Cognitive Impairement in Internal Carotid Artery Stenosis and the Influence of Therapeutical Interventions

Authors: D. Hořínek 1,4;  B. Urbanová 2;  D. Netuka 1;  S. Ostrý 1;  M. Vyhnálek 2;  M. Mohapl 1;  M. Bojar 2;  F. Charvát 3;  V. Beneš 1
Authors‘ workplace: Neurochirurgická klinika 1. LF UK a ÚVN Praha 1;  Neurologická klinika dospělých 2. LF UK a FN v Motole, Praha 2;  Radiodiagnostické oddělení ÚVN Praha 3;  FN u sv. Anny, Mezinárodní centrum klinického výzkumu, Brno 4
Published in: Cesk Slov Neurol N 2011; 74/107(3): 254-259
Category: Review Article


The paper reviews the literature on cognitive impairment in patients with internal carotid artery (ICA) stenosis, its possible causes and the influence of therapeutic interventions (carotid endarterectomy and carotid artery stenting – CEA and CAS) on cognitive function. The studies published are heterogenous in terms of patient samples, methods and results. There is a moderate evidence that ICA stenosis is an independent risk factor in cognitive impairment. Possible mechanisms influencing cognitive function are embolization and hypoperfusion. One recent hypothis is that cognitive dysfunction is related to impairment of cerebral haemodynamics rather than to structural changes arising out of embolization. The results of multicentre studies assessing the influence of therapeutic interventions on cognitive function have been inconclusive. The current state of knowledge is not sufficient to have any impact on indications for therapy.

Key words:
carotid artery disease – cognitive disorders – carotid artery stenting – carotid endarterectomy – intracranial embolism – hypoxia-ischemia of the brain


1. O’Leary DH, Polak JF, Kronmal RA, Kittner SJ, Bond MG, Wolfson SK jr et al. Distribution and correlates of sonographically detected carotid artery disease in the Cardiovascular Health Study. The CHS Collaborative Research Group. Stroke 1992; 23(12): 1752–1760.

2. Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN et al. Carotid endarterectomy – an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65(6): 794–801.

3. Hachinski V, Munoz DG. Cerebrovascular pathology in Alzheimer’s disease: cause, effect or epiphenomenon? Ann NY Acad Sci 1997; 826: 1–6.

4. Rockwood K, Wentzel C, Hachinski V, Hogan DB, MacKnight C, McDowell I. Prevalence and outcomes of vascular cognitive impairment. Vascular Cognitive Impairment Investigators of the Canadian Study of Health and Aging. Neurology 2000; 54(2): 447–451.

5. Sonková Z, Svátová K, Kemlink D, Kalina M, Sebesta P, Sonka K. Sleep apnea in carotid stenosis. Neuro Endocrinol Lett 2009; 30(1): 61–66.

6. Tatemichi TK, Desmond DW, Stern Y, Paik M, Sano M, Bagiella E. Cognitive impairment after stroke: frequency, patterns, and relationship to functional abilities. J Neurol Neurosurg Psychiatry 1994; 57(2): 202–207.

7. Desmond DW, Moroney JT, Sano M, Stern Y. Incidence of dementia after ischemic stroke. Stroke 2002; 33(9): 2254–2260.

8. Johnston SC, O‘Meara ES, Manolio TA, Lefkowitz D, O‘Leary DH, Goldstein S et al. Cognitive impairment and decline are associated with carotid artery disease in patients without clinically evident cerebrovascular disease. Ann Intern Med 2004; 140(4): 237–247.

9. Mathiesen EB, Waterloo K, Joakimsen O, Bakke SJ, Jacobsen EA, Banaa KH. Reduced neuropsychological test performance in asymptomatic carotid stenosis: The Tromsø Study. Neurology 2004; 62(5): 695–701.

10. Bakker FC, Klijn CJ, Jennekens-Schinkel A, van der Tweel I, Tulleken CA, Kappelle LJ. Cognitive impairment in patients with carotid artery occlusion and ipsilateral transient ischemic attacks. J Neurol 2003; 250(11): 1340–1347.

