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Research ArticleExtracranial Vascular
Open Access

Intervention versus Aggressive Medical Therapy for Cognition in Severe Asymptomatic Carotid Stenosis

C.-J. Lin, F.-C. Chang, K.-H. Chou, P.-C. Tu, Y.-H. Lee, C.-P. Lin, P.-N. Wang and I.-H. Lee
American Journal of Neuroradiology October 2016, 37 (10) 1889-1897; DOI: https://doi.org/10.3174/ajnr.A4798
C.-J. Lin
aFrom the Departments of Neurology (C.-J.L., P.-N.W., I.-H.L.)
dInstitute of Brain Science (C.-J.L., P.-C.T., I.-H.L.)
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F.-C. Chang
bRadiology (F.-C.C.)
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K.-H. Chou
eInstitute of Neuroscience (K.-H.C., C.-P.L.)
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P.-C. Tu
cMedical Education and Research (P.-C.T.), Taipei Veterans General Hospital, Taipei, Taiwan
dInstitute of Brain Science (C.-J.L., P.-C.T., I.-H.L.)
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Y.-H. Lee
fDepartment and Institute of Physiology (Y.-H.L.)
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C.-P. Lin
eInstitute of Neuroscience (K.-H.C., C.-P.L.)
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P.-N. Wang
aFrom the Departments of Neurology (C.-J.L., P.-N.W., I.-H.L.)
gSchool of Medicine (P.-N.W.), National Yang-Ming University, Taipei, Taiwan.
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I.-H. Lee
aFrom the Departments of Neurology (C.-J.L., P.-N.W., I.-H.L.)
dInstitute of Brain Science (C.-J.L., P.-C.T., I.-H.L.)
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    Fig 1.

    A, Procedure-related microemboli based on the diffusion-weighted images are overlaid on a standard Montreal Neurological Institute template from 12 of 25 patients in the stent-placement group, indicated by different colors. B, The increases (red-yellow) of fractional anisotropy (the white matter skeleton is shown in green) at 3 months after aggressive medical therapy alone (Med, upper row) or combined carotid artery stent placement (Med+CAS, middle row) and the between-group comparisons (lower row). The carotid stenotic side was set to the right in all subjects. The third column from the left represents the high-power views of the insets. Note significant FA increases at the posterior corpus callosum (arrowheads) and the posterior periventricular white matter ipsilateral to the CAS in the stent-placement group.

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    Fig 2.

    A and B, The functional connectivity correlation maps of both groups (Med indicates medical group; Med+CAS, stent placement group) before (pre) and 3 months after treatment (post). The carotid stenotic side was set to the right. Hollow circles indicate the predefined ROIs for individual networks at the right brain. Color bars represent T values. Q indicates the false discovery rate–corrected P value. The stent-placement group, not the medical group, showed within-group enhancement of Fc at the medial prefrontal cortex (MPF, T = 5.27, cluster size = 47, Q = .027) of the default mode network (DMN) and at the insular cortex (INS; T = 5.35, cluster size = 56, Q = .040) of the dorsal attention network (DAN) (arrowheads). C, The bar chart of the aforementioned cluster sizes with increased Fc is shown. FPN indicates frontoparietal network.

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    Fig 3.

    Scatterplots of the correlation analyses in the medical (Med) and the stent placement group (Med+CAS). A, The baseline whole-brain mean fractional anisotropy negatively correlates with dizziness alleviation (decreases in Dizziness Handicap Inventory [DHI]) in both groups. B, The focal FA increases in the posterior corpus callosum positively correlate with the improvement of immediate verbal memory only in the stent-placement group. C, The relationship is shown between the baseline presence of mild cognitive impairment/vascular cognitive impairment no dementia and the improvement of immediate verbal memory in the 2 groups. D, The baseline stenotic degree is not related to the changes of Complex Figure Test (Recall) scores.

