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Cognitive outcome after EC-IC bypass surgery in hemodynamic cerebral ischemia

  • Clinical Article
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Abstract

Objective

The purpose of this study was to evaluate cognitive functions in patients undergoing extracranial-intracranial (EC-IC) bypass surgery for cerebral ischemia.

Population and methods

From August 2003 to January 2009, 276 patients with occluded internal carotid arteries (ICA) were screened. Forty of these met the criteria for a low-flow EC-IC bypass. These patients were identified based on evidence of exhausted vasomotor reactivity (VMR) using the Doppler CO2 test and CT perfusion. These patients were invited to have a complete battery of neuropsychological tests preoperatively and 12 months after surgery. Complete neurocognitive testing was finished in 20 patients.

Results

This group of 20 patients showed preoperative cognitive impairment ranging from mild to medium-severe. There were no cases of stroke ipsilateral to the operated side during the follow-up period. VMR improvement was seen in all patients within 6 months of surgery. A comparison using a paired t-test demonstrated significant improvement 12 months after surgery in the following neuropsychological tests: WAIS-R (p = 0.01), Number Collection Test (p = 0.02), Trail Making Test (p = 0.03), and Benton Visual Retention Test (p = 0.05). Repeat analysis of variance (ANOVA) suggested the following predictors associated with cognitive improvement:the presence of ophthalmic collateral flow (p = 0.04), preoperative amaurosis fugax (p = 0.02), and external watershed infarction detected by MRI (p = 0.04).

Conclusion

Patients with occlusion of the ICA and exhausted VMR have cognitive impairment prior to EC-IC bypass surgery. Twelve months after surgery, there is significant improvement in various areas of cognition.

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Abbreviations

ANOVA:

Repeat analysis of variance

ASA:

Anopyrin acetylsalicylic acid

BH/HV:

Breath-holding/hyperventilation

CABG:

Coronary artery bypass graft

CAS:

Internal carotid artery stenting

CEA:

Carotid endarterectomy

VMR:

Vasomotor reactivity

DSA:

Digital subtraction angiography

EC-IC bypass:

Extracranial-intracranial bypass

ICA:

Internal carotid artery

MRI:

Magnetic resonance imaging

PCA:

Principle component analysis

STA:

Superficial temporal artery

TCD:

Transcranial Doppler

TIA:

Transient ischemic attack

WAIS-R:

Wechsler Adult Intelligence Scale-Revised

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Acknowledgements

The authors acknowledge the cooperation of V. Šnorek for his suggestions from the viewpoint of a psychologist standing outside the trial, Prof. J. Hernesniemi and M. Lehečka for critical remarks, and V. Apok for her assistance with the English version of the text.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, České Budějovice Hospital, B.Němcové 54, 370 87, České Budějovice, Czech republic

    Jiří Fiedler & Vladimír Přibáň

  2. Department of Neurosurgery, Masaryk University School of Medicine and Brno University Hospital, Brno , Czech Republic

    Jiří Fiedler & Vladimír Přibáň

  3. Department of Neurology, Jihlava Hospital, Jihlava, Czech Republic

    Ondřej Škoda

  4. Department of Neurology, Charles University 3rd School of Medicine, Královské Vinohrady University Hospital, Praha, Czech Republic

    Ondřej Škoda

  5. Department of Neurology, Písek, Czech Republic

    Ivo Schenk

  6. Clinical Psychology, Písek, Czech Republic

    Věra Schenková

  7. Faculty of Science, University of South Bohemia, České Budějovice, Czech Republic

    Simona Poláková

Authors
  1. Jiří Fiedler
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  2. Vladimír Přibáň
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  3. Ondřej Škoda
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  4. Ivo Schenk
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  5. Věra Schenková
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  6. Simona Poláková
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Corresponding author

Correspondence to Jiří Fiedler.

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Comment

The authors present data on the haemodynamic and cognitive recovery after EC-ICbypass surgery. Since the haemodynamic assessment used in the study did not represent the state of the art, only a general improvement of vasoreactivity could be identified postoperatively. Correlation of cognitive improvement with pre- and postoperative factors suggested the presence of ophthalmic collateral flow, preoperative amaurosis fugax and preoperative watershed infarction as principal factors for cognitive recovery. The principal question that remains because of a missing control group, is that part of the cognitive improvement may represent the natural recovery phase from preoperative strokes.

H. J. Steiger

Duesseldorf, Germany

In the present study, Fiedler and coworkers report on 20 patients with chronic hemodynamic insufficiency who underwent EC-IC bypass surgery. The patients were assessed preoperatively and postoperatively over a time period of 6 months by neurological exams, functional CBF studies as well as a detailed neuropsychological testing. The authors demonstrate a significant improvement of neurological deficits and cognitive function in their patients. This is an important manuscript. The primary aim of revascularisation surgery in chronic hemodynamic insufficiency is secondary stroke prevention. The fact that neurological and neuropsychological deficits may improve in parallel to CVRC normalization is, so far, an insufficiently recognized observation. The neuropsychological assessment in this study has been performed thoroughly, leaving no doubt about the important message of the manuscript. The authors state in the Discussion Section that ´ It is the evidence of hemodynamic failure in chronic ICA occlusion that is a primary indication for EC-IC bypass. Therefore, such a significant degree of improvement in neurological symptoms postoperatively might be expected´. I would disagree. Chronic hemodynamic insufficiency describes a state with only little to moderate reduction of baseline CBF and loss of CVRC. The mechanism describing how neuropsychological deficits can improve following normalization of CVRC remains not understood. This circumstance in fact makes the results of the authors scientifically interesting.

P. Vajkoczy

Berlin, Germany

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Fiedler, J., Přibáň, V., Škoda, O. et al. Cognitive outcome after EC-IC bypass surgery in hemodynamic cerebral ischemia. Acta Neurochir 153, 1303–1312 (2011). https://doi.org/10.1007/s00701-011-0949-x

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  • DOI: https://doi.org/10.1007/s00701-011-0949-x

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