Kingdom
| | - Michael H Lewis
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, United Kingdom.,Department of Surgery, Royal Glamorgan Hospital, Wales, United Kingdom
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, United Kingdom .,Faculty of Medicine, Reichwald Health Sciences Centre University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
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18
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Casas-Hernanz L, Garolera M, Badenes D, Quintana S, Millán S, Calzado N, de Francisco J, Royo J, Aguilar M. Neuropsychological Outcome One Year after Carotid Revascularization: A before-and-after Study. Vasc Specialist Int 2018; 33:146-155. [PMID: 29354625 PMCID: PMC5754064 DOI: 10.5758/vsi.2017.33.4.146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/07/2017] [Accepted: 11/24/2017] [Indexed: 11/20/2022] Open
Abstract
Purpose The aim of our study was to determine the clinical profile of patients considered cognitive 'responders' to surgery in order to establish clinical variables associated with a favorable cognitive performance. Materials and Methods A total of 70 patients were included in the study. A well-validated, comprehensive standardized neurocognitive battery of tests of about 2 hours was administered. Patients were examined twice, 1-week before surgery and 1-year postoperatively. The criterion to be included in the 'responder' group was the following: to obtain a positive difference between post-revascularization and pre-revascularization neuropsychological assessment ≥1 standard deviation in ≥2 tests. Results Twenty-seven patients (38.6%) were cognitive responders to treatment. In bivariate analysis between responders and non-responders, presence of atrophy (P=0.003), small vessels (P=0.577), symptoms (P=0.046), and age (P=0.030) were the factors statistically significant. When comparing cognitive performance before and after carotid revascularization, significant differences were observed in semantic fluency with a lower performance after 12 months (P=0.004, d=0.29), and in the Language index (Repeatable Battery for the Assessment of Neuropsychological Status) (P=0.005, d=0.34). Conclusion Patients without neurological symptoms, of a younger age and without atrophy and white matter small vessel lesions are better cognitive responders 1-year after carotid revascularization.
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Affiliation(s)
- Laura Casas-Hernanz
- Servei de Neurologia, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Departament de Psiquiatria i de Medicina Legal, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maite Garolera
- Neuropsychological Unit, Hospital of Terrassa-Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dolors Badenes
- Servei de Neurologia, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Salvador Quintana
- Servei de Medicina Intensiva, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Susana Millán
- Unitat d'Urgències, Hospital Plató, Barcelona, Spain
| | - Noemi Calzado
- Servei de Neurologia, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Jorge de Francisco
- Servei de Neurologia, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Josep Royo
- Servei de Cirurgia Vascular, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Miquel Aguilar
- Servei de Neurologia, Hospital Universitari Mútua Terrassa, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW To summarize why there are polarized opinions regarding the management of patients with asymptomatic carotid disease and whether it is possible to identify patients who might benefit from carotid interventions. RECENT FINDINGS Carotid Revascularization Endarterectomy Versus Stenting Trial and Asymptomatic Carotid Trial 1 (ACT-1) recently concluded that outcomes after carotid endarterectomy and carotid stenting were not significantly different in asymptomatic patients and that procedural risks were below the accepted 3% threshold. However, systematic reviews suggest that Carotid Revascularization Endarterectomy Versus Stenting Trial/ACT-1 results may not be generalizable into routine practice. In parallel, meta-analyses suggest that stroke rates on medical therapy may be declining, suggesting that Asymptomatic Carotid Atherosclerosis Study/Asymptomatic Carotid Surgery Trial data, which have underpinned every practice guideline since 1995, are too historical for use in 2017. A recent review has, however, identified a number of clinical/imaging features that may be associated with higher rates of stroke on medical therapy. SUMMARY The majority of surgeons/interventionists are unlikely to accept radical changes in practice until new randomized trials confirm that the risk of stroke on modern medical therapy is significantly lower than that previously accepted. In the interim, it would be preferable to target interventions into a smaller cohort who present with clinical/imaging features that might render them 'higher risk for stroke' on medical therapy.