11. Bakker FC, Klijn CJ, Jennekens-Schinkel A, Kappelle LJ. Cognitive disorders in patients with occlusive disease of the carotid artery: a systematic review of the literature. J Neurol 2000; 247(9): 669–676.

12. Kelly MP, Kaszniak AW, Garron DC. Neurobehavioral impairment patterns in carotid disease and Alzheimer disease. Intern J Clin Neuropsychol 1986; 8(4): 163–169.

13. Younkin D, Hungerbuhler JP, O’Connor M, Goldberg H, Burke A, Kushner M et al. Superficial temporal middle cerebral artery anastomosis: effects on vascular, neurologic, and neuropsychological functions. Neurology 1985; 35(4): 462–469.

14. Iddon JL, Sahakian BJ, Kirkpatrick PJ. Uncomplicated carotid endarterectomy is not associated with neuropsychological impairment. Pharmacol Biochem Behav 1997; 56(4): 781–787.

15. van den Burg W, Saan RJ, Van Zomeren AH, Boontje AH, Haaxma R, Wichmann TE. Carotid endarterectomy: does it improve cognitive or motor functioning? Psychol Med 1985; 15(2): 341–346.

16. Bakker FC, Klijn CJ, Jennekens-Schinkel A, van der Tweel I, van der Grond J, van Huffelen AC et al. Cognitive impairment is related to cerebral lactate in patients with carotid artery occlusion and ipsilateral transient ischemic attacks. Stroke 2003; 34(6): 1419–1424.

17. Heyer EJ, Adams DC, Solomon RA, Todd GJ, Quest DO, McMahon DJ et al. Neuropsychometric changes in patients after carotid endarterectomy. Stroke 1998; 29(6): 1110–1115.

18. Heyer EJ, Sharma R, Rampersad A, Winfree CJ, Mack WJ, Solomon RA et al. A controlled prospective study of neuropsychological dysfunction following carotid endarterectomy. Arch Neurol 2002; 59)2): 217–222.

19. De Rango P, Caso V, Leys D, Paciaroni M, Lenti M, Cao P. The role of carotid artery stenting and carotid endarterectomy in cognitive performance: a systematic review. Stroke 2008; 39(11): 3116– 3127.

20. Crawley F, Stygall J, Lunn S, Harrison M, Brown MM, Newman S. Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke 2000; 31(6): 1329–1334.

21. Sivaguru A, Gaines PA, Beard J, Venables GS. Neuropsychological outcome after carotid angioplasty: a randomised control trial. J Neurol Neurosurg Psychiatry 1999; 66 (Suppl): 262.

22. Witt K, Borsch K, Daniels C, Walluscheck K, Alfke K, Jansen O et al. Neuropsychological consequences of endarterectomy and endovascular angioplasty with stent placement for treatment of symptomatic carotid stenosis. A prospective randomized study. J Neurol 2007; 254(11): 1524–1532.

23. Antonelli Incalzi R, Gemma A, Landi F, Pagano F, Capparella O, Snider F, Manni R, et al. Neuropsychologic effects of carotid endarterectomy. J Clin Exp Neuropsychol 1997; 19(6): 785–794.

24. Lehrner J, Willfort A, Milekush I, Guttmann G, Minar E, Ahmadi R et al. Neuropsychological outcome 6 months after unilateral carotid stenting. J Clin Exp Neuropsychol 2005; 27(7): 859–866.

25. Moftakhar R, Turk AS, Niemann DB, Hussain S, Rajpal S, Cook T et al. Effects of carotid or vertebrobasilar stent placement on cerebral perfusion and cognition. AJNR Am J Neuroradiol 2005; 26(7): 1772–1780.

26. Grunwald IQ, Supprian T, Politi M, Struffert T, Falkai P, Krick C et al. Cognitive changes after carotid artery stenting. Neuroradiology 2006; 48(5): 319–323.

27. Xu G, Liu X, Meyer JS, Yin Q, Zhang R. Cognitive performance after carotid angioplasty and stenting with brain protection devices. Neurol Res 2007; 29(3): 251–255.