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    Table 1:

    Baseline characteristics

    MedMed+CASP Value
    Age (yr)68.8 ± 8.871.4 ± 7.8.348
    Male sex (%)11 (73)21 (84).687
    Education (yr)12 (7.5–12)10 (7–12).602
    Stenotic degree (%)81.3 ± 12.081.0 ± 9.8.928
    Total occlusion (No.) (%)3 (20)0 (0).543
    Hypertension (No.) (%)12 (80)20 (80).611
        Mean BP (mm Hg)95.1 ± 9.595.3 ± 10.2.887
    Diabetes mellitus (No.) (%)7 (47)9 (36).268
        HbA1c (%)6.6 ± 1.26.4 ± 0.4.254
    Hypercholesterolemia (No.) (%)9 (60)17 (68).444
        LDL (mg/dL)85.3 ± 20.189.1 ± 14.7.851
    Smoking (No.) (%)5 (33)9 (36).542
    Atrial fibrillation (No.) (%)1 (6.6)0 (0).118
    Double antiplatelets (No.) (%)8 (53)18 (72).345
    Statins (No.) (%)8 (53)15 (60).488
    Dizziness Handicap Inventory14.7 ± 19.518.3 ± 13.8.541
    Mini-Mental State Examination28.4 ± 1.228.2 ± 1.8.641
    Verbal memory tests
        Total immediate recall38.3 ± 10.546.1 ± 7.9.086
        Delayed recall7.3 ± 2.38.1 ± 2.3.571
    Attention tests
        Symbol Digit Modalities Test45.5 ± 16.341.9 ± 20.1.559
    Executive function tests
        Modified Trail-Making Test A16.4 ± 8.622.4 ± 15.1.214
        Modified Trail-Making Test B43.6 ± 28.953.1 ± 31.1.455
        Stroop Color and Word Test33. ± 13.432.9 ± 14.6.819
    Complex visuospatial perception
        Complex Figure Test (Copy)16.4 ± 1.215.5 ± 1.8.109
        Complex Figure Test (Recall)10.4 ± 4.59.7 ± 4.2.631
    MCI/VCIND (No.) (%)6 (40%)7 (28%).318
    Scheltens leukoaraiosis score5.2 ± 2.75.4 ± 3.1.889
    Hippocampal volume (mL)3.3 ± 0.33.2 ± 0.2.533
    Ipsilateral hemispheric FA0.50 ± 0.010.49 ± 0.01.471
    Contralateral hemispheric FA0.51 ± 0.010.50 ± 0.01.375
    • Note:—Med indicates medical therapy alone; Med+CAS, medical therapy combined with carotid artery stent placement; BP, blood pressure; LDL, low-density lipoprotein; HbA1c, hemoglobin A1c test.

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    Table 2:

    Interval changes within and between groups

    ΔChangesMedMed+CASP Value
    Dizziness Handicap Inventory−2.7 ± 4.8−6.7 ± 7.1a.045a
    Neuropsychological tests
        Mini-Mental State Examination−0.2 ± 1.70.1 ± 1.0.525
        Total immediate recall2.2 ± 5.64.2 ± 5.6a.296
        Delayed recall−0.3 ± 1.20.6 ± 1.7.050
        Symbol Digit Modalities Test1.7 ± 5.22.3 ± 4.4.710
        Modified Trail-Making Test A−0.1 ± 8.1−2.6 ± 4.5.309
        Modified Trail-Making Test B1.7 ± 31.9−4.9 ± 13.1.405
        Stroop Color and Word Test1.7 ± 5.82.9 ± 6.4.545
        Complex Figure Test (Copy)0.2 ± 1.41.1 ± 1.4a.064
        Complex Figure Test (Recall)0.1 ± 3.11.7 ± 3.7.157
    Scheltens leukoaraiosis score0.1 ± 0.30.2 ± 0.5.561
    Ipsilateral hemispheric FA0.002 ± 0.040.009 ± 0.004.447
    Contralateral hemispheric FA0.002 ± 0.050.004 ± 0.005.681
    • Note:—Med indicates medical therapy alone.

    • ↵a For dizziness and imaging measures, P < .05 was defined as significant. For the 9 neuropsychological tests, P < .0056 was defined as significant with the Bonferroni correction.

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American Journal of Neuroradiology: 37 (10)
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C.-J. Lin, F.-C. Chang, K.-H. Chou, P.-C. Tu, Y.-H. Lee, C.-P. Lin, P.-N. Wang, I.-H. Lee
Intervention versus Aggressive Medical Therapy for Cognition in Severe Asymptomatic Carotid Stenosis
American Journal of Neuroradiology Oct 2016, 37 (10) 1889-1897; DOI: 10.3174/ajnr.A4798

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Intervention versus Aggressive Medical Therapy for Cognition in Severe Asymptomatic Carotid Stenosis
C.-J. Lin, F.-C. Chang, K.-H. Chou, P.-C. Tu, Y.-H. Lee, C.-P. Lin, P.-N. Wang, I.-H. Lee
American Journal of Neuroradiology Oct 2016, 37 (10) 1889-1897; DOI: 10.3174/ajnr.A4798
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