Changes in Cognition, Depression and Quality of Life after Carotid Stenosis Treatment

Author(s): Elina Pucite*, Ildze Krievina, Evija Miglane, Renars Erts, Dainis Krievins, Andrejs Millers

Journal Name: Current Neurovascular Research

Volume 16 , Issue 1 , 2019

Become EABM
Become Reviewer
Call for Editor


Background: Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT).

Methods: Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months followup periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only.

Results: Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period.

Conclusion: Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.

Keywords: Cognition, depression, quality of life, carotid stenosis, endarterectomy, stenting, medical treatment.

Naylor AR. Why is the management of asymptomatic carotid disease so controversial? Surgeon 2015; 13(1): 34-43.
Sun J-H, Tan L, Yu J-T. Post-stroke cognitive impairment: Epidemiology, mechanisms and management. Ann Transl Med 2014; 2(8): 80.
Hackett ML, Pickles K, Part I. Frequency of depression after stroke: An updated systematic review and meta-analysis of observational studies. Int J Stroke 2014; 9(8): 1017-25.
Wang T, Mei B, Zhang J. Atherosclerotic carotid stenosis and cognitive function. Clin Neurol Neurosurg 2016; 146: 64-70.
Lal BK, Dux MC, Sikdar S, et al. Asymptomatic carotid stenosis is associated with cognitive impairment. J Vasc Surg 2017; 66(4): 1083-92.
Paraskevas KI, Lazaridis C, Andrews CM, et al. Comparison of cognitive function after carotid artery stenting versus carotid endarterectomy. Eur J Vasc Endovasc Surg 2014; 47(3): 221-31.
Naylor AR, Ricco JB, de Borst GJ, et al. Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55(1): 3-81.
Mott M, Koroshetz W, Wright CB. CREST-2: Identifying the best method of stroke prevention for carotid artery stenosis: National Institute of Neurological Disorders and Stroke Organizational Update. Stroke 2017; 48(5): e130-1.
Aizenstein HJ, Baskys A, Boldrini M, et al. Vascular depression consensus report – a critical update. BMC Med 2016; 14(1): 161.
De Smedt D, Clays E, De Bacquer D. Measuring health-related quality of life in cardiac patients. Eur Heart J 2016; 2(3): 149-50.
North American Symptomatic Carotid Endarterectomy Trial Collaborators1, Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, Fox AJ, Rankin RN, Hachinski VC, Wiebers DO, Eliasziw M. Beneficial effect of carotid endarter-ectomy in simptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325(7): 445-53.
Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke? Stroke 2010; 41(4): 661-6.
Warlow C. MRC European carotid surgery trial: Interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991; 337(8752): 1235-43.
Halliday AW, Thomas D, Mansfiel A. The Asymptomatic Carotid Surgery Trial (ACST) rationale and design. Eur J Vasc Surg 1994; 8(6): 703-10.
Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/ AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: A report of the American College of Cardiology Foundation/American Heart Association Task F. Circulation 2011; 124(4): e54-e130.
Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45(7): 2160-236.
Nasreddine Ziad MoCA Instruction Latvian. Available from: http: // Accessed 25 Feb 2015. .
Nasreddine Z, Phillips N, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005; 53(4): 695-9.
Pendlebury ST, Mariz J, Bull L, et al. MoCA, ACE-R, and MMSE versus the national institute of neurological disorders and stroke-canadian stroke network vascular cognitive impairment harmonization standards neuropsychological battery after TIA and stroke. Stroke 2012; 43(2): 464-9.
