Cognitive Effects After Carotid

Intervention: Can Patients Actually Have

Improved Function?

Wei Zhou, MD

Professor and Chief, Division of Vascular Surgery

University of Arizona

Banner University Medical Center

Disclosures

Grant funding

– AHA: CRP

– NIH NINDS

NIH R01: Cognitive effect of microemboli following CAS

NIH R21: Neuroimaging correlates of memory decline following carotid interventions

Cognition

3

- “A Problem for Our Age”

CVH Study: Cognitive

impairment and decline

Worse information-

processing speed,

executive function, and

global cognition

Stroke 2009; 40(5):1590-6

Higher silence

infarcts, larger white

matter hyper-intensity,

poorer executive

function

Carotid Disease and Cognition

Perform worse on

cognitive

measures

Perfusion

6

16.5% had embolic signals at baseline

> 40% of asymptomatic lesions have embolic signal during a follow-up of 4 years

Arch Neurol, 2010

Best medical therapy improves baseline microemboli 12.6%3.7%

Am J Psychiatry 2012

Carotid Revascularization

and Cognition

- Stroke 2011

Memory Changes

MMSE Changes

Carotid Interventions

26%

Improved

Declined

39%

Procedure-related Embolization

Subclinical microembolization

– common (25-70%), 3x more following carotid stenting

than carotid endarterectomy

– Not associated w/neurologic symptoms

Subclinical Embolization

Table I: Neuropsychological tests to evaluate cognitive function

Cognitive domains Tests

Individual Difference/General Screen

IQ estimate WTAR

General Functioning MMSE

Depression GDS (15 item)

Attention/Executive/Speed

Psychomotor speed Digit Symbol subtest (WAIS-III)

Psychomotor speed Trail Making Test (Part A)

Executive Trail Making Test (Part B)

Attention/Working Memory Digit Span subtest (WMS-III)

Attention/Working Memory/Executive

Letter/Number Span (WMS-III)

Motor speed and strength

Grooved Pegboard Task

Memory

Verbal Logical Memory subtest (WMS-III)

Verbal RAVLT

Visual Faces subtest (WMS-III)

Visuospatial Function

Clock Drawing

Language

Executive/language Category Fluency

Confrontation Naming Boston Naming Test (CERAD 15 item)

Regions implicated in executive

control, mental speed, and memory

- Rosen..Zhou et al, Neuroimage: Clinical, 2018

JVS 2012; 56: 1571-8

p = 0.05

No emboliN=35

With EmboliN=45

Δ S

core

Microemboli correlate with memory

(RAVLT) decline at one month postopJVS2016

Decline @ 1 mo,

recovered @ 6 mo

Improvement

Decline

CEA vs. CAS

*

JVS2017

Stroke 2012; 43:2567-

73

Baseline Brain Organization

Decliners

Community1&Component1

Community2

Community3&Component2

Community4&Component3

Non-Decliners

Community1

Community3Community2&Component1

Soman et al, Human Brain Mapping 37: 2185-94

Ann Surgery 2016, 264

Summary

Carotid disease affects cognition

Carotid intervention may have a positive or

negative effect on cognition. Need to

select right therapy for right lesion