OBJECTIVE Carotid intervention is safe and effective in stroke prevention in appropriately selected patients. Despite minimal neurologic complications, procedure-related subclinical microemboli are common and their cognitive effects are largely unknown. In this prospective longitudinal study, we sought to determine long-term cognitive effects of embolic infarcts. METHODS 119 patients including 46% symptomatic patients who underwent carotid revascularization were recruited. Neuropsychological testing was administered preoperatively and at 1, 6, and 12 months postoperatively. Rey Auditory Learning Test (RAVLT) was the primary cognitive measure with parallel forms to avoid practice effort. All patients also received 3T brain MRIs with a diffusion-weighted sequence (DWI) preoperatively and within 48 hours postoperatively to identify procedure-related new embolic lesions. Each DWI lesion was manually traced and input into a neuroimaging program to define volume. Embolic infarct volumes were correlated with cognitive measures. Regression models were used to identify relationships between infarct volumes and cognitive measures. RESULTS A total 587 DWI lesions were identified on 3T MRI in 81.7% of CAS and 36.4% of CEA patients with a total volume of 29327mm3. Among them, 54 DWI lesions were found in CEA patients and 533 in the CAS patients. Four patients had transient postoperative neurologic symptoms and one had a stroke. CAS was an independent predictor of embolic infarct (OR: 6.6 [2.1–20.4], p<.01) and infarct volume (P=.004). Diabetes and contralateral carotid severe stenosis/occlusion had a trend of positive association with infarct volume, while systolic blood pressure more or equal to 140mmHg had a negative association (P=.1, .09, and .1, respectively). There was a trend of improved RAVLT scores overall following carotid revascularization. Significantly higher infarct volumes were observed among those with RAVLT decline. Within the CAS cohort, infarct volume was negatively correlated with short and long-term RAVLT changes (P<0.05). CONCLUSIONS Cognitive assessment of procedure-related subclinical microemboli is challenging. Volumes of embolic infarct correlates with long-term cognitive changes, suggesting that micro-embolization should be considered as a surrogate measure for carotid disease management.

OBJECTIVE Carotid interventions are important in helping to reduce the risk of stroke for patients with high-grade carotid artery stenosis; however, incidence of subclinical cerebral microemboli can occur during these procedures. Previously, associations have been found between incidence of microemboli and postoperative decline in memory. We therefore sought to determine whether this decline persisted long-term and to assess changes in other cognitive domains. METHODS Patients were prospectively recruited under an IRB-approved protocol at a single academic center. Neuropsychological testing was administered preoperatively and at 1 month and 6 month intervals postoperatively. Cognitive domains that were evaluated included verbal memory, visual memory, psychomotor speed, dexterity, and executive function. Diffusion weighted MRI (DWI) sequencing was performed preoperatively and within 48 hours postoperatively to identify procedure-related microemboli. Univariate and multivariate regression models were used to identify relationships between microembolization, demographics, and cognition. RESULTS 80 patients were included; all were male and average age was 69 years. Forty patients underwent CAS and 40 CEA. 45% were diabetic, 50% had CAD, and 41% had prior neurologic symptoms. 45 (56%) of the patients had new postoperative microemboli. Microembolization was significantly more common in the CAS cohort (P<.005). Univariate analysis demonstrated that patients with procedure-related embolization showed decline 1 month postoperatively in verbal memory and Trail Making A measures. Multivariate analysis demonstrated that procedure-related embolization (OR: 2.8, P=.04) and pre-op symptomatic stenosis (OR: 3.2, P=.026) were independently predictors of decline for the RAVLT Short Delay measure at 1 month; however, at 6 months there was no significant relationship between emboli and decline on RAVLT Short Delay, while age (OR: 1.1, P=.005) and COPD (OR: 7.1, P=.018) were significantly associated with decline at 6 months following intervention. CONCLUSIONS Microembolization that is associated with carotid artery intervention predicts short-term cognitive decline. However, some of these cognitive deficits persist at 6 months following intervention, and further investigation is warranted to determine individual patient risk factors that may impact recovery.

Calcification of atherosclerotic plaques in elderly patients represents a potent risk marker of cardiovascular events. Plasma analyses of patients with or without calcified plaques reveal significant differences in chemokines, particularly eotaxin, which escalates with increased calcification. We therefore, hypothesize that eotaxin in circulation augments calcification of vascular smooth muscle cells (VSMCs) possibly via oxidative stress in the vasculature. We observe that eotaxin increases the rate of calcification significantly in VSMCs as evidenced by increased alkaline phosphatase activity, calcium deposition, and osteogenic marker expression. In addition, eotaxin promotes proliferation in VSMCs and triggers oxidative stress in a NADPH oxidase dependent manner. These primary novel observations support our proposition that in the vasculature eotaxin augments mineralization. Our findings suggest that eotaxin may represent a potential therapeutic target for prevention of cardiovascular complications in the elderly. J. Cell. Biochem. 118: 647-654, 2017. © 2016 Wiley Periodicals, Inc.

Precis: A drive-through clinic was created to obtain intraocular pressure measurements before a virtual visit with their provider, in order to provide care for patients in the Kellogg Glaucoma Clinic while minimizing risk of COVID-19 transmission. Purpose: The aim of this study was to establish a drive-through clinic model to provide glaucoma care for patients while minimizing the risk of COVID-19 transmission. Patients and Methods: A drive-through clinic was created by adapting a 1-lane, 1-way driveway adjacent to the Kellogg Eye Center building entrance. Patients were physicianselected from the Glaucoma Clinic at Kellogg Eye Center as existing patients who required intraocular pressure (IOP) checks and therapeutic management and were chosen based on their ability to be managed with an IOP measurement primarily. The entrance was otherwise closed to the public, allowing staff to utilize an adjacent vestibule with glass walls and sliding doors as a staffroom. Patients were instructed to arrive within a 15-minute time window at which time they would drive through the lane and stop their cars under an awning over the driveway. Ophthalmic technicians wearing appropriate personal protective equipment then approached each car, confirmed patient information, and measured IOP. Once the data were recorded using a mobile workstation, the physician was able to complete each visit by discussing the findings and therapeutic plan with the patient, either in-person in real time or virtually by phone or video visit at a later time. Results: A total of 241 visits were completed over 14 half day clinic sessions, with number of drive-through visits ranging from 5 to 45 per session. Conclusions: It is possible to institute a drive-through model of IOP checks for glaucoma patients which is efficient and minimizes the risk of exposure to COVID-19 for patients and staff.

Objective To determine factors affecting cognition and identify predictors of long-term cognitive impairment following carotid revascularization procedures. Background Cognitive impairment is common in older patients with carotid occlusive diseases. Methods Patients undergoing carotid intervention for severe occlusive diseases were prospectively recruited. Patients received neurocognitive testing before, 1, and 6 months after carotid interventions. Plasma samples were also collected within 24 hours after carotid intervention and inflammatory cytokines were analyzed. Univariate and multivariate logistic regressions were performed to identify risk factors associated with significant cognitive deterioration (>10% decline). Results A total of 98 patients (48% symptomatic) were recruited, including 55 patients receiving carotid stenting and 43 receiving endarterectomy. Mean age was 69 (range 54–91 years). Patients had overall improvement in cognitive measures 1 month after revascularization. When compared with carotid stenting, endarterectomy patients demonstrated postoperative improvement in cognition at 1 and 6 months compared with baseline. Carotid stenting (odds ratio 6.49, P = 0.020) and age greater than 80 years (odds ratio 12.6, P = 0.023) were associated with a significant long-term cognitive impairment. Multiple inflammatory cytokines also showed significant changes after revascularization. On multivariate analysis, after controlling for procedure and age, IL-12p40 (P = 0.041) was associated with a higher risk of significant cognitive impairment at 1 month; SDF1-α (P = 0.004) and tumor necrosis factor alpha (P = 0.006) were independent predictors of cognitive impairment, whereas interleukin-6 (P = 0.019) demonstrated cognitive protective effects at 6 months after revascularization. Conclusions Carotid interventions affect cognitive function. Systemic biomarkers can be used to identify patients at risk of significant cognitive decline postprocedures that benefit from targeted cognitive training.