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Carotid revascularization and cognitive impairment: the neglected role of cerebral small vessel disease

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Abstract

Carotid atherosclerosis is a pathological process that leads to narrowing of the vessel lumen and a consequent risk of stroke. Revascularization procedures such as carotid endarterectomy (CEA) and carotid stenting aim to reduce occurrence of stroke in selected patients. Due to the proven benefit and low intraoperative risk, CEA is currently the preferred choice in candidates for carotid revascularization. However, the risk of cognitive impairment subsequent to CEA has not been fully elucidated and is unclear whether certain conditions, such as frailty, may increase this risk. There is consistent evidence that shows that frail patients have higher risk of cognitive impairment after surgical procedure. Moreover, brain pre-existing conditions may play a role in cognitive impairment after CEA. Cerebral small vessel disease (SVD) is a pathology that involves microcirculation and is detectable with computed tomography or magnetic resonance. SVD shares common vascular risk factors with carotid atherosclerosis, is a major contributor to vascular cognitive impairment and vascular dementia, and has been proposed as a marker of brain frailty. In this review, we discuss the current evidence about the link between carotid revascularization and cognitive impairment and advance the hypothesis that SVD may play a relevant role in development of cognitive impairment after carotid revascularization.

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Authors and Affiliations

  1. Stroke Unit, AOU Careggi, Florence, Italy

    Francesco Arba, Federica Vit, Mascia Nesi & Chiara Rinaldi

  2. NEUROFARBA Department, University of Florence, Florence, Italy

    Federica Vit & Chiara Rinaldi

  3. Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy

    Mauro Silvestrini

  4. Institute of Neuroscience, Italian National Research Council, Florence, Italy

    Domenico Inzitari

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Search strategy

We searched articles from 1980 to 2021 in PubMed database. We used as key words “carotid stenosis” [Mesh], “endarterectomy” [Mesh], “Vascular Surgical Procedures” [Mesh], in combination with the following: “small vessel disease” [Mesh], “leukoaraiosis”[MeSH], “white matter changes” [Mesh], “lacunar stroke” [Mesh], “Neurocognitive Disorders” [Mesh], “Cognition Disorders” [Mesh], “Cognitive Dysfunction” [Mesh], “dementia” [Mesh]. We excluded articles not written in English. We did not systematically screen all titles and abstracts but selected those that fit the purpose of the review; we did not record the selection process. We also selected additional articles screening the references from originally identified articles. We performed a qualitative comparison between included and non-included articles.

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Arba, F., Vit, F., Nesi, M. et al. Carotid revascularization and cognitive impairment: the neglected role of cerebral small vessel disease. Neurol Sci 43, 139–152 (2022). https://doi.org/10.1007/s10072-021-05629-w

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