Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL IMPACT

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

Long-term cognitive and neurovascular changes after carotid endarterectomy

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.

Prevalence of Neurovascular Microemboli After Transcatheter Aortic Valve Replacement

Background

Neurolotic sequelae after transcatheter aortic valve replacement (TAVR) can cause significant morbidity and mortality. Transcranial Doppler (TCD) imaging can show real-time high intensity transient signals (HITS), which reflect active microembolization. Although it is well known that intraprocedural microembolism occurs, it is not known if this embolic phenomenon continues in the postprocedural period. We investigated whether microemboli occur post-TAVR and whether we could determine any clinical, procedural, or echocardiographic predictors.

Methods

We evaluated HITS in 51 consecutive patients undergoing unprotected TAVR with low-, intermediate-, or high-risk Society of Thoracic Surgeons score. Patients were excluded if they did not have temporal windows for insonation of the middle cerebral artery or if they were not willing to participate. Primary outcomes of HITS 24 hours post-TAVR were observed using a Philips iU22 TCD. TCD was performed at 3 time points (pre-, peri-, and post-TAVR) for each patient, before, during, and 24 hours postprocedure.

Results

While no HITS were detected in any of the patients preoperatively, all patients had HITS during the procedure. Interestingly, 56.8% had HITS 24 hours post-TAVR. One patient with HITS post-TAVR had a stroke 48 hours after TAVR.

Conclusion

We observed a high prevalence of microemboli 24 hours post-TAVR. None of the predictors for intraprocedural microembolism seemed to play an important role for post-TAVR microemboli.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between carotid revascularization for asymptomatic stenosis and cognitive functions

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

Relationship of pharmacotherapy and the incidence of embolic complications of carotid reconstructive surgery

Aim. To evaluate the relationship between lipid-lowering and antiplatelet therapy and the incidence of cerebral microembolism and related complications in open and endovascular revascularization of the carotid arteries (CA).

Material and methods. This single-center study involved patients with internal CA stenosis. The patients were divided into 2 groups depending on the surgery type performed: carotid endarterectomy (CEA)  — 163 patients; CA stenting (CAS)  — 71 patients. All patients underwent intraoperative transcranial Doppler monitoring to register cerebral embolism during CAS and CE.

Results. In CAS, microembolism episodes were observed in 66,2% vs 22,1% of patients in the CEA group (p=0,04), the largest number of which was recorded during catheterization of the internal CA and embolic filter installation (p=0,000). There were no significant differences between the groups in terms of the stroke incidence. In 8 patients in the CAS group and 1 patient in the CEA group, a transient ischemic attack was observed within 30 days after surgery (p=4x10-4 ). Intraoperative embolism was a predictor of a neurological event in the early postoperative period (odds ratio (OR), 33,08; 95% confidence interval (CI): 3,49-56,37 (p6 months before surgery reduces the likelihood of embolism by 4 times (OR 0,25; 95% CI: 0,11-0,58 (p=0,001), while lipid-lowering and antiplatelet therapy combination — by 12,5 times (OR, 0,08; 95% CI: 0,01-0,40 (p=0,001)).

Conclusion. Preoperative antiplatelet and statin therapy reduces the likelihood of embolism during the CA revascularization procedure.

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

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

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

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Lesions from carotid revascularization affect consistent brain targets.

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

Cognitive Function After Carotid Artery Revascularization

Clinical investigations designed to contrast the efficacy of carotid endarterectomy (CEA) versus best medical therapy and CEA versus carotid artery stenting (CAS) in patients with carotid artery stenosis have been based on the traditional endpoints of stroke, myocardial infarction, and death. Cognitive function is being increasingly recognized as an important outcome measure that affects patient well-being and functional status. However, it has not been evaluated systematically in the context of carotid revascularization. A decline in cognitive function could occur from microembolic ischemia during surgical dissection (CEA) or intravascular instrumentation (CAS). It could also occur from hypoperfusion during clamping (CEA) or balloon dilation (CAS). Conversely, restoring perfusion could improve cognitive dysfunction that might have occurred from a state of chronic hypoperfusion. It is still unclear whether these complex interactions ultimately result in a net improvement or a deterioration of cognitive function. Furthermore, it is not known whether the 2 methods of carotid revascularization have a differential effect on cognitive outcomes. It is becoming increasingly clear, though, that there is a positive relationship between improvement in cognition and improvement in functional outcome of patients. Vascular surgeons will be well served to remain informed and even actively engaged in the development of this field if they wish to continue providing the high-quality, well-informed care they have traditionally offered to patients with carotid stenosis.

Carotid Artery Stenting: Current Status and Future Directions

Carotid endarterectomy has been the mainstay of therapy for carotid occlusive disease in stroke prevention. Recent advances in endovascular technology has made carotid angioplasty and stenting a therapeutic modality in the treatment of carotid occlusive disease. The enthusiasm for this minimally invasive carotid intervention is hampered by the possibility of stentrelated cerebral embolization, which can result in neurologic complications. Although current available data indicate that the results regarding success and complication rates are similar between carotid stenting and endarterectomy, numerous prospective clinical trials are currently underway to evaluate the efficacy of carotid artery stenting using various forms of cerebral protection devices. This article reviews the current status of carotid stenting, including recent clinical studies and ongoing prospective trials. Strategies relating to cerebral embolization protection are also discussed.