28. Mocco J, Wilson DA, Komotar RJ, Zurica J, Mack WJ, Halazun HJ et al. Predictors of neurocognitive decline after carotid endarterectomy. Neurosurgery 2006; 58(5): 844–850.

29. Braekken SK, Reinvang I, Russell D, Brucher R, Svennevig JL. Association between intraoperative cerebral microembolic signals and postoperative neuropsychological deficit: comparison between patients with cardiac valve replacement and patients with coronary artery bypass grafting. J Neurol Neurosurg Psychiatry 1998; 65(4): 573–576.

30. Sylivris S, Levi C, Matalanis G, Rosalion A, Buxton BF, Mitchell A et al. Pattern and significance of cerebral microemboli during coronary artery bypass grafting. Ann Thorac Surg 1998; 66(5): 1674–1678.

31. Connolly ES jr, Winfree CJ, Rampersad A, Sharma R, Mack WJ, Mocco J et al. Serum S100B protein levels are correlated with subclinical neurocognitive declines after carotid endarterectomy. Neurosurgery 2001; 49(5): 1076–1082.

32. Heyer EJ, DeLaPaz R, Halazun HJ, Rampersad A, Sciacca R, Zurica J et al. Neuropsychological dysfunction in the absence of structural evidence for cerebral ischemia after uncomplicated carotid endarterectomy. Neurosurgery 2006; 58(3): 474–480.

33. Kishikawa K, Kamouchi M, Okada Y, Inoue T, Ibayashi S, Iida M. Effects of carotid endarterectomy on cerebral blood flow and neuropsychological test performance in patients with high-grade carotid stenosis. J Neurol Sci 2003; 213(1–2): 19–24.

34. Purandare N, Burns A, Daly KJ, Hardicre J, Morris J, Macfarlane G et al. Cerebral emboli as a potential cause of Alzheimer’s disease and vascular dementia: case–control study. BMJ 2006; 332(7550): 1119–1124.

35. Naylor AR, Merrick MV, Gillespie I, Sandercock PAG, Warlow CP, Cull RE et al. Prevalence of impaired cerebrovascular reserve in patients with symptomatic carotid artery disease. Br J Surg 1994; 81(1): 45–48.

36. Nielsen H, Hojer-Pedersen E, Gulliksen G, Haase J, Enevoldsen E. Reversible ischemic neurological deficit and minor strokes before and after EC/IC bypass surgery: a neuropsychological study. Acta Neurol Scand 1986; 73(6): 615–618.

37. Binder LM, Tanabe CT, Waller FT, Wooster NE. Behavioral effects of superficial temporal artery to middle cerebral artery bypass surgery: preliminary report. Neurology 1982; 32(4): 422–424.

38. Drinkwater JE, Thompson SK, Lumley JS. Cerebral function before and after extra-intracranial carotid bypass. J Neurol Neurosurg Psychiatry 1984; 47(9): 1041–1043.

39. Sasoh M, Ogasawara K, Kuroda K, Okuguchi T, Terasaki K, Yamadate K et al. Effects of EC-IC bypass surgery on cognitive impairment in patients with hemodynamic cerebral ischemia. Surg Neurol 2003; 59(6): 455–460.

40. Silvestrini M, Paolino I, Vernieri F, Pedone C, Baruffaldi R, Gobbi B et al. Cerebral hemodynamics and cognitive performance in patients with asymptomatic carotid stenosis. Neurology 2009; 72(12): 1062–1068.

41. Fearn SJ, Hutchinson S, Riding G, Hill-Wilson G, Wesnes K, McCollum CN. Carotid endarterectomy improves cognitive function in patients with exhausted cerebrovascular reserve. Eur J Vasc Endovasc Surg 2003; 26(5): 529–536.

42. Kwan LT, Reed BR, Eberling JL, Schuff N, Tanabe J, Norman D et al. Effects of subcortical cerebral infarction on cortical glucose metabolism and cognitive function. Arch Neurol 1999; 56(7): 809–814.

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