Zhou Wei, Baughman Brittanie D, Soman Salil, Wintermark Max, Lazzeroni Laura C, Hitchner Elizabeth, Bhat Jyoti, Rosen Allyson
Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif; Department of Surgery, Stanford University, Stanford, Calif.
Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif.
J Vasc Surg. 2017 Mar;65(3):686-694. doi: 10.1016/j.jvs.2016.09.057. Epub 2016 Dec 23.
Carotid intervention is safe and effective in stroke prevention in appropriately selected patients. Despite minimal neurologic complications, procedure-related subclinical microemboli are common and their cognitive effects are largely unknown. In this prospective longitudinal study, we sought to determine long-term cognitive effects of embolic infarcts.
The study recruited 119 patients including 46% symptomatic patients who underwent carotid revascularization. Neuropsychological testing was administered preoperatively and at 1 month, 6 months, and 12 months postoperatively. Rey Auditory Verbal Learning Test (RAVLT) was the primary cognitive measure with parallel forms to avoid practice effect. All patients also received 3T brain magnetic resonance imaging with a diffusion-weighted imaging (DWI) sequence preoperatively and within 48 hours postoperatively to identify procedure-related new embolic lesions. Each DWI lesion was manually traced and input into a neuroimaging program to define volume. Embolic infarct volumes were correlated with cognitive measures. Regression models were used to identify relationships between infarct volumes and cognitive measures.
A total of 587 DWI lesions were identified on 3T magnetic resonance imaging in 81.7% of carotid artery stenting (CAS) and 36.4% of carotid endarterectomy patients with a total volume of 29,327 mm. Among them, 54 DWI lesions were found in carotid endarterectomy patients and 533 in the CAS patients. Four patients had transient postoperative neurologic symptoms and one had a stroke. CAS was an independent predictor of embolic infarction (odds ratio, 6.6 [2.1-20.4]; P < .01) and infarct volume (P = .004). Diabetes and contralateral carotid severe stenosis or occlusion had a trend of positive association with infarct volume, whereas systolic blood pressure ≥140 mm Hg had a negative association (P = .1, .09, and .1, respectively). There was a trend of improved RAVLT scores overall after carotid revascularization. Significantly higher infarct volumes were observed among those with RAVLT decline. Within the CAS cohort, infarct volume was negatively correlated with short- and long-term RAVLT changes (P < .05).
Cognitive assessment of procedure-related subclinical microemboli is challenging. Volumes of embolic infarct correlate with long-term cognitive changes, suggesting that microembolization should be considered a surrogate measure for carotid disease management.
对于经过适当选择的患者，颈动脉介入治疗在预防卒中方面安全有效。尽管神经学并发症极少，但与手术相关的亚临床微栓子很常见，其对认知的影响很大程度上未知。在这项前瞻性纵向研究中，我们试图确定栓塞性梗死的长期认知影响。
该研究招募了119例患者，其中46%为有症状患者，均接受了颈动脉血运重建术。术前以及术后1个月、6个月和12个月进行神经心理学测试。雷伊听觉词语学习测验（RAVLT）是主要的认知测量方法，采用平行版本以避免练习效应。所有患者术前及术后48小时内均接受3T脑磁共振成像检查，采用弥散加权成像（DWI）序列以识别与手术相关的新栓塞性病变。每个DWI病变均手动追踪并输入神经影像程序以确定体积。栓塞性梗死体积与认知测量结果相关。采用回归模型确定梗死体积与认知测量结果之间的关系。
在接受颈动脉支架置入术（CAS）的患者中，81.7%以及接受颈动脉内膜切除术的患者中，36.4%在3T磁共振成像上共发现587个DWI病变，总体积为29327立方毫米。其中，颈动脉内膜切除术患者中发现54个DWI病变，CAS患者中发现533个。4例患者术后出现短暂性神经学症状，1例发生卒中。CAS是栓塞性梗死（优势比，6.6[2.1 - 20.4]；P <.01）和梗死体积（P =.004）的独立预测因素。糖尿病以及对侧颈动脉严重狭窄或闭塞与梗死体积呈正相关趋势，而收缩压≥140毫米汞柱则呈负相关（分别为P =.1、.09和.1）。颈动脉血运重建术后总体RAVLT评分有改善趋势。RAVLT评分下降者中观察到梗死体积明显更高。在CAS队列中，梗死体积与RAVLT短期和长期变化呈负相关（P <.05）。
对与手术相关的亚临床微栓子进行认知评估具有挑战性。栓塞性梗死体积与长期认知变化相关，这表明微栓塞应被视为颈动脉疾病管理的替代指标。