A comparative analysis of transcranial Doppler parameters acquired during carotid stenting and semi-eversion carotid endarterectomy

Background

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) have both been proposed for treatment of critical atherosclerotic stenosis located at the carotid bifurcation. Monitoring of hyperintense microembolic signals (MES) by transcranial Doppler ultrasound (TCD) is considered a method of quality control, both in CEA and in CAS.

Objective

To analyze temporal distribution of MES throughout both semi-eversion CEA and CAS procedures and to evaluate changes in mean velocity of blood flow through the ipsilateral middle cerebral artery (MCA).

Method

Thirty-three procedures (17 CEA and 16 CAS) were prospectively monitored using TCD and the data were related to three different stages of surgery (pre-cerebral protection, during cerebral protection and post-cerebral protection). Chi-square, Mann-Whitney, ANOVA and contrast tests were used for statistical analysis.

Results

The MES were uniformly distributed in the CEA group, but not in the CAS group (p = 0.208). The number of MES was higher in the CAS group in all stages. The average flow in the MCA was similarly lower in both groups during the protection stage.

Conclusion

CEA provoked a lower incidence of MES per procedure than CAS in all stages. The behavior of the averages of the mean of blood flow through the MCA was similar in both groups.

Transcranial Doppler Monitoring in Angioplasty and Stenting of the Carotid Bifurcation

Purpose:

To assess the impact of cerebral embolism and hemodynamic changes during the successive stages of carotid angioplasty and stenting (CAS) using transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA).

Methods:

In 297 patients (206 men; mean age 69.9±8.0 years), the association of various TCD emboli and velocity variables with procedure-related death and cerebral events (amaurosis fugax, transient ischemic attacks, and stroke) was evaluated. Baseline patient characteristics (age, sex, preoperative cerebral symptoms, and prior carotid endarterectomy) and their associations with procedure-related cerebral events were also assessed. A distinction was made between adverse events that occurred during CAS and those that happened within 7 days.

Results:

Of the 36 procedure-related retinal and cerebral events, 28 (78%) were encountered intraprocedurally; an additional 6 (2%) events occurred within 7 days after the procedure. Two (0.7%) patients died. At 1 week, the combined minor and major stroke and death rate was 3.7%. Adverse outcome was associated with >4 showers of microemboli at postdilation (odds ratio [OR] 3.2, 95% CI 1.3 to 7.8, p = 0.03), particulate macroemboli (OR 9.1, 95% CI 5.1 to 16.1, p<.001), massive air embolism from ruptured balloons (OR 11.3, 95% CI 7.6 to 16.6, p<0.001), and angioplasty-induced asystole with significant hypotension plus MCA blood flow reduction (OR 3.3, 95% CI 1.4 to 8.3, p = 0.03). Of the patient characteristics, male gender (OR 10.5, 95% CI 1.4 to 75.8, p = 0.02) and preoperative cerebral ischemia (OR 3.3, 95% CI 1.6 to 6.6, p = 0.003) were also related to outcome.

Conclusions:

In CAS, TCD monitoring provides insight into the pathogenesis of procedure-related cerebral events. Microemboli during poststent dilation, particulate macroembolism, massive air embolism, and angioplasty-induced asystole are associated with adverse outcome, as are male gender and prior cerebral ischemia.

Atherosclerotic carotid stenosis and cognitive function

Atherosclerosis carotid stenosis is associated with stroke and cognitive impairment. Progressive cognitive decline may be an even greater problem than stroke, but it has not been widely recognized and therefore must be adequately addressed. Although both Carotid Endarterectomy (CEA) and Carotid Artery Stenting (CAS) have been proven can prevent future stroke in patients with atherosclerotic carotid stenosis, the influence of CEA and CAS on cognitive function is not clear. In the first part of this review, we evaluated the literature concerning carotid stenosis and the risk of cognitive impairment. Studies have suggested that both symptomatic and asymptomatic carotid stenosis are associated with cognitive impairment. In the second part, we reviewed the impact of CEA and CAS on cognitive function, some studies have shown benefits, but others have not.

Transcervical Carotid Stenting With Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy

PURPOSE

To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates.

METHODS

Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow).

RESULTS

CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases.

CONCLUSION

TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS.

Post-carotid endarterectomy changes in cerebral glucose metabolism on 18F-fluorodeoxyglucose positron emission tomography associated with postoperative improvement or impairment in cognitive function

OBJECT

Cognitive function is often improved or impaired after carotid endarterectomy (CEA) for patients with cerebral hemodynamic impairment. Cerebral glucose metabolism measured using positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) correlates with cognitive function in patients with neurodegenerative diseases. The present study aimed to determine whether postoperative changes in cerebral glucose metabolism are associated with cognitive changes after CEA.

METHODS

In patients who were scheduled to undergo CEA for ipsilateral internal carotid artery (ICA) stenosis (≥ 70% narrowing), cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to acetazolamide were assessed preoperatively using brain perfusion single-photon emission computed tomography (SPECT). CBF measurement using SPECT was also performed immediately after CEA. For patients with reduced preoperative CVR to acetazolamide in the cerebral hemisphere ipsilateral to surgery, cerebral glucose metabolism was assessed using FDG-PET before surgery and 3 months after surgery and was analyzed using 3D stereotactic surface projection. Neuropsychological testing was also performed preoperatively and 3 months postoperatively.

