Ronald M Lazar1, Virginia G Wadley2, Terina Myers1, Michael R Jones3, Donald V Heck4, Wayne M Clark5, Randolph S Marshall6, Virginia J Howard7, Jenifer H Voeks8, Jennifer J Manly9, Claudia S Moy10, Seemant Chaturvedi11, James F Meschia12, Brajesh K Lal13, Thomas G Brott12, George Howard14. 1. UAB Evelyn F. McKnight Brain Institute, Department of Neurology (R.M.L., T.M.), The University of Alabama at Birmingham. 2. Department of Medicine (V.G.W.), The University of Alabama at Birmingham. 3. Cardiology, Baptist Health Lexington, KY (M.R.J.). 4. Diagnostic Radiology, Novant Health, Winston-Salem, NC (D.V.H.). 5. Department of Neurology, Oregon Health & Science University, Portland (W.M.C.). 6. Department of Neurology (R.S.M.), Columbia University Irving Medical Center, New York NY. 7. Department of Epidemiology (V.J.H.), The University of Alabama at Birmingham. 8. Department of Neurology, Medical University of South Carolina, Charleston, SC (J.H.V.). 9. Gertrude H. Sergievsky Center and the Taub Institute for Research in Aging and Alzheimer's Disease (J.J.M.), Columbia University Irving Medical Center, New York NY. 10. Department of Health & Human Services, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (C.S.M.). 11. Department of Neurology (S.C.), University of Maryland School of Medicine, Baltimore. 12. Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.). 13. Department of Surgery (B.K.L.), University of Maryland School of Medicine, Baltimore. 14. Department of Biostatistics, University of Alabama School of Public Health (G.H.).
Abstract
BACKGROUND AND PURPOSE: Studies of carotid artery disease have suggested that high-grade stenosis can affect cognition, even without stroke. The presence and degree of cognitive impairment in such patients have not been reported and compared with a demographically matched population-based cohort. METHODS: We studied cognition in 1000 consecutive CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) patients, a treatment trial for asymptomatic carotid disease. Cognitive assessment was after randomization but before assigned treatment. The cognitive battery was developed in the general population REGARDS Study (Reasons for Geographic and Racial Differences in Stroke), involving Word List Learning Sum, Word List Recall, and Word List fluency for animal names and the letter F. The carotid stenosis patients were >45 years old with ≥70% asymptomatic carotid stenosis and no history of prevalent stroke. The distribution of cognitive performance for the patients was standardized, accounting for age, race, and education using performance from REGARDS, and after further adjustment for hypertension, diabetes, dyslipidemia, and smoking. Using the Wald Test, we tabulated the proportion of Z scores less than the anticipated deviate for the population-based cohort for representative percentiles. RESULTS: There were 786 baseline assessments. Mean age was 70 years, 58% men, and 52% right-sided stenosis. The overall Z score for patients was significantly below expected for higher percentiles (P<0.0001 for 50th, 75th, and 95th percentiles) and marginally below expected for the 25th percentile (P=0.015). Lower performance was attributed largely to Word List Recall (P<0.0001 for all percentiles) and for Word List Learning (50th, 75th, and 95th percentiles below expected, P≤0.01). The scores for left versus right carotid disease were similar. CONCLUSIONS: Baseline cognition of patients with severe carotid stenosis showed below normal cognition compared to the population-based cohort, controlling for demographic and cardiovascular risk factors. This cohort represents the largest group to date to demonstrate that poorer cognition, especially memory, in this disease. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02089217.
BACKGROUND AND PURPOSE: Studies of carotid artery disease have suggested that high-grade stenosis can affect cognition, even without stroke. The presence and degree of cognitive impairment in such patients have not been reported and compared with a demographically matched population-based cohort. METHODS: We studied cognition in 1000 consecutive CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) patients, a treatment trial for asymptomatic carotid disease. Cognitive assessment was after randomization but before assigned treatment. The cognitive battery was developed in the general population REGARDS Study (Reasons for Geographic and Racial Differences in Stroke), involving Word List Learning Sum, Word List Recall, and Word List fluency for animal names and the letter F. The carotid stenosis patients were >45 years old with ≥70% asymptomatic carotid stenosis and no history of prevalent stroke. The distribution of cognitive performance for the patients was standardized, accounting for age, race, and education using performance from REGARDS, and after further adjustment for hypertension, diabetes, dyslipidemia, and smoking. Using the Wald Test, we tabulated the proportion of Z scores less than the anticipated deviate for the population-based cohort for representative percentiles. RESULTS: There were 786 baseline assessments. Mean age was 70 years, 58% men, and 52% right-sided stenosis. The overall Z score for patients was significantly below expected for higher percentiles (P<0.0001 for 50th, 75th, and 95th percentiles) and marginally below expected for the 25th percentile (P=0.015). Lower performance was attributed largely to Word List Recall (P<0.0001 for all percentiles) and for Word List Learning (50th, 75th, and 95th percentiles below expected, P≤0.01). The scores for left versus right carotid disease were similar. CONCLUSIONS: Baseline cognition of patients with severe carotid stenosis showed below normal cognition compared to the population-based cohort, controlling for demographic and cardiovascular risk factors. This cohort represents the largest group to date to demonstrate that poorer cognition, especially memory, in this disease. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02089217.
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