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lattanzi S, Carbonari L, Pagliariccio G, Bartolini M, Cagnetti C, Viticchi G, Buratti L, Provinciali L, Silvestrini M. Neurocognitive functioning and cerebrovascular reactivity after carotid endarterectomy. Neurology 2017; 90:e307-e315. [PMID: 29282326 DOI: 10.1212/wnl.0000000000004862] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/09/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate in patients with TIA and ipsilateral high-grade internal carotid artery (ICA) stenosis whether changes in cognitive performance and cerebral hemodynamics occurred after carotid endarterectomy (CEA) and to explore their relationship. METHODS Participants were patients who underwent CEA, had TIA within the last 6 months, and had an ipsilateral severe ICA stenosis. Coloured Progressive Matrices (CPM) plus Complex Figure Copy Test (CFCT) and phonemic (ph) plus categorical (ca) Verbal Fluency (VF) tests were performed to assess right and left hemisphere cognitive functions, respectively. Hemodynamics was assessed with transcranial Doppler ultrasonography by means of the cerebral vasomotor reactivity (CVR) to hypercapnia. RESULTS A total of 137 patients were included. Before CEA, patients with right ICA obtained lower scores on the CPM and CFCT; patients with left ICA stenosis performed worse on the phonemic and categorical VF tests. The CVR was decreased on the side of the stenosis. At 6 months from CEA, CVR and cognitive performance were significantly improved. The performance change in cognitive tests exploring the revascularized hemisphere was positively associated with the ipsilateral CVR variation (CPM: R2 for linear regression = 0.759, adjR2 = 0.737; CFCT: R2 = 0.734, adjR2 = 0.710; (ph)VF: R2 = 0.774, adjR2 = 0.749; (ca)VF: R2 = 0.732, adjR2 = 0.703). CONCLUSION Cognitive performance was enhanced at 6 months since CEA, and the improvement was related to the CVR increase. Cerebral hemodynamics may be an independent and potentially reversible determinant of cognitive dysfunction in severe carotid artery disease.
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Affiliation(s)
- Simona Lattanzi
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy.
| | - Luciano Carbonari
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Gabriele Pagliariccio
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Marco Bartolini
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Claudia Cagnetti
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Giovanna Viticchi
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Laura Buratti
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Leandro Provinciali
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
| | - Mauro Silvestrini
- From the Neurological Clinic, Department of Experimental and Clinical Medicine (S.L., M.B., C.C., G.V., L.B., L.P., M.S.), Marche Polytechnic University; and Vascular Surgery (L.C., G.P.), Ospedali Riuniti of Ancona, Italy
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Abstract
There is a clear association between carotid artery stenosis and cognitive impairment. However, there is no consensus as to how to interpret this association, and what, if any, impact this connection should have on the management of carotid stenosis. A review of the relevant literature suggests that although an intervention to relieve carotid stenosis in patients without clinically significant cognitive impairment does not improve cognition, there may be a cognitive benefit with intervention for carotid stenosis in those patients with clinically significant cognitive disorders.