RESULTS

Twenty-two patients with reduced preoperative CVR to acetazolamide successfully underwent FDG-PET studies and neuropsychological testing before and after CEA. Seven, 9, and 6 patients were defined as showing improved, unchanged, and impaired postoperative cognition, respectively, based on the neuropsychological assessments. The cortical area with increased postoperative glucose metabolism was greater in patients with improved postoperative cognition than in those with unchanged (p < 0.001) or impaired (p < 0.001) postoperative cognition. The cortical area with decreased postoperative glucose metabolism was greater in patients with impaired postoperative cognition than in those with improved (p < 0.001) or unchanged (p < 0.001) postoperative cognition. All 7 patients with improved cognition exhibited postoperative hemispheric increases in glucose metabolism, while 5 of the 6 patients with impaired cognition exhibited postoperative hemispheric decreases in glucose metabolism. Brain perfusion SPECT revealed that the latter 6 patients experienced postoperative cerebral hyperperfusion, and 2 of the 6 patients exhibited cerebral hyperperfusion syndrome. The cortical area with decreased postoperative glucose metabolism in these 2 patients was greater than that in other patients.

CONCLUSIONS

Postoperative changes in cerebral glucose metabolism, as measured using FDG-PET, are associated with cognitive improvement and impairment after CEA.

Intermediate- and Long-Term Cognitive Outcomes After Cardiovascular Procedures in Older Adults: A Systematic Review

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.

Cerebral microemboli and neurocognitive change after carotid artery stenting with different embolic protection devices

OBJECTIVES

Proximal cerebral protection devices have been developed as an alternative to filter protection devices for reducing neurological complications during carotid artery stenting (CAS). The aim of the present study was to evaluate the frequency of silent cerebral embolism after CAS using different cerebral embolic protection devices and the impact of silent cerebral embolism on neurocognitive function.

METHODS

One hundred consecutive patients who underwent CAS were enrolled. The patients were randomized to either proximal balloon occlusion or filter protection. Neurocognitive tests were performed before and six months after CAS. Cerebral embolisms were evaluated with diffusion-weighted magnetic resonance imaging (DW-MRI).

RESULTS

The number and volume of new ischemic lesions found with DW-MRI were higher in the filter protection group than in the proximal balloon occlusion group. According to our definition, nine (21%) patients in the balloon occlusion group and 16 (36%) patients in the filter protection group showed neurocognitive decline, and ten (23%) patients in the balloon occlusion group and four (9%) patients in the filter protection group showed neurocognitive improvement (NS). Regarding the group of patients with new cerebral ischemic lesions on DW-MRI, neurocognitive decline occurred in 14 (31%) of 45 patients with DW-MRI lesions and 11 (26%) of 43 patients without DW-MRI lesions (NS).

CONCLUSION

Neurocognitive outcome after CAS is unpredictable; both neurocognitive decline and improvement can occur. In this study, the proximal balloon occlusion system significantly decreased cerebral microemboli during CAS compared to filter protection. Cerebral microembolism was not found to be associated with neurocognitive decline.

Driving competences and neuropsychological factors associated to driving counseling in multiple sclerosis

Multiple Sclerosis (MS) significantly impacts daily living activities, including car driving. To investigate driving difficulties experienced with MS, we compared 50 MS patients with minor or moderate disability and 50 healthy controls (HC) using computerized driving tests (the ASDE driver test and the Useful Field of View (UFOV) test) and neuropsychological tests. Inclusion criteria included being active drivers. We evaluated whether cognitive deterioration in MS is associated with the results of driving tests by comparing MS patients without cognitive deterioration with HC. The results indicated that the MS patients performed worse than the HCs in attention, information processing, working memory and visuomotor coordination tasks. Furthermore, MS patients with cognitive impairments experienced more difficulties in the driving tests than did the non-impaired MS patients. Motor dysfunction associated with MS also played an important role in this activity. The results of this study suggest that MS should be assessed carefully and that special emphasis should be placed on visuomotor coordination and executive functions because patients with minor motor disability and subtle cognitive impairments can pass measures predictive of driving safety.

The impact of carotid revascularization on cognitive function

The concept that carotid disease may compromise cognitive function was initially proposed by Fisher in 1951, based on an autopsy case. However, some topics involving cognitive function remain controversial, such as its correlation with carotid obstructive disease. So, the authors of this review evaluate the impact of carotid revascularization on cognitive function and the repercussions of the revascularization technique (carotid stenting vs. endarterectomy) chosen. It was clear from the literature reviewed that carotid stenosis is related to a decline in cognitive function over time. However, controversy still remains over the impact of carotid revascularization on cognitive function. With elation to the technique employed (carotid stenting vs. endarterectomy), the majority of studies found no difference between the two techniques in terms of overall cognitive outcome.

Influence of cognitive impairment on the management of ischaemic stroke

BACKGROUND

Because of ageing of the population, it is more and more frequent to treat ischaemic stroke patients with pre-stroke cognitive impairment (PSCI). Currently, there is no specific recommendation on ischaemic stroke management in these patients, both at the acute stage and in secondary prevention. However, these patients are less likely to receive treatments proven effective in randomised controlled trials, even in the absence of contra-indication.

OBJECTIVE

To review the literature to assess efficacy and safety of validated therapies for acute ischaemic stroke and secondary prevention in PSCI patients.

