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Abstract

We would like to thank Dr Paraskevas for his comments on our report, “Asymptomatic carotid stenosis is associated with mobility and cognitive dysfunction and heightens falls in older adults.”1Gray V.L. Goldberg A.P. Rogers M.W. Anthony L. Terrin M.L. Guralnik J.M. et al.Asymptomatic carotid stenosis is associated with mobility and cognitive dysfunction and heightens falls in older adults.J Vasc Surg. 2020; 71: 1930-1937Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar These results extend our earlier findings of cognitive decline observed in asymptomatic carotid artery stenosis that we found were associated with attendant altered blood flow and cerebral hypoperfusion.2Lal B.K. Dux M.C. Sikdar S. Goldstein C. Khan A.A. Yokemick J. et al.Asymptomatic carotid stenosis is associated with cognitive impairment.J Vasc Surg. 2017; 66: 1083-1092Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar We agree that although intensive medical management in these patients reduces the risk for atheroembolic stroke, it might not necessarily target the mechanisms that contribute to declines in mobility and cognitive function. We also agree that plaque removal in these patients could ameliorate both of these mechanisms and could potentially attenuate the declines in mobility and cognition. We are approaching the therapeutic question cautiously. Before defining the best treatment, it is essential to thoroughly investigate all potential mechanisms that may be operative as a result of the atherosclerotic plaque. There are other biologic processes associated with the plaque that may also attenuate mobility and cognitive function besides cerebral hypoperfusion.2Lal B.K. Dux M.C. Sikdar S. Goldstein C. Khan A.A. Yokemick J. et al.Asymptomatic carotid stenosis is associated with cognitive impairment.J Vasc Surg. 2017; 66: 1083-1092Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Another potential explanation could be the inflammatory processes originating from or being amplified by the plaque.3Thakore A.H. Guo C. Larson M.G. Corey D. Wang T.J. Vasan R.S. et al.Association of multiple inflammatory markers with carotid intimal medial thickness and stenosis (from the Farmingham Heart Study).Am J Cardiol. 2007; 99: 1598-1602Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar Systemic inflammation and deficits in cognitive function are well documented.4Lin T. Liu G.A. Perez E. Rainer R.D. Febo M. Cruz-Almeida Y. et al.Systemic inflammation mediates age-related cognitive deficits.Front Aging Neurosci. 2018; 10: 236Crossref PubMed Scopus (35) Google Scholar We do acknowledge that plaque removal, in this instance, may also ameliorate the inflammation. However, there may be less invasive treatments that could remediate these altered biologic processes. Further research will enhance our knowledge and understanding of which approaches best modify the underlying mechanisms, inducing the cerebral changes that affect the neural networks essential for mobility and cognitive function. The results of our investigations are exciting, and we share Dr Paraskevas' optimism. We are actively engaged in trying to provide answers to some of these questions. Further studies using large sample sizes are encouraged to improve our understanding of the extent of mobility declines, the underlying mechanisms that impair mobility, and the best means of modifying those impairments in asymptomatic carotid artery stenosis. Management of cognitive dysfunction in patients with asymptomatic carotid stenosis with best medical treatment versus carotid endarterectomyJournal of Vascular SurgeryVol. 72Issue 4PreviewA recent study showed that ≥50% asymptomatic carotid artery stenosis (ACAS) is associated with impairments in mobility and cognitive function and a greater fall risk in older adults.1 These results extend the findings of an earlier study from the same group showing that approximately 50% of adults with ≥50% ACAS develop cognitive impairment, probably because of decreased cerebral perfusion (not atheroembolism).2 Full-Text PDF