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Kuliha M, Roubec M, Goldírová A, Hurtíková E, Jonszta T, Procházka V, Gumulec J, Herzig R, Školoudík D. Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study. J Atheroscler Thromb 2016; 23:839-47. [PMID: 26783048 PMCID: PMC7399266 DOI: 10.5551/jat.31799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 11/17/2015] [Indexed: 12/28/2022] Open
Abstract
AIM New ischemic lesions in the brain can be detected in approximately 50% of patients undergoing carotid artery stenting (CAS). We wished to discover the laboratory-based predictors of new infarctions in the brain after CAS. METHODS All consecutive patients with internal carotid artery stenosis of ≥70% with indication for CAS were enrolled in a prospective study for 16 months. All patients used dual antiplatelet therapy for ≥7 days before CAS. Neurologic examination and magnetic resonance imaging (MRI) of the brain were undertaken before and at 24 h after CAS. Samples of venous blood were collected at <24 h before CAS for the evaluation of hematology, reticulocytes, coagulation markers (PT, APTT, Fbg, Clauss), vWF antigen, PAI-1 activity, PAI-1 polymorphism 4G/5G, and the multiplate (aspirin and clopidogrel) resistance test. Blood samples for the assessment of anti-Xa activity were collected during CAS. Differences in the values of laboratory markers between patients with and without new ischemic lesions of the brain on control MRI were evaluated. RESULTS The cohort comprised 81 patients (53 males; mean age, 67.3±7.2 years). New ischemic infarctions in the brain on control MRI were found in 46 (56.8%) patients. Three of seven patients with resistance to aspirin or clopidogrel had a new ischemic infarction in the brain. No significant differences for particular markers were found between patients with and without an ischemic lesion in the brain. CONCLUSION A high risk of a new ischemic infarction in the brain was detected in patients undergoing CAS, but a laboratory-based predictor of such an infarction could not be identified.
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Affiliation(s)
- Martin Kuliha
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Roubec
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Andrea Goldírová
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Eva Hurtíková
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Tomáš Jonszta
- Department of Radiology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Václav Procházka
- Department of Radiology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Jaromír Gumulec
- Department of Hematology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czech Republic
| | - David Školoudík
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava, Czech Republic
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
- Department of Nursing, Faculty of Health Science, Palacký University Olomouc, Czech Republic
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Wissgott C, Schmidt W, Brandt C, Behrens P, Andresen R. Preliminary Clinical Results and Mechanical Behavior of a New Double-Layer Carotid Stent. J Endovasc Ther 2016; 22:634-9. [PMID: 26187981 DOI: 10.1177/1526602815593490] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE To evaluate the in vitro mechanical and clinical implant behavior of a next-generation double-layer stent designed for the carotid artery. METHODS The new double-layer CASPER-RX stent was implanted in 12 patients (median age 69 years; 8 men) with high-grade symptomatic internal carotid artery stenoses (mean 82%). In the in vitro experiments, the CASPER-RX stent (8-×40-mm model) was investigated with respect to its radial force on expansion and the bending stiffness of the stent system and of the stent in its expanded state, as well as the collapse pressure in a thin, flexible sleeve. The wall adaptation of the expanded stents was assessed by fluoroscopy after release in a step and curve model. RESULTS Technical success was achieved in all patients without complications; there was no peri- or postinterventional stroke and no stroke or restenosis after 6 months. In the experimental studies, the bending stiffness of the stent on the delivery system (154.9 N mm(2)) was significantly lower than when expanded in a 7-mm flexible tube (467.4 N mm(2)). The radial force on expansion of the stent to 7 mm was low (0.011 N/mm). The collapse pressure was relatively high (0.56 bar) as a result of the stent's particular stent structure. The stent exhibited significant foreshortening of 27.6%. The conformability to the wall in the step model was relatively smooth; in the curve model, straightening occurred with consecutive slight stenosis. CONCLUSION The first clinical results showed a safe implantation behavior without the occurrence of any ischemia. The structure of the new CASPER-RX stent creates an acceptable flexibility, low radial force, and high collapse pressure. The large foreshortening during implantation should be considered as well as the higher bending stiffness, especially when used in elongated carotid arteries.