Bocti C, Legault V, Leblanc N, et al. Vascular cognitive impairment: most useful subtests of the Montreal Cognitive Assessment in minor stroke and transient ischemic attack. Dement Geriatr Cogn Disord 2013; 36(3-4): 154-62.
Koski L. Validity and applications of the montreal cognitive assessment for the assessment of vascular cognitive impairment. Cerebrovasc Dis 2013; 36(1): 6-18.
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9): 606-13.
Kroenke K, Spitzer RL, Williams JBW, Löwe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. Gen Hosp Psychiatry 2010; 32(4): 345-59.
Kung S, Alarcon RD, Williams MD, et al. Comparing the Beck Depression Inventory-II (BDI-II) and Patient Health Questionnaire (PHQ-9) depression measures in an integrated mood disorders practice. J Affect Disord 2013; 145(3): 341-3.
Beutel ME, Wiltink J, Kirschner Y, et al. History of depression but not current depression is associated with signs of atherosclerosis: data from the Gutenberg Health Study. Psychol Med 2014; 44(05): 919-25.
Williams LS, Brizendine EJ, Plue L, et al. Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke 2005; 36(3): 635-8.
De Man-Van Ginkel JM, Hafsteinsdottir T, et al. An efficient way to detect poststroke depression by subsequent administration of a 9-item and a 2-item patient health questionnaire. Stroke 2012; 43(3): 854-6.
Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann 2002; 32(9): 509-15.
Vrublevska J, Trapencieris M, Rancans E. Adaptation and validation of the Patient Health Questionnaire-9 to evaluate major depression in a primary care sample in Latvia. Nord J Psychiatry 2018; 72(2): 112-8.
Optum. SF-36 Health Survey Latvian and Russian version- 2015 [cited 2015 Mar 3]. Available from: https: //
Ware JE. Deciding Which Short Form Survey to Use. Features of the Short Form Surveys. An excerpt from the user’s manual for the SF-36v2 health survey 2nd ed.. 2007.
Shan L, Shan J, Saxena A, Robinson D. Quality of life and functional status after carotid revascularisation: A systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2015; 49(6): 634-45.
De Rango P, Caso V, Leys D, et al. The role of carotid artery stenting and carotid endarterectomy in cognitive performance: A systematic review. Stroke 2008; 39(11): 3116-27.
Prins ND, Scheltens P. White matter hyperintensities, cognitive impairment and dementia: An update. Nat Rev Neurol 2015; 11(3): 157-65.
Plessers M, Van Herzeele I, Hemelsoet D, et al. Prospective comparison of cognitive effects of carotid endarterectomy versus carotid stenting with flow reversal or distal filters. J Clin Exp Neuropsychol 2015; 37(8): 834-41.
Baumgart M, Snyder HM, Carrillo MC, et al. Summary of the evidence on modifiable risk factors for cognitive decline and dementia: A population-based perspective. Alzheimers Dement 2015; 11(6): 718-26.
Watanabe J, Ogata T, Higashi T, Inoue T. Cognitive Change 1 Year after CEA or CAS compared with medication. J Stroke Cerebrovasc Dis 2017; 26(6): 1297-305.
Alosco ML, Gunstad J, Jerskey BA, et al. The adverse effects of reduced cerebral perfusion on cognition and brain structure in older adults with cardiovascular disease. Brain Behav 2013; 3(6): 626-36.
Ghogawala Z, Amin-Hanjani S, Curran J, et al. The effect of carotid endarterectomy on cerebral blood flow and cognitive function. J Stroke Cerebrovasc Dis 2013; 22(7): 1029-37.
Baracchini C, Mazzalai F, Gruppo M, et al. Carotid endarterectomy protects elderly patients from cognitive decline: A prospective study. Surgery 2012; 151(1): 99-106.
Yan Y, Yuan Y, Liang L, et al. Influence of carotid artery stenting on cognition of elderly patients with severe stenosis of the internal carotid artery. Med Sci Monit 2014; 20: 1461-8.
Wapp M, Everts R, Burren Y, et al. Cognitive improvement in patients with carotid stenosis is independent of treatment type. Swiss Med Wkly 2015; 145: 1-7.
