MILD COGNITIVE IMPAIRMENT IN PATIENTS WITH CAROTID DISEASE

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MILD COGNITIVE IMPAIRMENT IN PATIENTS WITH
CAROTID DISEASE

• Irena Martinic Popovic1, M.D, Arijana
  Lovrencic-Huzjan1, M.D, Ph. D,
• Ana-Maria Simundic2, Ph.D, Vida Demarin1, M.D,
  Ph.D
• University Department of Neurology1 and Clinical
  Institute of Chemistry2,
• Sestre milosrdnice University Hospital Center
• Zagreb, Croatia

1Referal Centre for Neurovascular Disorders of
Croatian Ministry of Health 1Referal Centre for
Headaches of Croatian Ministry of Health
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Conflict of Interest Disclosure Irena Martinic
Popovic, M.D.Arijana Lovrencic-Huzjan, M.D,
Ph.DAna-Maria Simundic, Ph.DVida Demarin, M.D,
Ph.D

• Have no real or apparent conflicts of interest
• to report.

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CAROTID DISEASE

• Risk factor for TIA/stroke
• Each 10 increase in the degree of CS 26
  increase in risk of TIA/stroke
• Severe carotid disease advanced
  stenosis (gt70) and /or occlusion of the internal
  carotid artery (ICA) ICA s/o
• Associated with silent cerebral infarctions

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ASYMPTOMATIC CAROTID DISEASE

• Narrowing or occlusion of carotid arteries (ICA)
• State of increased risk for cerebrovascular
  incident
• Increased risk for cognitive decline

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ASYMPTOMATIC CAROTID DISEASE VASCULAR RISK

• associated with multiple VRFs (arterial
  hypertension, diabetes, hyperlipoproteinaemia,
  increased body-mass index (BMI) and cigarette
  smoking)
• VRFs the risk for atherosclerotic
  disease and for brain injury
• VRFs detrimental effects on cognitive
  abilities

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THE AIMS OF THE STUDY

• Besides standard MMSE, we used MoCA to
  investigate the association of ICA s/a and
  cognition in asymptomatic ICA s/o
• Assessment of predicitive value of ICA s/o and
  vascular risk factors with respect to performance
  on cognitive domains (covered by MoCA)

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STUDY PROTOCOL

• Clinical history
• Data on vascular risk factors
• Brain CAT scan (patients)
• Color Doppler Flow Imaging (CDFI) of carotid
  arteries
• Cognitive testing (MMSE and MoCA)

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DEMOGRAPHIC VASCULAR RISK DATA
Variable PATIENTS (n70) CONTROLS (n70) p
Age/years (median, min-max) 67.5 (43 -85) 67.0 (42-82) 0.675
Females (proportion, n) 0.37 (26) 0.44 (31) 0.640
Education/years (mean, SD) 11.58 (2.45) 11.78 (3.24) 0.681
Hypertension (proportion, n) 0.83 (58) 0.81 (57) 0.959
Diabetes (proportion, n) 0.26 (18) 0.29 (20) 0.867
Hyperlipidaemia (proportion, n) 0.74 (52) 0.41 (29) 0.009
Coronary disease (proportion, n) 0.39(27) 0.27 (19) 0.356
Current smoking (proportion, n) 0.23 (16) 0.29 (20) 0.995
Ex-smoking (proportion, n) 0.31 (22) 0.19 (13) 0.238
Obesity (proportion, n) 0.23 (16) 0.19 (13) 0.792
sign. difference (z-test) t-test
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CRITERIA FOR THE STUDY

• INCLUSION CRITERIA
• PATIENTS
• Asymptomatic (stroke/TIA free) patients
  right-handed
• CAT scan normal
• Diagnosed with severe ICA stenosis (gt70) or with
  ICA occlusion
• CONTROLS
• Asymptomatic (stroke/TIA free) patients
  right-handed
• Without severe ICA stenosis (gt70) or with ICA
  occlusion

• EXCLUSION CRITERIA
• BOTH PATIENTS AND
• CONTROLS
• A history or presence of stroke/TIA
• Dementia (DSM-IV)
• Depressive disorder (DSM-IV)
• Inability to perform the cognitive testing

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CAROTID ARTERIES ASSESSMENT

• COLOR DOPPLER FLOW
• IMAGING (CDFI)
• (10 MHz transducer)
• - morphological changes of
• the carotid arteries
• the degree of stenosis (B mode)
• impairment of carotid
• hemodynamics (M mode)