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Affiliation(s)
- Christian Wissgott
- Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide-Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany
| | - Wolfram Schmidt
- Institute for Biomedical Engineering, University Medicine, University of Rostock, Germany
| | - Christoph Brandt
- Institute for Biomedical Engineering, University Medicine, University of Rostock, Germany
| | - Peter Behrens
- Institute for Biomedical Engineering, University Medicine, University of Rostock, Germany
| | - Reimer Andresen
- Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide-Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany
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Soman S, Prasad G, Hitchner E, Massaband P, Moseley ME, Zhou W, Rosen AC. Brain structural connectivity distinguishes patients at risk for cognitive decline after carotid interventions. Hum Brain Mapp 2016; 37:2185-94. [PMID: 27028955 DOI: 10.1002/hbm.23166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 11/12/2022] Open
Abstract
While brain connectivity analyses have been demonstrated to identify ill patients for a number of diseases, their ability to predict cognitive impairment after brain injury is not well established. Traditional post brain injury models, such as stroke, are limited for this evaluation because pre-injury brain connectivity patterns are infrequently available. Patients with severe carotid stenosis, in contrast, often undergo non-emergent revascularization surgery, allowing the collection of pre and post-operative imaging, may experience brain insult due to perioperative thrombotic/embolic infarcts or hypoperfusion, and can suffer post-operative cognitive decline. We hypothesized that a distributed function such as memory would be more resilient in patients with brains demonstrating higher degrees of modularity. To test this hypothesis, we analyzed preoperative structural connectivity graphs (using T1 and DWI MRI) for 34 patients that underwent carotid intervention, and evaluated differences in graph metrics using the Brain Connectivity Toolbox. We found that patients with lower binary component number, binary community number and weighted community number prior to surgery were at greater risk for developing cognitive decline. These findings highlight the promise of brain connectivity analyses to predict cognitive decline following brain injury and serve as a clinical decision support tool. Hum Brain Mapp 37:2185-2194, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Salil Soman
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Massachusetts
| | - Gautam Prasad
- Laboratory of Neuro Imaging (LONI), Imaging Genetics Center (IGC), Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, California
| | - Elizabeth Hitchner
- Department of Vascular Surgery, Stanford University/Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Payam Massaband
- Department of Radiology, Stanford University/Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Michael E Moseley
- Department of Radiology, Stanford University/Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Wei Zhou
- Department of Vascular Surgery, Stanford University/Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Allyson C Rosen
- Department of Psychiatry and Behavioral Sciences, Stanford University/Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Castagno C, Varetto G, Sperti F, Rossato D, Faletti R, Rispoli P. Preoperative and Postoperative Evaluation of New Double Mesh Carotid Stents with Contrast-Enhanced Ultrasound and Diffusion-Weighted Imaging. Ann Vasc Surg 2016; 33:228.e9-228.e13. [PMID: 26970445 DOI: 10.1016/j.avsg.2016.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/09/2015] [Accepted: 03/01/2016] [Indexed: 11/26/2022]
Abstract
In this case series, we selected 4 patients with asymptomatic severe carotid stenosis due to unstable plaques, which were identified with contrast-enhanced ultrasound. These patients underwent carotid stenting with a new generation double mesh stent. Diffusion-weighted magnetic resonance imaging (DW-MRI) was executed before and after the procedure to detect early cerebral microembolizations. No early neurological complications occurred nor cerebral microembolizations were detected at DW-MRI. New double mesh carotid stents appear to be a safe option also in asymptomatic patients with unstable plaques at high risk for surgery.
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Affiliation(s)
- Claudio Castagno
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Torino, Italy
| | - Gianfranco Varetto
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Torino, Italy
| | - Francesca Sperti
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Torino, Italy
| | - Denis Rossato
- Division of Radiology, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Torino, Italy
| | - Riccardo Faletti
- Division of Radiology, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Torino, Italy
| | - Pietro Rispoli
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Torino, Italy.
