title: Longitudinal evaluation of neurobehavioral outcomes after carotid revascularization.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina. Electronic address: matthewcorriere@gmail.com.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Corriere
authors.affiliation: Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Edwards
authors.affiliation: Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
authors.forename: Carol P
authors.initials: CP
authors.lastname: Geer
authors.affiliation: Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
authors.forename: Donna R
authors.initials: DR
authors.lastname: Keith
authors.affiliation: Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
authors.forename: Dwight D
authors.initials: DD
authors.lastname: Deal
authors.affiliation: Departments of Vascular and Endovascular Surgery, Radiology, Cardiothoracic Surgery and Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
authors.forename: David A
authors.initials: DA
authors.lastname: Stump
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D002560:Cerebrovascular Circulation; D003071:Cognition; D003072:Cognition Disorders / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000523:psychology; D038524:Diffusion Magnetic Resonance Imaging; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D011446:Prospective Studies; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome