Neurocognitive Improvement in Patients Undergoing Carotid Endarterectomy for Atherosclerotic Occlusive Carotid Artery Disease

Near-Infrared Spectroscopy-Guided, Individualized Arterial Blood Pressure Management for Carotid Endarterectomy under General Anesthesia: A Randomized, Controlled Trial

Background: Differences in blood pressure can influence the risk of brain ischemia, perioperative complications, and postoperative neurocognitive function in patients undergoing carotid endarterectomy (CEA). Methods: In this single-center trial, patients scheduled for CEA under general anesthesia were randomized into an intervention group receiving near-infrared spectroscopy (NIRS)-guided blood pressure management during carotid cross-clamping and a control group receiving standard care. The primary endpoint was postoperative neurocognitive function assessed before surgery, on postoperative days 1 and 7, and eight weeks after surgery. Perioperative complications and cerebral autoregulatory capacity were secondary endpoints. Results: Systolic blood pressure (p < 0.001) and norepinephrine doses (89 (54-122) vs. 147 (116-242) µg; p < 0.001) during carotid cross-clamping were lower in the intervention group. No group differences in postoperative neurocognitive function were observed. The rate of perioperative complications was lower in the intervention group than in the control group (3.3 vs. 26.7%, p = 0.03). The breath-holding index did not differ between groups. Conclusions: Postoperative neurocognitive function was comparable between CEA patients undergoing general anesthesia in whom arterial blood pressure during carotid cross-clamping was guided using NIRS and subjects receiving standard care. NIRS-guided, individualized arterial blood pressure management resulted in less vasopressor exposition and a lower rate of perioperative complications.

New insight into biology, molecular diagnostics and treatment options of unstable carotid atherosclerotic plaque: a narrative review

Indications for intervention in hemodynamically relevant carotid artery stenosis (carotid endarterectomy or stenting) are primarily based on a degree of stenosis and symptomatology. To date the plaque vulnerability is rarely taken into account in clinical decision making although development of molecular imaging allows a better understanding of plaque biology and provides new techniques detecting potentially vulnerable plaque at risk. A significant number of reports describing the mechanisms of unstable plaque formation suggest that it is a multifactorial process. Inflammation, lipid accumulation, apoptosis, proteolysis, the thrombotic process and angiogenesis are among the main factors of carotid plaque destabilization. Although inflammation is a key process in development of plaque vulnerability, the hemostasis and neoangiogenesis should be regarded as equally important. Only a small group of asymptomatic patients may benefit from the invasive treatment and it remains a challenge to determine whether initially asymptomatic carotid plaque become unstable or vulnerable. Currently, the main task of research on atherosclerotic lesion imaging is focused on functional state of the plaque. The presence of one or more features such as stenosis progression, large plaque area, large juxta-luminal black area, plaque echolucency, intra-plaque hemorrhage, impaired cerebral vascular reserve and spontaneous embolization may indicate patients at higher risk for stroke suitable for revascularization. Treatment of carotid stenosis as one of the manifestations of generalized atherosclerosis requires a broad approach. Nowadays pharmacological treatment options for the atherosclerotic process are largely aimed at stimulating the plaque stabilization, but in symptomatic patients and selected asymptomatic patients, carotid plaque should be removed as a potential source of embolism.

Humanin-S14G Ameliorates Vascular Dementia Through Regulating miR-134

Humanin-S14G is a synthetic derivative of Humanin with neuroprotective effects. miR-134 involves in the regulation of the nervous system. However, whether Humanin-S14G ameliorates VD through miR-134 remains poorly understood. Healthy male rats were assigned into sham group; VD group and Humanin-S14G group followed by analysis of learning ability by the Morris water maze test, expression of miR-134, Bcl-2 and Bax by Real time PCR, BDNF protein level by Western blot, IL-6 secretion by ELISA as well as pathological changes of hippocampal nerve region by HE staining. In VD model group, the learning and cognitive ability of the rats was significantly decreased and miR- 134 and IL-6 was significantly upregulated along with downregulated Bcl-2 and BDNF and upregulated Bax expression compared to sham group (P <0.05). Humanin-S14G significantly improved the learning and cognitive ability of VD model rats, decreased miR-134 and IL-6 level, increased Bcl-2 and BDNF expression, as well as inhibited Bax expression (P <0.05) and nerve damage was significantly improved. Humanin-S14G regulates miR-134 expression in the brain tissue of VD rats, promote the expression of BDNF, regulate cell apoptosis, inhibit inflammation, improve the learning function of vascular dementia, and delay the occurrence and development of vascular dementia.

Endovascular revascularization of symptomatic chronic total occlusions of the internal carotid artery using a proximal balloon protection device

To investigate the feasibility, efficacy, and safety of endovascular recanalization for symptomatic chronic internal carotid artery occlusions (ICAO). Thirty patients with symptomatic chronic ICAO were treated using the endovascular recanalization method. Proximal balloon protection devices were used to prevent embolic migration by completely blocking the blood flow. The morphology of the internal carotid artery (ICA) at the occluded segment based on catheter angiography was analyzed. Recanalization of symptomatic chronic internal carotid artery occlusion (CICAO) was successful in 20 of the 30 patients (66.7%). The time required for successful revascularization ranged from 120 to 180 min (mean, 150 min). Of the 20 successful patients, 14 were at the cervical ICAs, and six were at the intracranial ICAs. No permanent complications occurred in our study. Ischemic symptoms related to chronic ICAO did not occur during the 18.3 month follow-up period (range, 12-24 months) in the 20 successful patients. Endovascular revascularization can improve hemodynamic compromise. The treated sites of all 20 successfully recanalized patients were patent on computed tomographic angiography or carotid duplex sonography, and no case with >50% restenosis was observed during the follow-up period. Three patients with failed recanalization had a stroke during the follow-up period. Endovascular revascularization of symptomatic CICAO using a proximal balloon protection device is technically feasible in selected patients, and the outcomes are favorable for patients who benefit from revascularization.

eGFR and deep white matter hyperintensity as predictors of cognitive decline long after carotid endarterectomy

Chronic kidney disease and white matter hyperintensity (WMH) are associated with cognitive decline. The aim of this study was to assess the correlations between estimated glomerular filtration rate (eGFR) or WMH and cognitive function in patients who have undergone carotid endarterectomy (CEA). Cognitive functions were investigated using the Neurobehavioral Cognitive Status Examination (Cognistat) in 83 patients who had undergone CEA. The eGFR at 5 years prior to examination was significantly associated with severe cognitive impairment (odds ratio, 0.89 per 1-mL/min/1.73 m² increase, 95% confidence interval 0.82–0.97, p = 0.0004). Receiver operating characteristic analysis revealed that a cutoff eGFR of 46.8 mL/min/1.73 m² at 5 years prior to examination offered the most reliable predictor of severe cognitive impairment (sensitivity 88.9%, specificity 76.5%, area under the curve 0.848). The eGFR at 5 years prior to examination showed a significant linear association with total Cognistat score (r² = 0.11035, p = 0.0032) compared to eGFR at 3 years prior to examination (r² = 0.06455, p = 0.0230) or at examination (r² = 0.0210, p = 0.0210). Spearman’s correlation coefficient revealed that orientation, comprehension, repetition, construction, memory, and similarity correlated with eGFR at 5 years prior to examination. Conversely, Fazekas grade for deep WMH at examination was associated with total Cognistat score (p = 0.0016), unlike that at 3 years (p = 0.0100) or 5 years prior to examination (p = 0.0172). While eGFR correlates with future cognitive function, deep WMH associates with present cognitive function in patients who have undergone CEA.