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Carta MG, Lecca ME, Saba L, Sanfilippo R, Pintus E, Cadoni M, Sancassiani F, Moro MF, Craboledda D, Lo Giudice C, Finco G, Musu M, Montisci R. Patients with carotid atherosclerosis who underwent or did not undergo carotid endarterectomy: outcome on mood, cognition and quality of life. BMC Psychiatry 2015; 15:277. [PMID: 26563766 PMCID: PMC4642779 DOI: 10.1186/s12888-015-0663-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 10/27/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To compare the six-month outcome on mood, cognition and quality of life (QoL) in patients with severe carotid atherosclerosis (CA) who underwent carotid endarterectomy (CEA) with subjects who refused treatment. METHODS Cohort study on consecutive inpatients with CA (stenosis ≥ 50 %) (N = 46; age 72.56 ± 7.26; male 65.2 %). Intervention cohort: subjects who decided to undergo CEA (N = 35); Control cohort patients who refused CEA (N = 11). DSM-IV-Psychiatric diagnosis made by clinicians using interviews, QoL measured by Short Form Health Survey (SF-12); cognitive performance by WAIS Intelligent Coefficient (IC). RESULTS The study showed a better improvement during six months in Overall IC, Performance IC and Verbal IC in the group that underwent CEA. QoL in the two cohorts did not reach statistical significance. Percentages of patients who improved in the CEA group were significantly higher with regard to Overall and Verbal IC scores, and at the limits of statistical significance in Performance IC. The differences of subject with improvement in SF-12 score in the two groups did not reach statistical significance. Ages below 68 were found to be determinant of a good outcome in Overall IC score. Limit: study conducted with a small sample size. CONCLUSIONS Patients with severe carotid atherosclerosis who underwent CEA enhanced their cognitive performance.
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Affiliation(s)
- Mauro Giovanni Carta
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy. .,Center for Liaison Psychiatry, Psychosomatics, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
| | - Maria Efisia Lecca
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy. .,Center for Liaison Psychiatry, Psychosomatics, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), of Cagliari, Polo di Monserrato s.s. 554, Monserrato, 09045, Cagliari, Italy.
| | - Roberto Sanfilippo
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria (A.O.U.), of Cagliari, Polo di Monserrato, s.s. 554 Monserrato, Cagliari, 09045, Italy.
| | - Elisa Pintus
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy. .,Center for Liaison Psychiatry, Psychosomatics, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
| | - Michela Cadoni
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy. .,Center for Liaison Psychiatry, Psychosomatics, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
| | - Federica Sancassiani
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy. .,Center for Liaison Psychiatry, Psychosomatics, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
| | - Maria Francesca Moro
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy. .,Center for Liaison Psychiatry, Psychosomatics, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
| | - Davide Craboledda
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria (A.O.U.), of Cagliari, Polo di Monserrato, s.s. 554 Monserrato, Cagliari, 09045, Italy.
| | - Chiara Lo Giudice
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria (A.O.U.), of Cagliari, Polo di Monserrato, s.s. 554 Monserrato, Cagliari, 09045, Italy.
| | - Gabriele Finco
- Department of Medical Science, University of Cagliari, Cagliari, Italy.
| | - Mario Musu
- Department of Medical Science, University of Cagliari, Cagliari, Italy.
| | - Roberto Montisci
- Department of Vascular Surgery, Azienda Ospedaliero Universitaria (A.O.U.), of Cagliari, Polo di Monserrato, s.s. 554 Monserrato, Cagliari, 09045, Italy.
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Kim JJ, Schwartz S, Wen J, DeVirgilio C, Lobue A, Walot I, Koopmann M, Donayre C, White RA. Comparison of Neurocognitive Outcomes after Carotid Endarterectomy and Carotid Artery Stenting. Am Surg 2015. [DOI: 10.1177/000313481508101020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cognitive and emotional outcomes after carotid endarterectomy (CEA) and carotid artery stenting with embolic protection device (CAS + EPD) are not clear. Patients were entered prospectively into a United States Food and Drug Administration-approved single-center physician-sponsored investigational device exemption between 2004 and 2010 and received either CEA or CAS + EPD. Patients underwent cognitive testing preprocedure and at 6, 12, and 60 months postprocedure. Cognitive domains assessed included attention, memory, executive, motor function, visual spatial functioning, language, and processing speed. Beck Depression and anxiety scales were also compared. There were a total of 38 patients that met conventional indications for carotid surgery (symptomatic with ≥50% stenosis or asymptomatic with ≥70% stenosis)—12 patients underwent CEA, whereas 26 patients underwent CAS + EPD. Both CEA and CAS + EPD patients showed postprocedure improvement in memory and executive function. No differences were seen at follow-up in regards to emotional dysfunction (depression and anxiety), attention, visual spatial functioning, language, motor function, and processing speed. Only two patients underwent neuropsychiatric testing at 60 months—these CAS + EPD patients showed sustained improvement in memory, visual spatial, and executive functions. In conclusion, cognitive and emotional outcomes were similar between CEA and CAS + EPD patients.
