Carotid Endarterectomy Improves Cognitive Function in Patients with Exhausted Cerebrovascular Reserve

Fearn, Shirley J.; Hutchinson, Suzanne; Riding, G.; Hill-Wilson, G; Wesnes, Keith; McCollum, Charles

doi:10.1016/s1078-5884(03)00384-8

Cited by 80 publications

(67 citation statements)

References 34 publications

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“…Reduced cerebrovascular resistance (CVR) on the side of carotid occlusion or stenosis indicates preexisting autoregulatory vasodilation and has been associated with cognitive impairment in patients with asymptomatic carotid stenosis at baseline 29 and with cognitive improvement when the impaired CVR is reversed after endarterectomy. 30 Other studies have shown a lack of association between CVR and cognitive impairment. 31 In an important single case study, cerebral hemodynamic measures were assessed in a 55-year-old man with bilateral ICA occlusions presenting with subacute onset of severe behavioral and cognitive changes.…”

Section: Resultsmentioning

confidence: 97%

Cerebral hemodynamics and cognitive impairment

Marshall¹,

Festa²,

Cheung³

et al. 2012

Neurology

100

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Objective: To determine whether unihemispheral hemodynamic failure is independently associated with cognitive impairment among participants in the National Institute of Neurological Disorders and Stroke-sponsored, multicenter, randomized clinical trial, Randomized Evaluation of Carotid Occlusion and Neurocognition (RECON). Methods:Forty-three patients were randomized into RECON after recent symptomatic carotid artery occlusion and asymmetrically increased oxygen extraction fraction (OEF) by PET (OEF ratio Ͼ1.13), indicating stage II hemodynamic failure on the side of occlusion. The PET-positive patients were compared with 28 RECON-enrolled patients who met all clinical and radiographic inclusion/exclusion criteria but had no OEF asymmetry. A multivariable regression compared patients with PET OEF Ͼ1.13 or Յ1.13, stratifying by TIA vs stroke as the qualifying event. The dependent variable was a composite neurocognitive score derived from averaging age-normalized z scores on a test battery that included global and internal carotid artery (ICA) side-relevant hemisphere-specific tests.Results: There were no differences in demographic, clinical, or radiologic characteristics between the PET-positive and PET-negative patients except for PET OEF asymmetry. The unadjusted average neurocognitive z score was Ϫ1.45 for the PET-positive and Ϫ1.25 for the PET-negative patients, indicating cognitive impairment in both groups but no difference between them (p ϭ 0.641). After adjustment for age, education, side of occlusion, depression, and previous stroke, there was a significant difference between PET-positive and PET-negative patients among those with TIA as a qualifying event (average z score ϭ Ϫ1.41 vs Ϫ0.76, p ϭ 0.040). Older age and right ICA side were also significant in this model. Conclusion:Hemodynamic failure is independently associated with cognitive impairment in patients with carotid occlusion. This finding establishes the physiologic parameter upon which the extracranial-intracranial bypass will be tested. Neurology ® 2012;78:250-255

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Section: Resultsmentioning

confidence: 97%

Cerebral hemodynamics and cognitive impairment

Marshall¹,

Festa²,

Cheung³

et al. 2012

Neurology

100

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“…18,27,47 Overall, 16 used one or more control groups varying from healthy subjects to patients affected by different diseases. 18 Ten focused exclusively on symptomatic 5,17,21,28,33,35,43,45,27,47 and one on asymptomatic patients. 19 Time of cognitive assessment varied from 24 hours to 8 years after revascularization and 4 reported at 1 year or later (3 and 8 years).…”

Section: Search Resultsmentioning

confidence: 99%

“…To compare cognitive outcome, 12 studies used single or multiple control groups varying from healthy people (nϭ7), 19,25,29,33,34,41,42 to patients with vascular risk factors (nϭ1), 19 to those with peripheral disease (nϭ2), 20,25 those undergoing orthopedic surgery (nϭ3), 21,30,38 or those undergoing urologic surgery (nϭ1). 28 One study analyzed cognitive outcome exclusively in asymptomatic 19 and 5 in symptomatic carotid stenosis. 5,21,28,33,35 Comparing post-CEA assessment with preoperative condition with a control group, 6 reported no substantial changes after CEA, 20,23,30,33,40,42 5 highlighted impairment, 5,19,24,31,38 and 4 improvement, 21,22,35,41 although not all psychological tests were consistently changed.…”

Section: Neuropsychological Outcome After Carotid Endarterectomymentioning

confidence: 99%

The Role of Carotid Artery Stenting and Carotid Endarterectomy in Cognitive Performance

