The effect of small infarcts and carotid endarterectomy on postoperative psychologic test performance

Owens, Milton L.; Pressman, Marcia; Edwards, Allan E.; Tourtellotte, Wallace W.; Rose, Judith G.; Stern, David; Peters, George; Stabile, Bruce E.; Wilson, Samuel E.

doi:10.1016/0022-4804(80)90117-1

Cited by 34 publications

(25 citation statements)

References 19 publications

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“…30 These increases may lead to improved neuropsychometric performance. 15 In general, improvement occurred in those patients who had low flowendangered brains. 15,31,32 This may explain why patients having CEA with low preoperative CBF had greater improvement in a battery of neuropsychometric tests than a control group also having CEA for carotid artery stenosis but with hemodynamically insignificant lesions.…”

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confidence: 99%

“…Only those with small infarcts improved at later follow-up testing (3 to 6 months). 15 Our patients all had greater than 70% stenosis; some were symptomatic, but most were asymptomatic. This population falls into the group that others have shown to have the most improvement in postoperative neuropsychometric performance.…”

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confidence: 99%

“…31 However, rarely, this increased flow may be deleterious. 21 Owens et al 15 demonstrated that if patients with greater than 50% stenosis had normal CT scans and computerized radionuclide angiograms before and after CEA, they showed cognitive improvement as measured by a battery of neuropsychometric tests in the immediate postoperative period (3 to 10 days) but deteriorated in their cognitive performance if these tests demonstrated evidence of small infarcts or if there was clinical evidence of a stroke. Only those with small infarcts improved at later follow-up testing (3 to 6 months).…”

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Neuropsychometric Changes in Patients After Carotid Endarterectomy

Heyer

Adams

Solomon

et al. 1998

Stroke

133

127

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Background and Purpose-One hundred twelve patients undergoing elective carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis were enrolled in a prospective study to evaluate the incidence of change in postoperative cerebral function. Methods-Patients were evaluated preoperatively and postoperatively before hospital discharge and at follow-up 1 and 5 months later with a battery of neuropsychometric tests. The results were analyzed by both event-rate and group-rate analyses. For event-rate analysis, change was defined as either a decline or improvement in postoperative neuropsychometric performance by 25% or more compared with a preoperative baseline. Results-Approximately 80% of patients showed decline in one or more test scores, and 60% had one or more improved test scores at the first follow-up examination. The percentage of declined test scores decreased and the percentage of improved test scores increased with subsequent follow-up examinations. Group-rate analysis was similar for group performance on individual tests. However, a decline in performance was seen most commonly on verbal memory tests, and improved performance was seen most commonly on executive and motor tests. Conclusions-Neuropsychometric evaluation of patients undergoing carotid endarterectomy for significant carotid artery stenosis demonstrates both declines and improvements in neuropsychometric performance. The test changes that showed decreased performance may be associated with ischemia from global hypoperfusion or embolic phenomena, and the improvement seen may be related to increased cerebral blood flow from removal of stenosis. (Stroke. 1998;29:1110-1115.)

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Neuropsychometric Changes in Patients After Carotid Endarterectomy

Heyer

Adams

Solomon

et al. 1998

Stroke

133

127

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“…Using much more primitive imaging technology, Owens and colleagues demonstrated that small "asymptomatic" lesions after carotid endarterectomy were associated with measurable cognitive decline. 2 The authors report a 5.3% clinical stroke or death rate within 30 days of the procedure. Based on prior randomized endarterectomy trials, the data indicate that there is little to be gained by repairing an asymptomatic stenosis if the complication rate exceeds 3% and a symptomatic stenosis if the complication rate exceeds 5%.…”

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Incidence of New Brain Lesions After Carotid Stenting With and Without Cerebral Protection

Cohen

2007

Stroke

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Kastrup and colleagues describe their experience with carotid angioplasty and stenting (CAS) both with and without distal protective devices. 1 They performed CAS on patients with ipsilateral symptoms within the last 6 months and ultrasound documented Ն70% stenosis (57%). They also performed procedures on asymptomatic patients with Ն90% stenosis (43%). Using a combination of clinical end points and imaging end points, they were able to document their complication rate. Postprocedure strokes were considered "minor" if they increased the National Institutes of Health Stroke Scale (NIHSS) by Ͻ3 at the end of 30 days and major if the NIHSS was increase by Ͼ3. No mention was made of how a patient was classified if the NIHSS increased by 3. Of the 353 consecutive patients who had the procedure in a 38-month period, 206 were included in the analysis. Thirty-nine percent were asymptomatic. Of the symptomatic patients, 10% had only transient monocular blindness. The remainder had a stroke or transient ischemic attack within 6 months. The authors did not indicate how many, if any, of their patients were not candidates for carotid endarterectomy.The authors are to be congratulated for obtaining pre-and postprocedure diffusion-weighted imaging (DWI). The DWI documented 639 new lesions in their 206 patients after CAS, with over half the patients having at least one new lesion. Enlargement of a prior lesion was not counted as a new lesion. The finding of 639 new DWI positive lesions should give pause to anyone performing this procedure. There is potential for "asymptomatic" lesion burden to be associated with cognitive decline. Using much more primitive imaging technology, Owens and colleagues demonstrated that small "asymptomatic" lesions after carotid endarterectomy were associated with measurable cognitive decline. 2 The authors report a 5.3% clinical stroke or death rate within 30 days of the procedure. Based on prior randomized endarterectomy trials, the data indicate that there is little to be gained by repairing an asymptomatic stenosis if the complication rate exceeds 3% and a symptomatic stenosis if the complication rate exceeds 5%. 3,4 Although the authors did not report the complication rate for asymptomatic patients and symptomatic patients separately, it is reasonable to assume that the overall 5.3% complication rate represents a higher than acceptable rate for each category. Analysis of data from the symptomatic carotid endarterectomy trials indicate that the maximum benefit is gained when the surgery is done within 2 weeks of the symptoms. 5 The benefit drops greatly when the repair of the stenosis is delayed 6 months. The authors did not indicate the mean delay between symptoms and the CAS procedure.The authors focus their conclusions on the potential benefit of a distal protection device and the potential role of DWI to quantify injury after CAS procedures. Another potential conclusion from these data are that, with a clinical stroke rate in excess of 5% in a mixed symptomatic and asymptomatic population, the...

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“…Five studies assessed a limited number of cognitive domains [6,13,[19][20][21], while others used a neuropsychological battery, nevertheless the number of tests used did not seem to influence the reported outcome.…”

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Psychological impact of carotid endarterectomy: A review of the studies

Sciarroni

Gremigni

Pedrini

2016

Monaldi Arch Chest Dis

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Results of the 39 studies considered suggest that, although few studies show cognitive deterioration, most of them show stability with a tendency to improve both in cognitive functions and in other psychological areas. Further research is needed to clarify when it would be appropriate the use of CEA, the characteristics of eligible patients, and psychological as well as physical expected outcomes.

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The effect of small infarcts and carotid endarterectomy on postoperative psychologic test performance

Cited by 34 publications

References 19 publications

Neuropsychometric Changes in Patients After Carotid Endarterectomy

Neuropsychometric Changes in Patients After Carotid Endarterectomy

Incidence of New Brain Lesions After Carotid Stenting With and Without Cerebral Protection

Psychological impact of carotid endarterectomy: A review of the studies

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