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Affiliation(s)
- Jerry J. Kim
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Samuel Schwartz
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Johnny Wen
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Christian DeVirgilio
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Abeline Lobue
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Irwin Walot
- Interventional Neuroradiology at Harbor-University of California Medical Center and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Matthew Koopmann
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Carlos Donayre
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Rodney A. White
- Departments of Surgery and Los Angeles Biomedical Research Institute at Harbor-University of California
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Plessers M, Van Herzeele I, Hemelsoet D, Vermassen F, Vingerhoets G. Prospective comparison of cognitive effects of carotid endarterectomy versus carotid stenting with flow reversal or distal filters. J Clin Exp Neuropsychol 2015; 37:834-41. [DOI: 10.1080/13803395.2015.1060952] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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30
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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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31
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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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Effects of Carotid Endarterectomy on Cerebral Reperfusion and Cognitive Function in Patients with High Grade Carotid Stenosis: A Perfusion Weighted Magnetic Resonance Imaging Study. Eur J Vasc Endovasc Surg 2015; 50:5-12. [DOI: 10.1016/j.ejvs.2015.03.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 03/16/2015] [Indexed: 11/20/2022]
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Antonopoulos CN, Kakisis JD, Sfyroeras GS, Moulakakis KG, Kallinis A, Giannakopoulos T, Liapis CD. The impact of carotid artery stenting on cognitive function in patients with extracranial carotid artery stenosis. Ann Vasc Surg 2015; 29:457-69. [PMID: 25591487 DOI: 10.1016/j.avsg.2014.10.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/10/2014] [Accepted: 10/27/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND The effect of carotid artery stenting (CAS) on cognitive function in patients with extracranial carotid artery stenosis is equivocal. The aim of this study was to examine the impact of CAS on various domains of cognitive function. METHODS We performed a meta-analysis of the studies evaluating various domains of cognitive function before and after CAS, namely, (1) global cognition using Mini-Mental State Examination (MMSE) and Rey Auditory Verbal Learning Test (RAVLT), (2) executive function using Trail Making Test (TMT) A or Color Trails Test (CTT) A and TMT B or CTT B, (3) language ability using Boston Naming Test (BNT), (4) memory, (5) attention/psychomotor speed, and (6) functional ability, using various cognitive tests. Pooled weighted mean differences (WMDs) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were appropriately calculated using fixed or random effects models after assessing between-study heterogeneity. Meta-regression analysis was performed with number of patients per study; mean age (years); follow-up (months); proportion of men; proportion of patients with hypertension, diabetes mellitus, hyperlipidemia, smoking, and coronary artery disease; proportion of symptomatic patients; and degree of ipsilateral and degree of contralateral carotid stenosis as covariates. RESULTS Sixteen studies were eligible, including a total of 626 CAS patients. A statistically significant improvement of global cognition was detected with MMSE (WMD = 0.67, 95% CI = 0.29-1.05, P < 0.001; follow-up = 5.6 months), but not with RAVLT (SMD = 0.45, 95% CI = -0.03 to 0.93, P = 0.07; follow-up = 2.4 months). Significant improvement of memory (SMD = 0.33, 95% CI = 0.11-0.55, P < 0.01; follow-up = 4.1 months) and attention/psychomotor speed (SMD = 0.21, 95% CI = 0.04-0.39, P = 0.02; follow-up = 4 months) was also detected. No statistically significant effect on executive function (TMT A/CTT A and TMT B/CTT B; SMD = 0.08, 95% CI = -0.10 to 0.26, P = 0.39; follow-up = 3.9 months and SMD = -0.02, 95% CI = -0.20 to 0.16, P = 0.82, respectively; follow-up = 3.9 months), language ability (BNT; SMD = 0.24, 95% CI = -0.05 to 0.54, P = 0.10; follow-up = 4 months), and functional ability (SMD = -0.05, 95% CI = -0.25 to 0.15, P = 0.63; follow-up = 3.8 months) was observed. No significant effects of the examined covariates were demonstrated in the meta-regression analyses. CONCLUSIONS CAS may be associated with improvement in global cognition, memory, and attention/psychomotor speed. There was no positive effect on executive function, language, and functional ability, but CAS was not associated with a decline in any area of cognitive function. Future studies in larger groups of patients are probably needed to fully investigate the long-term effect of CAS on cognition in patients with carotid artery stenosis.
