Does Carotid Endarterectomy Provide Benefits in Cognitive Functions in Patients With Severe Extracranial Cerebrovascular Disease?

This prospective study intends to determine the effect of carotid endarterectomy (CEA) on cognitive performance in patients with severe extracranial cerebrovascular disease (ECD). Between November 2021 and May 2023, 29 consecutive symptomatic and asymptomatic patients with ECD qualified for CEA were assessed. Twenty-four patients were prospectively enrolled to evaluate cognitive performance before/after CEA (Fig 1). Patient characteristics are shown in Table 1. ECD was documented by duplex ultrasound according to NASCET criteria, and confirmed by CT angiography, or MR angiography. Exclusion criteria included: psychiatric comorbidity, brain injury, or surgery and medical systemic disease that can affect the cognitive function. Indication for CEA was established according to current guidelines and performed under general anesthesia using standard protocols. The cognitive performance was evaluated using the Mini-mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) and carried out before and after CEA (1-3 months, respectively). Statistical analysis was performed using Student t-test for paired samples and carried out independently for the sets of data pertaining each of the domains tested (Excel 18.0 software, 2021). P value <.05 was considered as statistically significant. Statistically significant pre/post difference was observed in all the group of patients (MoCA: P = .0001; MMSE: P = .0414). Neurological assessment improved in two of seven domains tested in MoCa: "attention" (P = .0079) and "abstraction" (P = .0414), whereas in the sub score of MMSE, only "registration" improved (P = .0213) (Table 2). When the patients were analyzed according to symptomatology, we noted that symptomatic patients evaluated with MoCA, improved remarkably (P = .0040) but we observed no difference between the pre and post scoring with MMSE (P = .0819) (Table 3). In the group of asymptomatic patients, although we detected improvement of total scale index (MoCA: P = .0055; MMSE: P = .0232), the difference between each domain point tested could not be statistically demonstrated (P > .05) (Table 4). Our findings showed that CEA could improve cognitive performance in patients with significant ECD. Although, some variables associated ("practice effect," learning, anxiety) could not have been considered, post intervention performance resulted better in several domains. Both symptomatic and asymptomatic patients reflected positive changes after surgery. In the asymptomatic group, statistical differences tested by domains could not be demonstrated. The strengths of this study include a prospective evaluation and estimate of cognitive performance with two versions of neurological tests. However, the number of patients who were enrolled in this study was small. Larger sample size and longer follow-up should be performed. Table IPatient characteristics (n = 23)Demographics Age, years65.8 ± 6.69 GenderMale19 (83)Female4 (17)Risk factors Hypertension22 (96) Diabetes6 (26) Hyperlipemia22 (96) Current smoker2 (9) Ex-smoker19 (83) No smoker2 (9) Cardiac disease3 (13) PAD2 (9)Carotid stenosis features Right > 70%9 (39) Left > 70%14 (61) Contralateral stenosis4 (17) Vertebral stenosis1 (4)Clinical presentation Symptomatic16 (70)Stroke12 (75)Amaurosis fugax3 (19)TIA1 (6)Type of lesionUnilateral15 (94)Contralateral1 (6)Side of operationRight6 (37)Left10 (63) Asymptomatic7 (30)Unilateral stenosis (>70%)3 (43)Contralateral stenosis (50 - 69%)3 (43)Ulcer plaque1 (14)Side of operationRight4 (57)Left3 (43)PAD, Peripheral artery disease.Data are means ± standard deviation or number of cases and percentage in brackets. Open table in a new tab Table IIChange of cognitive function before and after surgery: all patients (N = 23)Cognitive domainPre CEAPost CEAP valueMoCA Visuospatial/ construction3.30 (4) (±1.10)3.47 (4) (±1.08).1786 Naming2.82 (3) (±0.49)2.82 (3) (±0.65).5 Attention4.52 (4.5) (±0.84)4.82 (5) (±0.93).0079 Language2.47 (3) (±0.94)2.73 (3) (±0.61).0152 Abstraction1.86 (2) (±0.34)2 (2) (+/0).0414 Delay recall1.52 (1) (±1.95)1.30 (1) (±1.18).2794 Orientation5.73 (6) (±0.54)5.86 (6) (±0.45).0927 Total21.95 (22) (±2.91)23.04 (23) (±2.65).0001MMSE Copying0.91 (1) (±0.28)0.95 (1) (±0.20).1640 Registration2.91 (3) (±0.41)3.08 (3) (±0.20).0213 Attention and calculation3.69 (4) (±1.06)3.65 (4) (±1.07).1640 Language6.17 (6) (±0.65)6.26 (6) (±0.68).1640 Recall1.95 (2) (±0.20)2.04 (2) (±0.20).0809 Orientation7.34 (7) (±1.11)7.43 (8) (±1.12).0809 Total23 (23) (±2.69)23.21 (24) (±2.64).0414CEA, Carotid endarterectomy; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment.Baseline: mean (median) (± standard deviation). Open table in a new tab Table IIIChange of cognitive function before and after surgery: symptomatic group (n = 16)Cognitive domainPre CEAPost CEAP valueMoCA Visuospatial/ construction3.25 (4) (± 1)3.31 (3.5) (±0.94).3591 Naming2.93 (3) (± 0.25)3 (3) (0).1665 Attention4.56 (4.5) (±0.81)4.87 (5) (±0.88).0098 Language2.5 (3) (± 1.03)2.62 (3) (±0.71).0819 Abstraction1.93 (2) (±0.25)2 (2) (0).1665 Delay recall1.25 (1) (±1.12)1.37 (1) (±1.25).0819 Orientation5.68 (6) (± 0.60)5.87 (6) (±0.5).0412 Total22.12 (22.5) (±3.18)23 (23) (±2.75).0040MMSE Copying0.93 (1) (±0.25)1 (1) (±0.36).1665 Registration2.87 (3) (±0.34)2.93 (3) (±0.25).1665 Attention and calculation3.68 (4) (±1.19)3.62 (4) (±1.20).1665 Language6.18 (6) (±0.65)6.25 (6) (±0.68).1665 Recall1.93 (2) (±0.25)2.06 (2) (±0.25).0819 Orientation7.25 (7) (±1.29)7.37 (8) (±1.31).0819 Total22.75 (23) (±3.15)23 (23.5) (±3.05).0819CEA, Carotid endarterectomy; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment.Baseline: mean (median) (± standard deviation). Open table in a new tab Table IVChange of cognitive function before and after surgery: asymptomatic group (n = 7)Cognitive domainPre CEAPost CEAP valueMoCA Visuospatial/ construction3.42 (4) (±1.39)3.85 (4) (±1.34).2035 Naming2.57 (3) (±0.78)2.57 (3) (±1.13).5 Attention4.42 (4) (±0.97)4.71 (5) (±1.11).1779 Language2.42 (3) (±0.78)3 (3) (±0).0515 Abstraction1.71 (2) (±0.48)2 (2) (±0).0861 Delay recall2.07 (2) (±3.18)1.14 (1) (±1.06).2174 Orientation5.85 (6) (±0.37)5.85 (6) (±0.37).5 Total21.57 (22) (±2.37)23.28 (23) (±2.36).0055MMSE Copying0.85 (6) (±0.37)1 (1) (±0).1779 Registration2.71 (3) (±0.48)2.85 (3) (±0.37).1779 Attention and calculation3.57 (4) (±0.78)3.71 (4) (±0.75).1779 Language6.14 (6) (±0.69)6.28 (6) (±0.75).3018 Recall1.85 (2) (±0.37)2 (2) (±0).1779 Orientation7.42 (7) (±0.53)7.57 (8) (±0.53).1779 Total22.71 (22) (±1.70)23.42 (24) (±1.71).0232CEA, Carotid endarterectomy; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment.Baseline: mean (median) (± standard deviation). Open table in a new tab