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CAROTID PATHOLOGY THE SIDE THE DEGREE OF
STENOSIS
Proportion (n) PATIENTS
Left ICA advanced stenosis 0.38 (27)
Right ICA advanced stenosis 0.4 (28)
Billateral ICA advanced stenosis 0.04 (3)
Left ICA occlusion 0.03 (2)
Right ICA occlusion 0.07 (5)
Billateral ICA occlusion 0.03 (2)
Left ICA occlusion and right ICA advanced stenosis 0.03 (2)
Right ICA occlusion and left ICA advanced stenosis 0.01 (1)
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COGNITIVE IMPAIRMENTpatients vs. controls
MMSE score lt 24 proportion (n) MoCA score 26 proportion (n) P
Patients 0.185 (13) 0.871 (61) P lt 0.001
Controls 0.086 (6) 0.271 (19) P 0.008
z-test
Proportion of abnormal scores (indicating
cognitive impairment) in patients and controls
when tested by MMSE and MoCA
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TOTAL COGNITIVE TESTING SCORES patients vs.
controls
PATIENTS (n70) CONTROLS (n70) p
Median Q1 Q3 Median Q1 Q3 p
MoCA (total score) 23 20 25 24.5 23 26 lt0.001
MMSE 27.5 25 29 27 26 28 0.575
Patients and controls did not differ
significantly in MMSE scores. Median total MoCA
scores were significantly lower in patients.
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MoCA SUBTESTS SCORES patients vs. controls
MoCA subtests scores PATIENTS (n70) CONTROLS (n70) P
MoCA subtests scores Median Q1 Q3 Median Q1 Q3 P
VSE 3 2 4 4 3 5 0.018
Naming 3 3 3 3 3 3 0.662
Attention 5 4 6 5 4 6 0.723
Language 2 2 3 2 2 3 0.204
Abstraction 1 1 1 2 1 2 lt0.001
Delayed recall 2 0 3 3 2 4 lt0.001
Orientation 6 6 6 6 6 6 0.451
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COGNITIVE IMPAIRMENT VASCULAR RISK
Parameter Univariate regression analysis Univariate regression analysis Multivariate regression analysis Multivariate regression analysis
Parameter OR (95 CI) P OR (95 CI) P
Age 0.87 (0.794 - 0.955) 0.0034 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Gender 1.85 (0.482 - 7.152) 0.3682 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Hypertension 0.80 (0.147 - 4.343) 0.7960 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Diabetes 6.00 (1.458 - 24.687) 0.0130 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Hyperlipidemia 3.56 (0.418 - 30.271) 0.2453 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Coronary disease 1.73 (0.449 - 6.638) 0.4262 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Smoking 1.26 (0.552 - 2.879 0.5824 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Obesity 0.95 (0.672 - 1.352) 0.7907 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Left ICA s/o 1.18 (0.415 - 3.339) 0.7582 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Right ICA s/o 0.96 (0.335 - 2.752) 0.9391 0.86 (0.780 - 0.956) 6.41 (1.277 - 32.220) 0.004 0.024
Regression model for prediction of cognitive
impairment (defined as MoCA cutoff score 26)
with respect to vascular risk factors and the
side of ICA s/o
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COGNITIVE IMPAIRMENT VASCULAR RISK

• Patients with ICA s/o AND diabetes performed
  worse (p lt0.001) at delayed
  recall
• Patients with ICA s/o AND increased BMI performed
  worse at delayed recall (p0.02)
• Patients with diabetes had lower attention
  (p0.065) and naming (p0.06) MoCA subtests
  scores
• Hyperlipemic patients scored worse at attention
  (p0.064)
• Patients with hypertension scored lower at naming
  MoCA subtests (p0.04)
• The side of stenosis was not associated with
  lower performance on MoCA subtests

Differences not statistically significant
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What were THE LIMITATIONS OF OUR STUDY?

• No neuroimaging in controls ?
• Influence of potential cofounders
  (antihypertensive drugs, statin therapy...) not
  analyzed ?
• Duration of exposure to vascular risk factors ?

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What are OUR PRINCIPAL FINDINGS?

• Patients with severe carotid disease often do
  have subtle cognitive abnormalities
• MoCA is far more suitable for cognitive
  assessment in patients with carotid disease than
  MMSE
• Decreased median MoCA scores in controls is
  probably due to the presence of vascular risk and
  likely to the silent brain injury (no
  neuroimaging was done in controls!)

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What are OUR PRINCIPAL FINDINGS?

• Patients with severe carotid disease had impaired
  multiple cognitive domains when MoCA subtests
  were analyzed
• ...VISUOSPATIAL, EXECUTIVE, ATTENTION...
• Our results are similar to those of other
  researchers (who mostly used extensive
  neuropsychological testing batteries!)

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What are OUR PRINCIPAL FINDINGS?

• Decreased total MoCA scores in older patients
  with ICA s/o
• Decreased total MoCA scores in diabetic patients
  with carotid disease in line with
  previous research (diabetes is well known
  indipendent factor for cognitive decline)

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What can we CONCLUDE ?

• Stroke/TIA free patients with advanced carotid
  disease are routinely considered asymptomatic
• Cognitive impairment in patients with ICA s/o is
  not questioned during routine clinical visits
• The use of MoCA could facilitate early
  recognition of cognitive problems in patients
  with carotid disease

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THANK YOU!
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