Rango

Caso

Leys

et al. 2008

Stroke

134

115

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Background and Purpose-Change in cognition is being increasingly recognized as an important outcome measure; however, the role of carotid revascularization on this issue remains to be determined. It is still under debate whether carotid artery stenting and carotid endarterectomy have the same influence on neuropsychological functions. Summary of Review-This article systematically reviews recent literature in an attempt to clarify this issue. A total of 32 papers reporting on neurocognition after carotid endarterectomy (nϭ25), carotid artery stenting (nϭ4), or carotid artery stenting versus carotid endarterectomy (nϭ3) were identified. The studies were different for many methodological factors, eg, sample size, type of patients and control group, statistical measure, type of test, timing of assessment, and so on. There was a lack of consensus in defining the improvement or impairment after either carotid artery stenting or carotid endarterectomy. Furthermore, there were nonuneqivocal results regarding the same domain of assessment (memory, visuomotor, attention). Based on available evidence, it is probable that carotid endarterectomy as well as carotid artery stenting do not change neuropsychological function "per se." Conclusions-Assessment of cognition after carotid revascularization is probably influenced by many confounding factors such as learning effect, type of test, type of patients, and control group, which are often minimized in their importance. The role of carotid revascularization is to prevent stroke in patients with severe carotid stenosis as highlighted by previous large randomized trials. Although an effect of carotid revascularization on cognition could be missed as a consequence of underpowered studies included in this review, at this time, no prediction can be done regarding its repercussions on higher intellectual functions. Larger studies appropriately designed and powered to assess cognition after carotid revascularization might change this view. (Stroke. 2008;39:3116-3127.)

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“…EETs are important regulators of parenchymal blood flow and neurovascular coupling (23) and studies suggest that cognitive impairment in humans is linked to dysfunctional cerebral eicosanoid signaling (35). For comparative analysis of the effect of BCAS on arterioles and the major collateral artery between the posterior and anterior cerebral circulation, we also studied structural and mechanical changes in the PAs as well as posterior communicating arteries (PComAs) and evaluated cerebrovascular reserve capacity, a critical prognostic factor for cognitive impairment (17). The aim of this study was to evaluate changes in the PAs and collaterals such as the PComAs in a model of cognitive impairment to understand the mechanism by which cerebral perfusion and brain functions are linked.…”

mentioning

confidence: 99%

Bilateral common carotid artery stenosis in normotensive rats impairs endothelium-dependent dilation of parenchymal arterioles

Matin

Fisher

Jackson

et al. 2016

American Journal of Physiology-Heart and Circulatory Physiology

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Matin N, Fisher C, Jackson WF, Dorrance AM. Bilateral common carotid artery stenosis in normotensive rats impairs endotheliumdependent dilation of parenchymal arterioles. Am J Physiol Heart Circ Physiol 310: H1321-H1329, 2016. First published March 11, 2016; doi:10.1152/ajpheart.00890.2015.-Chronic cerebral hypoperfusion is a risk factor for cognitive impairment. Reduced blood flow through the common carotid arteries induced by bilateral carotid artery stenosis (BCAS) is a physiologically relevant model of chronic cerebral hypoperfusion. We hypothesized that BCAS in 20-wk-old WistarKyoto (WKY) rats would impair cognitive function and lead to reduced endothelium-dependent dilation and outward remodeling in the parenchymal arterioles (PAs). After 8 wk of BCAS, both shortterm memory and spatial discrimination abilities were impaired. In vivo assessment of cerebrovascular reserve capacity showed a severe impairment after BCAS. PA endothelial function and structure were assessed by pressure myography. BCAS impaired endothelial function in PAs, as evidenced by reduced dilation to carbachol. Addition of nitric oxide synthase and cyclooxygenase inhibitors did not change carbachol-mediated dilation in either group. Inhibiting CYP epoxygenase, the enzyme that produces epoxyeicosatrienoic acid (EETs), a key determinant of endothelium-derived hyperpolarizing factor (EDHF)-mediated dilation, abolished dilation in PAs from Sham rats, but had no effect in PAs from BCAS rats. Expression of TRPV4 channels, a target for EETs, was decreased and maximal dilation to a TRPV4 agonist was attenuated after BCAS. Together these data suggest that EET-mediated dilation is impaired in PAs after BCAS. Thus impaired endothelium-dependent dilation in the PAs may be one of the contributing factors to the cognitive impairment observed after BCAS. cerebral microcirculation; vascular remodeling; endothelium-dependent dilation; parenchymal arterioles; posterior communicating artery; epoxyeicosatrienoic acid NEW & NOTEWORTHY This is the first study investigating changes in endothelium-dependent dilation in parenchymal arterioles from a model of chronic cerebral hypoperfusion. Our findings correlate changes in the dilatory pathways of arterioles with cognitive deficits observed after chronic cerebral hypoperfusion.CHRONIC CEREBRAL HYPOPERFUSION has been implicated in dementias ranging from vascular cognitive impairment (20) to Alzheimer's disease (1, 12). Animal models of chronic cerebral hypoperfusion exhibit neuronal loss, white matter lesions, and increased levels of reactive astrocytes (10,28,29). Few studies have investigated the effect of chronic cerebral hypoperfusion on the parenchymal arterioles (PAs) (27, 49). However, none have reported changes in endothelial function in PAs or studied the effects of prolonged hypoperfusion.PAs arise from the pial arteries, perfuse the parenchyma, and eventually branch into the capillaries. These capillaries are in intimate contact with neurons, astrocytes, and pericytes and together these cell types form...

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Carotid Endarterectomy Improves Cognitive Function in Patients with Exhausted Cerebrovascular Reserve

Abstract: Attention improved at 2 months following CEA in patients with impaired CVR. CEA may offer more than reduced stroke risk to patients with impaired CVR.

Cited by 80 publications

References 34 publications

Cerebral hemodynamics and cognitive impairment

Cerebral hemodynamics and cognitive impairment

The Role of Carotid Artery Stenting and Carotid Endarterectomy in Cognitive Performance

Bilateral common carotid artery stenosis in normotensive rats impairs endothelium-dependent dilation of parenchymal arterioles

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