Corriere Matthew A, Edwards Matthew S, Geer Carol P, Keith Donna R, Deal Dwight D, Stump David A
Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Ann Vasc Surg. 2014 May;28(4):874-81. doi: 10.1016/j.avsg.2013.06.032. Epub 2013 Nov 1.
Carotid revascularization, including carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), is performed for stroke risk reduction but may also impact cognitive function. Cognitive outcomes observed after carotid revascularization have been inconsistent, and mechanistic relationships with procedural factors are poorly understood. To further explore associations between carotid revascularization and cognitive outcomes, a prospective longitudinal evaluation was conducted of patients undergoing elective CEA or CAS for hemodynamically significant carotid stenosis.
Patients undergoing primary carotid artery revascularization for hemodynamically significant stenosis were evaluated with neurologic and neuropsychological testing at baseline and at 1 and 6 months after revascularization. A subgroup of patients was also studied with baseline and postoperative magnetic resonance imaging (MRI). Outcomes included neurologic or neuropsychological deficits and imaging findings (including quantitative assessment of cerebral blood flow).
Sixteen patients underwent carotid revascularization with both preoperative and postoperative neurologic and neuropsychological testing; preoperative and postoperative MRIs were also performed on eight patients. Five of 16 treated carotid lesions (31%) were considered symptomatic, and severity of carotid stenosis was 60-79% for 6 of 16 lesions and 80% or more in all others. A single perioperative neurologic deficit was identified; all other patients (15/16) had no abnormalities detected by neurologic examination. Neuropsychological testing identified new postoperative deficits in 3 patients (19%), among whom 2 had a normal neurologic examination at all time points, whereas 1 had clinical evidence of stroke. Quantitative analysis of mean cerebral blood flow revealed postrevascularization increases for both gray matter (48.6 ± 13.9 mL per 100 g/min vs 75.3 ± 70.8 mL per 100 g/min) and white matter (31.8 ± 10.6 mL per 100 g/min vs 55.2 ± 30.1 mL per 100 g/min)(P = 0.04). New postoperative MRI foci of restricted diffusion were identified in 2 patients, both of whom had no neurologic or neuropsychological deficit. Among patients with postoperative neuropsychological deficits, MRI revealed globally increased cerebral perfusion without new postoperative abnormalities in 2 of 3.
The relationship between carotid revascularization and cognitive function is complex, and cognitive deficits may occur in the presence of increased cerebral perfusion without detectable embolization.
颈动脉血运重建术，包括颈动脉内膜切除术（CEA）和颈动脉血管成形术及支架置入术（CAS），旨在降低中风风险，但也可能影响认知功能。颈动脉血运重建术后观察到的认知结果并不一致，且与手术因素的机制关系尚不清楚。为进一步探讨颈动脉血运重建术与认知结果之间的关联，对因血流动力学显著的颈动脉狭窄而接受择期CEA或CAS的患者进行了一项前瞻性纵向评估。
对因血流动力学显著狭窄而接受原发性颈动脉血运重建术的患者在基线时以及血运重建术后1个月和6个月进行神经学和神经心理学测试。还对一组患者进行了基线和术后磁共振成像（MRI）检查。结果包括神经学或神经心理学缺陷以及影像学表现（包括脑血流量的定量评估）。
16例患者接受了颈动脉血运重建术，并进行了术前和术后神经学及神经心理学测试；8例患者还进行了术前和术后MRI检查。16个接受治疗的颈动脉病变中有5个（31%）被认为有症状，16个病变中有6个的颈动脉狭窄严重程度为60%-79%，其他所有病变的狭窄程度均为80%或更高。确定了1例围手术期神经学缺陷；所有其他患者（15/16）经神经学检查未发现异常。神经心理学测试发现3例患者（19%）术后出现新的缺陷，其中2例在所有时间点的神经学检查均正常，而1例有中风的临床证据。脑血流量平均值的定量分析显示，血运重建术后灰质（每100 g/min 48.6±13.9 mL对75.3±70.8 mL）和白质（每100 g/min 31.8±10.6 mL对55.2±30.1 mL）均增加（P = 0.04）。2例患者术后MRI出现新的扩散受限灶，这2例患者均无神经学或神经心理学缺陷。在术后有神经心理学缺陷的患者中，MRI显示3例中有2例脑灌注整体增加，术后无新的异常。
颈动脉血运重建术与认知功能之间的关系很复杂，在脑灌注增加且无可检测到的栓塞的情况下可能会出现认知缺陷。