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Affiliation(s)
- Constantine N Antonopoulos
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece.
| | - John D Kakisis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - George S Sfyroeras
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Konstantinos G Moulakakis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Aristides Kallinis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Triantafillos Giannakopoulos
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
| | - Christos D Liapis
- Department of Vascular Surgery, University of Athens Medical School, "Attikon" University Hospital, Athens, Greece
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Kuliha M, Roubec M, Procházka V, Jonszta T, Hrbáč T, Havelka J, Goldírová A, Langová K, Herzig R, Školoudík D. Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting. Br J Surg 2014; 102:194-201. [DOI: 10.1002/bjs.9677] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/02/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Silent infarction in the brain can be detected in around 34 per cent of patients after carotid endarterectomy (CEA) and 54 per cent after carotid angioplasty and stenting (CAS). This study compared the risk of new infarctions in the brain in patients undergoing CEA or CAS.
Methods
Consecutive patients with internal carotid artery (ICA) stenosis exceeding 70 per cent were screened for inclusion in this prospective study. Patients with indications for intervention, and eligible for both methods, were allocated randomly to CEA or CAS. Neurological examination, cognitive function tests and MRI of the brain were undertaken before and 24 h after intervention.
Results
Of 150 randomized patients, 73 (47 men; mean age 64·9(7·1) years) underwent CEA and 77 (58 men; 66·4(7·5) years) had CAS. New infarctions on MRI were found more frequently after CAS (49 versus 25 per cent; P = 0·002). Lesion volume was also significantly greater after CAS (P = 0·010). Multiple logistic regression analyses identified intervention in the right ICA as the only independent predictor of brain infarction (odds ratio 2·10, 95 per cent c.i. 1·03 to 4·25; P = 0·040). Stroke or transient ischaemic attack occurred in one patient after CEA and in two after CAS. No significant differences were found in cognitive test results between the groups.
Conclusion
These data confirm a higher risk of silent infarction in the brain on MRI after CAS in comparison with CEA, but without measurable change in cognitive function. Registration number: NCT01591005 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Kuliha
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - M Roubec
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - V Procházka
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - T Jonszta
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - T Hrbáč
- Departments of Neurosurgery, Comprehensive Stroke Centre, University Hospital Ostrava, Ostrava, Czech Republic
| | - J Havelka
- Departments of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - A Goldírová
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Nursing, Faculty of Health Sciences, Palacký University, Olomouc, Czech Republic
| | - K Langová
- Department of Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacký University, Olomouc, Czech Republic
| | - R Herzig
- Department of Neurosurgery, Comprehensive Stroke Centre, Military University Hospital, Prague, Czech Republic
| | - D Školoudík
- Departments of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Nursing, Faculty of Health Sciences, Palacký University, Olomouc, Czech Republic
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Giannoukas A, Paraskevas K, Bulbulia R, Halliday A. Ocular Defects as Surrogate End-Points in Trials Comparing Carotid Endarterectomy and Stenting. Eur J Vasc Endovasc Surg 2014; 48:105-6. [DOI: 10.1016/j.ejvs.2014.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
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