Carta MG, Lecca ME, Saba L, et al. Patients with carotid atherosclerosis who underwent or did not undergo carotid endarterectomy: outcome on mood, cognition and quality of life. BMC Psychiatry 2015; 15: 277.
Dempsey RJ, Jackson DC, Wilbrand SM, et al. The preservation of cognition 1 yr after carotid endarterectomy in patients with prior cognitive decline. Neurosurgery 2018; 82(3): 322-8.
Kim JJ, Schwartz S, Wen J, et al. Comparison of neurocognitive outcomes after carotid endarterectomy and carotid artery stenting. Am Surg 2015; 81(10): 1010-4.
Kougias P, Collins R, Pastorek N, et al. Comparison of domain-specific cognitive function after carotid endarterectomy and stenting. J Vasc Surg 2015; 62(2): 355-62.
Aleksic M, Huff W, Hoppmann B, et al. Cognitive function remains unchanged after endarterectomy of unilateral internal carotid artery stenosis under local anaesthesia. Eur J Vasc Endovasc Surg 2006; 31(6): 616-21.
Altinbas A, Van Zandvoort MJE, Van Den Berg E, et al. Cognition after carotid endarterectomy or stenting: A randomized comparison. Neurology 2011; 77(11): 1084-90.
Alexopoulos GS, Meyers BS, Young RC, et al. “Vascular depression” hypothesis. Arch Gen Psychiatry 1997; 54(10): 915-22.
Gupta A, Chazen JL, Hartman M, et al. Cerebrovascular reserve and stroke risk in patients with carotid stenosis or occlusion: A systematic review and meta-analysis. Stroke 2012; 43(11): 2884-91.
Mlekusch W, Mlekusch I, Minar E, et al. Is there improvement of “vascular depression” after carotid artery stent placement? Radiology 2006; 240(2): 508-14.
Feliziani FT, Polidori MC, De Rango P, et al. Cognitive performance in elderly patients undergoing carotid endarterectomy or carotid artery stenting: A twelve-month follow-up study. Cerebrovasc Dis 2010; 30(3): 244-51.
Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: A clinical review. Eur Heart J 2014; 35(21): 1365-72.
Chabowski M, Grzebien A, Ziomek A, et al. Quality of life after carotid endarterectomy: A review of the literature. Acta Neurol Belg 2017; 117(4): 829-35.
Martin P, Fotopoulou M, Baker G, Humphrey P. Health-related quality of life after transient ischemic attack and minor stroke: is medical or surgical treatment influential? J Stroke Cerebrovasc Dis 1998; 7(1): 70-5.
Bauer AM, Bain MD, Rasmussen PA. Chronic cerebral ischemia: where “evidence-based medicine” fails patients. World Neurosurg 2015; 84(3): 714-8.
CaRESS Steering Committee Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-Year results. J Vasc Surg 2005; 42(2): 213-9.
Stolker JM, Mahoney EM, Safley DM, et al. Health-related quality of life following carotid stenting versus endarterectomy: Results from the SAPPHIRE (Stenting and Angioplasty with Protection in Patients at HIgh Risk for Endarterectomy) trial. JACC Cardiovasc Interv 2010; 3(5): 515-23.
Cohen DJ, Stolker JM, Wang K, et al. Health-related quality of life after carotid stenting versus carotid endarterectomy: Results from CREST (Carotid Revascularization Endarterectomy versus Stenting Trial). J Am Coll Cardiol 2011; 58(15): 1557-65.
Swenson JR. Quality of life in patients with coronary artery disease and the impact of depression. Curr Psychiatry Rep 2004; 6(6): 438-45.
Martinelli LMB, Mizutani BM, Mutti A, et al. Quality of life and its association with cardiovascular risk factors in a community health care program population. Clinics 2008; 63(6): 783-8.
Grunwald IQ, Papanagiotou P, Reith W, et al. Influence of carotid artery stenting on cognitive function. Neuroradiology 2010; 52: 61-6.

open access plus

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2019
Published on: 12 May, 2019
Page: [47 - 62]
Pages: 16
DOI: 10.2174/1567202616666190129153409

Article Metrics

PDF: 63
PRC: 1