RESULTS

Most randomised trials did not take into account the pre-stroke cognitive status. The few observational studies conducted at the acute stage or in secondary prevention, did not provide any information that the benefit could be either lost or replaced by harm in the presence of PSCI.

CONCLUSIONS

There is no reason not to treat ischaemic stroke patients with PSCI according to the currently available recommendations for acute management and secondary prevention. Further observational studies are needed and pre-stroke cognition should be taken into account in future stroke trials.

Neurocognitive functioning after carotid revascularization: a systematic review

BACKGROUND

The objective of this study was to review the recent literature regarding the neurocognitive consequences of carotid endarterectomy (CEA) and carotid stenting (CAS).

METHODS AND RESULTS

A PubMed and Web of Science search was conducted using the key words 'carotid' in combination with 'cognitive', 'cognition', 'neurocognition', 'neurocognitive', 'neuropsychology', and 'neuropsychological'. Bibliographies of relevant articles were cross-referenced. We included 37 studies published since 2007 of which 18 examined CEA, 12 CAS, and 7 compared CEA to CAS. There is a wide variability in the reported neurocognitive outcome following CEA and CAS. Nonetheless, none of the included studies unveiled significant differences between CEA and CAS on postoperative neurocognitive functioning. Postoperative changes observed for CEA and CAS separately seem limited to a small percentage (around 10-15%) of patients and can either present as an improvement or impairment.

KEY MESSAGES

The available data seem to suggest that no obvious cognitive differences between CAS and CEA can be observed after intervention. Both improvement and deterioration in cognitive functioning can be observed following CAS or CEA. Methodological differences such as patient heterogeneity, implementation and type of control groups, type of psychometric tests used, statistical analyses, or timing of the assessments play an important role in explaining the sometimes divergent results of the included studies. Large-scale and methodologically solid studies comparing CEA and CAS on neurocognitive outcome remain warranted. Future studies should implement adequate control groups to correct for practice effects in the target groups.

Cognitive performance after carotid angioplasty and stenting with brain protection devices

OBJECTIVE

Neuropsychological outcomes after carotid endarterectomy (CEA) have been investigated extensively. However, cognitive impacts of carotid angioplasty and stenting (CAS), an emerging alternative to CEA, have not been studied. This study is aimed at investigating pattern and degree of cognitive changes after CAS among patients with high-grade carotid stenosis.

PATIENTS AND METHODS

Fifty-four patients with high-grade carotid artery stenosis and received elective CAS were followed. Sixty-six patients with similar medical conditions requiring carotid angiography (CAG) were enrolled as controls. Cognitive functions among patients in both groups were evaluated at baseline and follow-ups utilizing a battery of neuropsychometric tests. Results were analysed by inter-group and within-group comparisons.

RESULTS

There were no statistically significant differences between CAS and CAG patients regarding demographic characteristics, risk factors for stroke and baseline cognitive performance (p>0.05). CAS patients performed significantly better than CAG patients in Rey auditory verbal learning tests (RAVLT) at week 1 (41.2 +/- 5.2 versus 37.4 +/- 4.0, p<0.001) and week 12 follow-ups (43.3 +/- 7.7 versus 37.3 +/- 4.5, p<0.001). Comparison of z score also indicated CAS patients improved significantly more than CAG patients in RAVLT at both weeks 1 (1.08 +/- 1.29 versus 0.25 +/- 0.99, p<0.001) and 12 follow-ups (1.62 +/- 1.95 versus 0.05 +/- 1.02, p<0.001).

CONCLUSION

CAS patients demonstrated improvement in verbal memory after procedures. Correction of cerebral hypoperfusion and reduction of artery-to-artery embolization after CAS are postulated responsible for the cognitive improvement.

Protocols and Results of Resident Neurosurgeon's Transfemoral Catheter Angiography Training Supervised by Neuroendovascular Specialists

Objective

Transfemoral catheter angiography (TFCA) is a basic procedure in neurovascular surgery with increasing importance in surgical and non-invasive treatments. Unfortunately, resident neurosurgeons have relatively few opportunities to perform TFCA in most institutions. We report a method developed in our hospital for training resident neurosurgeons to perform TFCA and evaluate the efficacy of this training.

Methods

From May 2011 to September 2011, a total of 112 consecutive patients underwent TFCA by one resident neurosurgeon supervised by two neuroendovascular specialists. Patients who underwent elective diagnostic procedures were included in this study. Patients who underwent endovascular treatment were excluded. Demographic data, indications for TFCA, side of approach, number of selected arteries, and complications were analyzed.

Results

This study included 64 males and 48 females with a mean age of 51.6 (12-81) years. All procedures were performed in the angiography suite. Common indications for procedures were as follows: stroke-induced symptoms in 61 patients (54.5%), Moyamoya disease and arteriovenous malformation in 13 patients (11.6%), and unruptured intracranial aneurysm in eight patients (7.1%). Right and left femoral puncture was performed in 98.2% and 1.8% of patients, respectively. A total of 465 selective angiographies were performed without complications. Angiographic examination was performed on 4.15 vessels per patient.

Conclusion

TFCA can be performed safely by resident neurosurgeons based on anatomical study and a meticulous protocol under the careful supervision of neuroendovascular specialists.

