Cognitive Dysfunction and Mortality After Carotid Endarterectomy

Kristiina Relander,Krista Nuotio,Eija Saimanen,Petra Ijäs,Perttu J Lindsberg,Marja Hietanen,Irene Tikkala,Lauri Soinne

doi:10.3389/fneur.2020.593719

Abstract

Background: Carotid endarterectomy (CEA) has been associated with both postoperative cognitive dysfunction (POCD) and improvement (POCI). However, the prognostic significance of postoperative cognitive changes related to CEA is largely unknown. The aim of this study was to examine the associations between postoperative cognitive changes after CEA and long-term survival.Methods: We studied 43 patients 1 day before CEA as well as 4 days and 3 months after surgery with an extensive neuropsychological test array, and followed them for up to 14 years. POCD and POCI relative to baseline were determined with the reliable change index derived from 17 healthy controls. Associations between POCD/POCI and mortality within the patient group were studied with Cox regression analyses adjusted for confounders.Results: POCD in any functional domain was evident in 28% of patients 4 days after surgery and in 33% of patients 3 months after surgery. POCI was shown in 23% of patients at 4 days and in 44% of patients at 3 months. POCD at 3 months was associated with higher long-term mortality (hazard ratio 5.0, 95% CI 1.8–13.9, p = 0.002) compared with patients with no cognitive decline.Conclusions: Our findings suggest that POCD in a stable phase, 3 months after CEA predicts premature death. Evaluation of postoperative cognitive changes is essential, and POCD in a stable phase after CEA should prompt scrutiny of underlying factors and better adherence to therapies to prevent recurrences and to promote early intervention in imminent deterioration.

Highlights

Carotid endarterectomy (CEA) is an effective treatment for symptomatic [1, 2] and asymptomatic [3] high-grade carotid stenosis to prevent stroke, but findings on the cognitive consequences of CEA are strikingly mixed
Cognitive functioning in an early postoperative phase can be obscured by surgery-related factors, such as medication, postoperative pain and emotional stress, for which postoperative cognitive dysfunction (POCD) is more reliably defined in a stable phase, preferably more than 30 days after operation [15]
The criterion of domain-wise POCD/postoperative cognitive improvement (POCI) was set to domain-specific z-score ± 2 and a patient with POCD/POCI in any domain was classified as having POCD/POCI

Summary

Introduction

Carotid endarterectomy (CEA) is an effective treatment for symptomatic [1, 2] and asymptomatic [3] high-grade carotid stenosis to prevent stroke, but findings on the cognitive consequences of CEA are strikingly mixed. Cognitive functioning in an early postoperative phase can be obscured by surgery-related factors, such as medication, postoperative pain and emotional stress, for which POCD is more reliably defined in a stable phase, preferably more than 30 days after operation [15]. It has not yet been established whether efficient cognitive performance as a function of an essentially unbroken neural network of the cerebrum plays a role in later well-being and survival after CEA. Carotid endarterectomy (CEA) has been associated with both postoperative cognitive dysfunction (POCD) and improvement (POCI). The aim of this study was to examine the associations between postoperative cognitive changes after CEA and long-term survival

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Conclusion