Microembolization is associated with transient cognitive decline in patients undergoing carotid interventions

Abstract

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.

One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field

“…On the other hand, there is increasing evidence that carotid plaque-related cerebral embolisation may have a negative effect on cognitive function [ 76 ] (and intervention may be beneficial provided minimal intervention-related brain embolism [ 76 – 81 ]). Understanding is thus increasing today that the total burden of DW-MRI-depicted microembolisation in patients undergoing carotid revascularisation by CEA or CAS may be associated with transient cognitive decline [ 82 ]. In a proportion of patients, part of the deficit may persist months after the intervention [ 82 , 83 ].…”

“…Understanding is thus increasing today that the total burden of DW-MRI-depicted microembolisation in patients undergoing carotid revascularisation by CEA or CAS may be associated with transient cognitive decline [ 82 ]. In a proportion of patients, part of the deficit may persist months after the intervention [ 82 , 83 ]. Thus, any carotid intervention, to have a positive impact on brain function, needs to be associated with minimised cerebral embolism.…”

Association Between Cerebral Hypoperfusion and Cognitive Impairment in Patients With Chronic Vertebra-Basilar Stenosis

“…Studies showed that the state of ischaemia and hypoxia was associated with damage to the neural network between the brainstem or cerebellar regions and the anterior circulation ( 25 – 27 ). Low perfusion leads to a decrease in thrombus clearance; additionally, the formation of microemboli that result from lesions caused by cerebral vascular stenosis also leads to VCI ( 28 ). In animal studies, microemboli were found to decrease the number of brain-derived neurotrophic factors in the hippocampus and lead to impaired memory in mice ( 29 ).…”

Cognitive function dynamics in comorbid patients after angioreconstructive interventions

“…Полученные в настоящей работе данные, как и немногочисленные сообщения других авторов, свидетельствуют о возможном ухудшении когнитивных функций после ангиореконструктивных вмешательств у пациентов с коморбидным СД 2-го типа. Так, больные с СД 2-го типа превалировали (с частотой 56%) среди пациентов с микроэмболизацией при ангиореконструкции [10]. В опубликованных в 2020 г. результатах исследования C. Kraemer и соавт.…”

“…Ассоциированная с КАС микроэмболизация в ближайшем послеоперационном периоде является предиктором когнитивного снижения, которое может сохраняться до 6 мес после вмешательства [10,11]. Собственные результа-ты, а также данные других авторов позволяют нам предположить, что степень периоперационного повреждения мозга при наличии СД 2-го типа коррелирует с долгосрочными когнитивными изменениями [12].…”