Results of carotid artery stenting with transcervical access

OBJECTIVE

Carotid artery stenting (CAS) is usually performed with femoral access; however, this access may be impeded by anatomic limitations. Moreover, many embolic events happen during aortic arch catheterization. To overcome these problems, transcervical access to the carotid artery can be used as an alternative approach for CAS.

METHODS

An electronic search of the literature using PubMed was performed. All studies reporting the results of CAS using the transcervical approach were retrieved and analyzed.

RESULTS

The analysis included 12 studies reporting the results of 739 CAS procedures performed in 722 patients (mean age, 75.5 years). Of 533 lesions reported, 235 (44%) were symptomatic, with no data regarding symptomatic status available for 206 lesions. Two techniques were used: direct CAS with transcervical access (filter protected or unprotected) in 250 patients and CAS with transcervical access under reversed flow (with arteriovenous shunt in most cases) in 489 patients. Local anesthesia was used in 464 of 739 procedures (63%), and the remaining were performed under general anesthesia or cervical block. Technical success was 96.3% for 579 procedures with available data (558 successful procedures and 21 failures: inability to cross the lesion, 10; dissection, 5; failure of predilatation, 1; stent thrombosis, 1; patient agitation, 1; and no data, 3). The incidence of conversion to open repair was 3.0% (20 of 579 procedures: 18 carotid endarterectomies and two common carotid-internal carotid bypass grafts). Stroke occurred in eight patients (two fatal) and a fatal myocardial infarction in one patient. The incidence of stroke, myocardial infarction, and death was 1.1%, 0.14%, and 0.41%, respectively. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P > .05). Transient ischemic attack occurred in 20 patients (2.7%). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas and two patients with transient laryngeal palsy.

CONCLUSIONS

CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy.

Improvement and impairment in cognitive function after carotid endarterectomy: comparison of objective and subjective assessments

Objective and subjective assessments of postoperative improvement and impairment in cognition were prospectively compared in patients who underwent carotid endarterectomy (CEA). Each patient underwent subjective cognitive assessment by a neurosurgeon and the patient's next of kin, and neuropsychological testing consisting of five test scores within 7 days before surgery and between 1 and 2 months after surgery. Of 213 patients studied, 24 (11%), 166 (78%), and 23 (11%) patients were defined as having subjectively improved, unchanged, and impaired cognition, respectively, following surgery. In all neuropsychological tests, differences in test scores between the two tests (postoperative test score - preoperative test score) significantly differentiated patients with subjectively improved, unchanged, and impaired cognition after surgery. Receiver operating characteristic analysis showed that the cut-off point for the differences in neuropsychological test scores in detecting subjective improvement and impairment in cognition after surgery was identical to mean +2 standard deviations (SDs) and mean -2 SDs, respectively, of the control value obtained from normal subjects. Of 27 patients with differences in neuropsychological test scores more than the upper cut-off point and 26 patients with differences in neuropsychological test scores less than the lower cut-off point in one or more neuropsychological tests, 24 (89%) and 23 (88%) exhibited subjectively improved and impaired cognition, respectively, after surgery. The present study indicates that neuropsychological test scores reflect the subjective assessment of postoperative change in cognition, and can detect subjective improvement and impairment in cognition after CEA using the optimal cut-off points for the test scores.

Silent cerebral ischemic lesions after carotid artery stenting with distal cerebral protection

OBJECTIVE

To evaluate by MR diffusion weighted image (DWI-MR) the presence of new ischemic cerebral lesions after carotid artery stenting (CAS) and distal cerebral protection, in patients with internal carotid artery (ICA) stenosis >70.

METHODS

Sixty-seven CAS were performed under cerebral protection with a distal filter. Mean age of the patients was 68.3 years (range 37-86) and 42 patients (62.7%) were symptomatic. An EZ filter device was used in all cases. The mean length of the procedure was 22.2 minutes (range 8-110). All patients had a cerebral MRI done in the 3 days before CAS and a DW-MR (eco planar single shot, b=1000 mm2/seconds) was done the day after.

RESULTS

As a consequence of the CAS, three transient ischemic attacks were observed. There was one minor stroke (1.5%) on day 21, but no major stroke, death or myocardial infarction in a 30-day period. DW-MRI after CAS showed 26 new silent ischemic lesions in 11 asymptomatic patients (16.4%). In six, they were multiple (range 2-5). Lesions were mainly seen in the ipsilateral medial cerebral artery (21); four in the posterior fossa, and one in the contralateral medial cerebral artery.

DISCUSSION

Although the use of distal cerebral protection was safe, new cerebral ischemic lesions, supposedly embolic, were observed in 16.4% of the patients. Although without clinical consequences in our series, their moderate high incidence should promote the investigation of safer techniques and devices.

Postoperative changes in cerebral metabolites associated with cognitive improvement and impairment after carotid endarterectomy: a 3T proton MR spectroscopy study

BACKGROUND AND PURPOSE

Cognitive function can improve or decline after carotid endarterectomy. Proton MR spectroscopy can be used evaluate cerebral metabolites, such as N-acetylaspartate, choline, and creatine, in vivo. The purpose of the present study was to determine whether postoperative changes in cerebral metabolites measured by using 3T proton MR spectroscopy were associated with changes in cognitive function after CEA.

