Florina Antochi

Microemboli detection in patients with carotid artery stenting — A potential marker for future cognitive impairment?

AIMS To monitor the long-term cognitive function evolution of patients undergoing carotid artery stenting (CAS), using detection of embolic signals (ES) as a potential marker of cognitive decline. METHODS This is an ongoing prospective nonrandomized single-center study of patients undergoing carotid artery angioplasty and stenting using standard techniques. Neurologic status is evaluated by history, physical examination and the National Institutes of Health Stroke Scale. A complete Doppler-ultrasound investigation of the brain-supplying arteries has been performed in every patient. A 45minute cognitive battery designed to assess motor speed/coordination and executive function, psychomotor speed, language (naming), working memory/concentration, verbal fluency, and learning/memory is performed by a certified neuropsychologist in the first week after CAS and repeated a year after the procedure. Each patient undergoes bilateral ultrasonographic-Doppler monitoring of the middle cerebral artery (MCA) for microemboli detection. The patients are monitored during the first week after CAS and again a year after stenting. RESULTS 32 patients were included. The mean baseline Mini-Mental State Examination (MMSE) score was 28.7 points. During the first ultrasonographic monitoring 28 patients (87.5%) had at least three times more ES detected on the stented side (a mean of 24ES/30minutes was detected in the stented side compared to a mean of 4ES/30min in the non-stented side). At the one-year follow-up 68% of the patients who have undergone CAS maintain a high number of ES detected in the territory of the stented carotid artery, finding that is well correlated with the cognitive decline in those patients, as assessed by the MMSE score. CONCLUSIONS ES detection is a useful tool for predicting cognitive decline that can be used to monitor CAS patients and adjust preventive measures in order to avoid progression of vascular cognitive impairment. It is important that further studies comparing carotid endarterectomy and CAS monitor long-term cognitive function outcome.

Neurocognitive disorders in DSM 5 project — Personal comments

The actual criteria for diagnosis of dementia have many shortages, due to the fact that both DSM 4 and ICD 10 criteria are essentially based on the typical evolution of Alzheimers disease, which is the most frequent, but not the only one cause of dementia in the general population. In the new project of DSM-5, proposed for public debate by the American Psychiatric Association (APA), new criteria for neurocognitive disorders are defined which seem more suitable to cover in a much more appropriate way all the entities potentially leading to dementia. In our view, these new criteria are also in line with the updated knowledge about these diseases as they are reflected in the recent publications and recommendations of international experts and medical associations.

Cervico-cerebral Arteries Dissection

Cervico-cerebral arteries dissection is probably an underdiagnosed cause of stroke, even nowadays, but the new high-resolution imaging could help to increase the accurate diagnosis of arterial wall damage. The trauma of the head and neck, even minor, and/or an underlying arteriopathy are the most frequent causative factors, especially in young adults with arterial dissections.

Carotid Angioplasty and Stenting

Carotid angioplasty and stenting represent a good choice and alternative for patients with significant hemodynamic carotid stenosis in secondary prevention of stroke, in experienced centers, and supervised by a team made of neurologist, interventional neuroradiologist, and vascular surgeon. Our results encouraged us to continue this endovascular technique to reduce the incidence of recurrent stroke and mortality, with careful selection of patients.