Original title: Association of the Recovery of Objective Abnormal CerebralPerfusion with Neurocognitive Improvement after CarotidRevascularization. Reference: Ching-Chang Huanget al. J Am CollCardiol 2013. Article in press.
Cognitive impairment was observed in patients with severe asymptomatic carotid injury but a possible explanation for this is hyper-perfusion. Intuitively restored flow may improve neurocognitive capacity but so far studies have been inconsistent.
This study included 61 consecutive patients with severe carotid lesions or total occlusions, all of them underwent perfusion CT and a battery of neuropsychological tests before and three months after carotid intervention. The CT analyzed the volume and cerebral blood flow, peak time and mean transit time. Of the 61 patients studied, 22 had chronic total occlusion and 39 severe injury of the internal carotid. CT showed insufficient perfusion in all the patients who had total occlusion and 20 of the 39 with severe injury.
Technical success was achieved in 14 of the 22 total occlusions, (64%), and in all the severe injuries. The reason for failures in the total occlusions was the impossibility of reaching the distal bed with the guide. One patient with total occlusion developed hemorrhagic stroke five hours after successful recanalization, possibly due to hyper-perfusion. One patient with asymptomatic severe injury suffered an ischemic stroke and required thrombolysis. Both patients were discharged and excluded from subsequent neurocognitive assessments.
For the analysis, patients were divided into three groups based on the result of the CT and the procedure. Group 1 (n = 8) patients with abnormal perfusion and failed angioplasty, Group 2 (n = 33) with abnormal perfusion and successful angioplasty and Group 3 (n = 18) with normal perfusion and successful angioplasty. There were no significant differences in the baseline results of neurocognitive tests among the three groups. After angioplasty, no changes in the result of neurocognitive tests or brain perfusion were observed in either group 1 or 3. Conversely, there were significant improvements both in neurocognitive tests and cerebral perfusion tomography in group 2.
Conclusion:
Successful carotid angioplasty improves neurocognitive function in those patients who had objectified abnormal ipsilateral cerebral perfusion. The improvement in cognition correlates well with improvement in perfusion.
Commentary:
Group 1 functions as an ideal control since its baseline did not differ with the rest and it was also exposed to the risk of the procedure. The tests investigated different areas of cognition and several of them must be performed in order to get an overall idea but this has the limitation that it can become very tedious for patients. Besides perfusion tomography, metabolic imaging can be performed with 18F-fluorodeoxyglucose to help anatomically correlate reperfusion and recover specific cortical functions after angioplasty. The improvement in cognition must be counterbalanced with the complications inherent in the procedure (in this case, an ischemic stroke and hemorrhagic stroke).
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