MATERIALS AND METHODS

In 100 patients undergoing CEA for ipsilateral cervical internal carotid artery stenosis (≥70%), brain proton MR spectroscopy was performed before and after surgery. NAA/Cr and Cho/Cr ratios were measured in regions of interest placed in the centrum semiovale of both cerebral hemispheres. Neuropsychological testing was also performed preoperatively and 1 month postoperatively. Multivariate statistical analysis of factors related to postoperatively changed cognition was performed, and odds ratios with 95% confidence intervals were calculated.

RESULTS

On the basis of the neuropsychological assessments, 10 (10%), 80 (80%), and 10 (10%) patients were defined as having postoperatively improved, unchanged, and impaired cognition, respectively. A positive and high ΔNAA/Cr ratio (postoperative value-preoperative value) in the cerebral hemisphere ipsilateral to the operative site was significantly associated with postoperatively improved cognition (95% CI, 13.3-21.3; P = .0016). Negative and high absolute values of the ΔNAA/Cr ratio (95% CI, 0.018-0.101; P = .0039) and ΔCho/Cr ratio (95% CI, 0.042-0.135; P = .0046) in the ipsilateral cerebral hemisphere were significantly associated with postoperatively impaired cognition.

CONCLUSIONS

Postoperative changes in cerebral metabolites measured by using proton MR spectroscopy were associated with changes in cognitive function after CEA.

Effects of carotid artery stenting on cognitive function in patients with mild cognitive impairment and carotid stenosis

Carotid stenosis is known to be an independent risk factor in the transformation process of mild cognitive impairment (MCI) to dementia and is treated by carotid artery stenting (CAS); however, the effects of CAS on cognitive function are unclear. In this study, 240 patients were prospectively assigned to a CAS or control group according to patient preference and underwent detailed neuropsychological examinations (NPEs) before and 6 months after treatment. Cerebral perfusion was assessed with computed tomography perfusion (CTP). Among the 240 patients included in the study, 208 patients completed NPEs at baseline and 6 months after therapy. The patients in the two groups did not differ with regard to baseline characteristics, educational level, vascular risk factors (VRFs) and NPEs prior to therapy. Significant improvements in the Mini-Mental State Examination (MMSE; before, 24.6±1.7 vs. after, 24.8±1.9; P=0.016), Montreal Cognitive Assessment (MOCA; before, 23.7±1.7 vs. after, 24.1±2.0; P=0.006), Fuld Object Memory Evaluation (FOME; before, 13.8±2.2 vs. after, 14.0±2.3; P=0.031) and Wechsler Adult Intelligence Scale-digital span (WAIS-DS; before, 6.7±2.1 vs. after, 6.9±2.3; P=0.040) were observed in the CAS group; however, improvements were not observed in the control group. Of the 84 patients in the CAS group who received CTP follow-up, 72 (86%) presented improvements in ipsilateral brain perfusion 6 months after the procedure; however, no improvement was observed in the control group. Close correlations were identified between the change in perfusion and the change in MMSE (r=0.575) and MOCA (r=0.574). CAS improves global cognitive function in patients with carotid stenosis and MCI and the improvement of cognition is closely related to the improvement of cerebral perfusion.

Strategies of clopidogrel load and atorvastatin reload to prevent ischemic cerebral events in patients undergoing protected carotid stenting. Results of the randomized ARMYDA-9 CAROTID (Clopidogrel and Atorvastatin Treatment During Carotid Artery Stenting) study

OBJECTIVES

This study sought to evaluate whether a strategy with a 600-mg clopidogrel load and a short-term, high-dose atorvastatin reload would improve outcomes in clopidogrel-naïve, statin-treated patients undergoing protected carotid stenting.

BACKGROUND

Optimal clopidogrel loading dose during carotid stenting has not been investigated; in addition, statin neuroprotection in this setting has not been described.

METHODS

A total of 156 patients were randomized using a 2 × 2 factorial design to receive either a 600-mg (n = 78) or 300-mg (n = 78) clopidogrel load given 6 h before intervention and either a atorvastatin reload (n = 76; 80 mg + 40 mg initiating 12 h before the procedure) or no statin reload (n = 80). The primary endpoint was the 30-day incidence of transient ischemic attack/stroke or new ischemic lesions on cerebral diffusion-weighted magnetic resonance imaging performed at 24 to 48 h.

RESULTS

Occurrence of the primary outcome measure was significantly lower in the 600-mg clopidogrel arm (18% vs. 35.9% in the 300-mg group; p = 0.019) and in the atorvastatin reload arm (18.4% vs. 35.0% in the no statin reload group; p = 0.031). High-dose clopidogrel also significantly reduced the transient ischemic attack/stroke rate at 30 days (0% vs. 9%, p = 0.02, secondary endpoint), without an increase in bleeding risk.

CONCLUSIONS

In patients undergoing carotid stenting, a strategy using both a 600-mg clopidogrel load and a short-term reload with high-dose atorvastatin protects against early ischemic cerebral events. These results, obtained along with routine mechanical neuroprotection, provide new evidence of the optimization of drug therapy before percutaneous carotid intervention. (Clopidogrel and Atorvastatin Treatment During Carotid Artery Stenting [ARMYDA-9 CAROTID]; NCT01572623).

Cognitive Outcome and Clinically Silent Thromboembolic Events After Coiling of Asymptomatic Unruptured Intracranial Aneurysms

BACKGROUND:

Thromboembolic events are the most common complication after coiling of unruptured intracranial aneurysms (UIAs). However, it remains unclear whether these clinically silent ischemic lesions (CSILs) have any clinical significance.

