Background Systemic inflammation has been implicated in the development of cognitive dysfunction following carotid endarterectomy (CEA). Neutrophil-lymphocyte ratio (NLR) is a reliable measure of systemic inflammation. We hypothesize that patients with elevated preoperative NLR have increased risk of cognitive dysfunction 1 day after CEA. Methods Five hundred fifty-one (551) patients scheduled for CEA were enrolled at Columbia University in New York, NY from 1995 to 2012. NLR was retrospectively reviewed; only 432 patients had preoperative NLR values available within 2 weeks of CEA. NLR was analyzed as a continuous variable and categorically with a cutoff of ≥5 and <5 and equal tertiles, as done in previous studies. Results Patients with cognitive dysfunction had significantly higher NLR than those without cognitive dysfunction (4.5±4.0 vs. 3.2±2.6, P<0.001). The incidence of cognitive dysfunction was significantly higher in patients with NLR ≥5 than NLR <5 (34.7% vs. 12.8%, P<0.001). Significantly fewer patients in the low tertile had cognitive dysfunction than in the high tertile (6.9% vs. 25.9%, P<0.001) and middle tertile (6.9% vs. 17.4%, P=0.006). In the final multivariate model, diabetes mellitus (OR: 2.03 [1.08–3.75], P=0.03) and NLR ≥5 (OR: 3.38 [1.81–6.27], P<0.001) were significantly associated with higher odds of cognitive dysfunction, while statin use was significantly associated with lower odds (OR: 0.48 [0.27–0.84], P=0.01). Conclusions Preoperative NLR is associated with cognitive dysfunction 1 day after CEA. NLR ≥5 and diabetes mellitus are significantly associated with increased odds of cognitive dysfunction while statin use is significantly associated with decreased odds.

Background A common practice during cross-clamp of carotid endarterectomy (CEA) is to manage mean arterial pressure (MAP) above baseline to optimize collateral cerebral blood flow and reduce risk of ischemic stroke. Objective To determine whether MAP management ≥20% above baseline during cross-clamp is associated with lower risk of early cognitive dysfunction, a subtler form of neurologic injury than stroke. Methods One hundred eighty-three patients undergoing CEA were enrolled in this ad hoc study. All patients had radial arterial catheters placed prior to induction of general anesthesia. MAP was managed at the discretion of the anesthesiologist. All patients were evaluated with a battery of neuropsychometric tests pre-operatively and 24hrs post-operatively. Results Overall, 28.4% of CEA patients exhibited early cognitive dysfunction (eCD). Significantly fewer patients with MAP ≥20% above baseline during cross-clamp exhibited eCD than those managed <20% above (11.6% vs. 38.6%, P<0.001). In a multivariate logistic regression model, MAP ≥20% above baseline during the cross-clamp period was associated with significantly lower risk of eCD (OR: 0.18 [0.07–0.40], P<0.001), while diabetes mellitus (OR: 2.73 [1.14–6.61], P=0.03) and each additional year of education (OR: 1.19 [1.06–1.34], P=0.003) were associated with significantly higher risk of eCD. Conclusion The observations of this study suggest MAP management ≥20% above baseline during cross-clamp of the carotid artery may be associated with lower risk of eCD after CEA. More prospective work is necessary to determine whether MAP ≥20% above baseline during cross-clamp can improve the safety of this commonly performed procedure.

OBJect Neurocognitive performance is used to assess multiple cognitive domains, including motor coordination, before and after carotid endarterectomy (CEA). Although gross motor strength is impaired with ischemia of large cortical areas or of the internal capsule, the authors hypothesize that patients undergoing CEA demonstrate significant motor deficits of hand coordination contralateral to the operative side, which is more clearly manifest in the nondominant hand than in the dominant hand with ischemia of smaller cortical areas. MetHODS The neurocognitive performance of 374 patients was evaluated with a battery of neuropsychometric tests. Both asymptomatic and symptomatic patients undergoing CEA were included. The authors evaluated the patients' dominant and nondominant hand performance on the Grooved Pegboard test, a test of hand coordination, to demonstrate their functional laterality. Neurocognitive dysfunction was evaluated as the difference in performance before and after CEA according to group-rate and event-rate analyses. The z scores were generated for all tests using a reference group of patients who were having simple spine surgery. Dominant and nondominant motor coordination functions were evaluated as raw scores and as calculated z scores. reSultS According to event-rate analysis, significantly more patients undergoing CEA of the opposite carotid artery demonstrated nondominant than dominant hand deficits of coordination (41.2% vs 26.4%, respectively, p = 0.02). Similarly, according to group-rate analysis, in patients undergoing CEA of the opposite carotid artery, raw difference scores from the Grooved Pegboard test reflected greater nondominant than dominant hand deficits of coordination (21.0 ± 54.4 vs 9.7 ± 37.0, respectively, p = 0.02). cOncluSiOnS Patients undergoing CEA of the opposite carotid artery are more likely to demonstrate nondominant than dominant hand deficits of coordination because of greater dexterity in the dominant hand before surgery.Clinical trial registration no.: NCT00597883 (ClinicalTrials.gov) http://thejns.org/doi/abs/10.3171/2014.8.JNS1459KeY WOrDS cerebrovascular disease/stroke; carotid endarterectomy; laterality; motor dysfunction; vascular disorders aBBreviatiOn CEA = carotid endarterectomy.