OBJECTIVE:

To evaluate cognitive outcome after coil embolization of asymptomatic UIAs and its relationship with CSILs after the procedure.

METHODS:

We prospectively enrolled 40 UIA patients who showed no new focal neurological deficit after coil embolization. CSILs were assessed with diffusion-weighted imaging (DWI) within 1 day after the procedure. A battery of neuropsychological tests was performed 3 times: preoperatively and postoperatively at 1 and 4 weeks after coil embolization.

RESULTS:

The incidence of cognitive impairment after coiling in patients with UIAs was 44% (17 of 39) at 1 week and 19% (7 of 37) at 4 weeks after coil embolization. DWI within 1 day after coil embolization revealed that 60% of patients (24 of 40) showed CSILs. However, no significant difference was found in any mean cognitive scores or in the number of cognitively impaired variables between patients with and without CSILs at weeks 1 and 4. Additional correlation analysis revealed no correlations between the number of CSILs on DWI and the cognitive sum z score at both 1 and 4 weeks.

CONCLUSION:

Exhaustive neuropsychological evaluation of UIA patients who underwent coil embolization demonstrated recovery or improvements from baseline cognitive function after 4 weeks, although some patients still showed cognitive deficits at 4 weeks after the procedure. However, we found no statistically significant relationship between the presence and number of CSILs on DWI and cognitive changes after the procedure.

A diffusion-weighted magnetic resonance imaging-based study of transcervical carotid stenting with flow reversal versus transfemoral filter protection

BACKGROUND

Transfemoral carotid artery stenting (CAS) has been associated with a high incidence of embolic phenomena and silent brain infarction. The goal of this study was to compare the incidence of new ischemic cerebral lesions on diffusion-perfusion magnetic resonance imaging (MRI) sequences after transcervical CAS performed with carotid flow reversal vs stenting via transfemoral approach with distal filter protection.

METHODS

During a 26-month period, 64 consecutive patients diagnosed with significant carotid stenosis by ultrasound imaging were assigned to transcervical CAS with carotid flow reversal or a transfemoral approach with a distal filter. The Rankin stroke scale was administered by an independent neurologist, and diffusion-weighted MRI (DW-MRI) studies were performed ≤24 hours before and ≤24 to 48 hours after the procedure. DW-MRI studies were compared by two neuroradiologists not involved in the study and blinded for time, clinical status, and treatment option. Hyperintense DW-MRI signals found after the procedure were interpreted as postoperative ischemic infarcts. All patients were assessed at 1, 6, and 12 months after the intervention.

RESULTS

The distribution of demographic and pathologic variables was similar in both groups. All procedures were technically successful, with a mean carotid flow reversal time of 22 minutes. Twenty-one (70%) and 23 patients (69.69%) were symptomatic in the transcervical and transfemoral groups, respectively (P=.869). After intervention, new postprocedural DW-MRI ischemic infarcts were found in four transcervical (12.9%) and in 11 transfemoral (33.3%) patients (P=.03), without new neurologic symptoms. No major adverse events occurred at 30 days after the intervention. All patients remained neurologically intact, without an increase in stroke scale scoring. All stents remained patent, and all patients remained stroke-free during follow-up. In multivariate analysis, age (relative risk [RR], 1.022; P<.001), symptomatic status (RR, 4.109; P<.001), and open-cell vs closed-cell stent design (RR, 2.01; P<.001) were associated with a higher risk of embolization in the transfemoral group but not in the transcervical group.

CONCLUSIONS

These data suggest that transcervical carotid stenting with carotid flow reversal carries a significantly lower incidence of new ischemic brain infarcts than that resulting from transfemoral CAS with a distal filter. The transcervical approach with carotid flow reversal may improve the safety of CAS and has the potential to improve results in especially vulnerable patients such as the elderly and symptomatic.

Age-dependent effects of carotid endarterectomy or stenting on cognitive performance

Although evidence is accumulating that age modifies the risk of carotid angioplasty and stenting (CAS) versus endarterectomy (CEA) for patients with significant carotid stenosis, the impact of age on cognition after either CEA or CAS remains unclear. In this study, we analyzed the effects of age on cognitive performance after either CEA or CAS using a comprehensive neuropsychological test battery with parallel test forms and a control group to exclude a learning effect. The neuropsychological outcomes after revascularization were determined in 19 CAS and 27 CEA patients with severe carotid stenosis. The patients were subdivided according to their median age (<68 years and ≥68 years); 27 healthy subjects served as a control group. In all patients clinical examinations, MRI scans and a neuropsychological test battery that assessed four major cognitive domains were performed immediately before, within 72 h, and 3 months after CEA or CAS. While patients <68 years of age showed no significant cognitive alteration after either CEA or CAS, a significant cognitive decline was observed in patients ≥68 years in both treatment groups (p = 0.001). Notably, this cognitive deterioration persisted in patients after CEA, whereas it was only transient in patients treated with CAS. These results demonstrate an age-dependent effect of CEA and CAS on cognitive functions. In contrast to the recently observed increased clinical complication rates in older subjects after CAS compared with CEA, CEA appears to be associated with a greater, persistent decline in cognitive performance than CAS in this subgroup of patients.

Treatment of vascular dementia. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

Scientific Department of Cognitive Neurology and Aging of ABN had a consensus meeting to write recommendations on treatment of vascular dementia, there was no previous issue. This disease has numerous particularities and can be considered a preventable dementia. Prevention treatment is primary care of vascular risk factors or a secondary prevention of factors that could cause recurrence of ischemic or hemorrhagic brain modifications. In these guidelines we suggested only symptomatic treatment, pharmacologic or non-pharmacologic. We have reviewed current publications on MEDLINE (PubMed), LILACS e Cochrane Library databases. Recommendations are concern to the following factors and their prevention evidences, association, or treatment of vascular dementia: physical activity, tobacco use, diet and food supplements, arterial hypertension, diabetes mellitus, obesity, statins, cardiac failure, atrial fibrillation, antithrombotics, sleep apnea, carotid revascularization, symptomatic pharmacological treatment.

Cognitive changes after surgery vs stenting for carotid artery stenosis

OBJECTIVES

Cognitive function has not been evaluated systematically in the context of carotid endarterectomy (CEA) versus carotid artery stenting (CAS). Cognitive decline can occur from microembolization or hypoperfusion during CEA or CAS. Carotid revascularization may, however, also improve cognitive dysfunction resulting from chronic hypoperfusion. We compared cognitive outcomes in consecutive asymptomatic patients undergoing CAS or CEA.

METHODS

This is a prospective nonrandomized single-center study of patients with asymptomatic carotid stenosis ≥ 70% undergoing CAS or CEA using standard techniques. Neurologic symptoms were evaluated by history, physical examination, and the National Institutes of Health Stroke Scale. A 50-minute cognitive battery was performed 1 to 3 days before and 4 to 6 months after CEA/CAS. The tests (Trail Making Tests A/B, Processing Speed Index (PSI) of the Wechsler Adult Intelligence Scale - Third Edition (WAIS-III), Boston Naming Test, Working Memory Index (WMI) of the Wechsler Memory Scale - Third Edition (WMS-III), Controlled Oral Word Association, and Hopkins Verbal Learning Test) for six cognitive domains (motor speed/coordination and executive function, psychomotor speed, language (naming), working memory/concentration, verbal fluency, and learning/memory) were conducted by a neuropsychologist. The primary analysis of impact of treatment modality was a normalized cognitive change score.

RESULTS

Forty-six patients underwent prepost testing (CEA = 25, CAS = 21). Women comprised 36% of the cohort, mean preprocedural stenosis was 84%, and 54% were right-sided lesions. All patients were successfully revascularized without periprocedural complications. The scores for each test improved after CEA except WMI, which decreased in 20 of 25 patients. Improvement occurred in all tests after CAS except PSI, which decreased in 18 of 21 patients. In addition to comparing the changes in individual test scores, overall cognitive change was measured by calculating the change in composite cognitive score (CCS) postprocedure versus baseline. To compute the CCS, the raw scores from each test were transformed into z scores and then averaged to calculate each patient's composite score. The composite score at baseline was then compared with that from the postprocedure testing. The CCS improved after both CEA and CAS, and the changes were not significantly different between the groups (.51 vs .47; P = NS).

CONCLUSIONS

Carotid revascularization results in an overall improvement in cognitive function. There are no differences in the composite scores of five major cognitive domains between CEA and CAS. When individual tests are compared, CEA results in a reduction in memory, while CAS patients show reduced psychomotor speed. Larger studies will help confirm these findings.

[Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging]

OBJECTIVES

To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting.

MATERIAL AND METHODS

We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ = 0.001 ml = 1 μl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24 hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables.

RESULTS

Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables.

CONCLUSIONS

Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development.

Significance of blood aspiration in carotid artery stenting with Angioguard XP

BACKGROUND AND PURPOSE

In some patients, angiographic flow impairment is observed during carotid artery stenting (CAS) using Angioguard XP (AGXP), resulting in neurological symptoms. CAS was thus modified to improve clinical outcome.

METHODS

Ninety-seven patients were treated with CAS using AGXP from January 2008 to October 2009. In period I (January-December 2008; n = 53), blood aspirations were performed only in no-flow cases. In period II (January-October 2009; n = 44), blood aspirations were performed in no-flow and slow-flow cases. Clinical outcome, detection of microembolic lesions on diffusion-weighted imaging (DWI) and flow impairment during CAS were examined between these two periods before and after modifying the CAS procedure.

RESULTS

Periprocedural transient ischemic attacks occurred in 10 patients (18.9%) and one patient (2.27%) in periods I and II, respectively (P = .018). Minor and major strokes were observed in two patients in each period (P = .849). New ipsilateral DWI lesions were detected in 25 patients (47.2%) and 11 patients (25.0%) in periods I and II, respectively (P = .024). Among 18 slow-flow cases, new DWI lesions were detected in one patient (9.09%) and five patients (71.4%) with (n = 11) and without (n = 7) blood aspirations, respectively (P = .013). Neurological symptoms were observed only in three of seven patients (42.9%) without aspirations, compared to one of 11 patients (9.1%) with aspirations (P = .043).

CONCLUSION

Postoperative symptomatic stroke and new DWI lesions are significantly associated with blood flow impairment during CAS using AGXP. When flow impairment occurs, blood aspiration should be performed.