颈动脉硬化与老年人认知功能损害的相关性研究
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摘要
随着中国逐渐进入老年化社会，老年认知功能损害的发病率日益提升，并广受关注。认知损害可分为轻度认知损害（Mild cognition impairment，MCI）和痴呆两个阶段。MCI是认知功能下降的早期阶段，并有很高的几率转化为痴呆(10%~15%每年)，较普通人群高10倍。国内外有大量工作者致力于研究老年人认知功能损害的危险因素，MCI作为痴呆前的过度状态备受关注，因此研究导致MCI患者认知功能减退及其进展为痴呆的危险因素显得更加重要。颈动脉粥样硬化性斑块和狭窄不仅是缺血性卒中及认知功能损害的独立危险因素,同时也被认为是MCI向痴呆转化过程中的独立危险因素。因此，在早期阶段认识MCI的相关危险因素，并给予适当干预是阻止其进展为痴呆的重要策略。
痴呆最常见的类型就是阿尔茨海默病(Alzheimer’s disease, AD)和血管性痴呆（Vascular dementia, VaD）。以往大家认为AD与VaD是两类不同性质的疾病，有不同的发病机制和病理基础。近年来血管因素在AD发病中的作用不断受到重视，许多与血管因素或血流动力学相关的危险因素均能增大AD的患病风险。高血压、糖尿病、吸烟、饮酒和颈动脉硬化被认为是痴呆的常见血管危险因素（vascular risk factors，VRFs)。动脉硬化是老年人最常见的疾病之一。它是由多个血管危险因素造成的，导致内中膜厚度增加、斑块形成、颈动脉硬化性狭窄甚至闭塞的病理过程。颈动脉粥样硬化性斑块形成和狭窄不仅意味着颅内或者全身的动脉粥样硬化，而且也可能是导致认知功能减退的直接原因。颈动脉斑块引起的微栓子栓塞和脑血流动力学低灌注可能是无症状颈动脉狭窄导致认知功能损害的两个重要机制。
颈动脉内膜切除术(carotid endarterectomy，CEA)或颈动脉支架成形术(carotidartery stenting，CAS)是目前治疗颈动脉斑块和狭窄的常用手段。颈动脉血管成形术（CEA和CAS）主要通过改善脑组织血流灌注、减少斑块脱落引起的脑栓塞事件、减轻脑白质病变等机制来改善颈动脉狭窄患者的认知功能。然而颈动脉血管成形术对认知功能的影响仍然充满争议。很多因素会导致患者术后认知功能产生差异，包括患者基线的灌注状态，术中的微栓塞，短暂的血流阻断和血流动力学改善后患者的获益程度等等。因此有必要制定更加客观的近期和远期评价标准，采用完善、细化的神经心理学测试，科学严谨的实验设计，结合影像学检查对CAS术后不同时期的认知功能变化进行评估。
本课题开展了颈动脉硬化与中国老年人认知损害的相关性研究,并针对其行CAS治疗的疗效观察，共分为两个部分：(1)通过对重庆市老年人认知功能的现状调查来揭示颈动脉硬化、吸烟、饮酒与中国老年人的认知损害的相关性。(2)采用病例对照的前瞻性研究，对颈动脉狭窄的MCI病人分别行CAS和药物治疗，并在治疗前后分别进行认知功能评价和随访，探讨CAS对颈动脉狭窄的MCI患者认知功能的影响。
第一部分颈动脉硬化对老年人认知功能损害的研究
目的：在中国，老年人认知损害的发生率日益提高，与其有关的危险因素研究备受重视。本研究主要通过现状调查研究明确颈动脉硬化、吸烟、饮酒与中国老年人的认知损害的相关性。
对象和方法：连续性选择2011年1月－2012年10月期间来自重庆大坪医院神经内科的1367例60岁以上病人进行了现状调查研究。通过B超及64排CT筛查，691例有颈动脉斑块的病人纳入斑块组，676例无斑块的纳入对照组。斑块组患者通过64排CT血管造影(Computerized Tomography angiography，CTA)或数字减影血管造影(digital subtraction angiography，DSA)检查确定狭窄程度和斑块类型,并进行一般临床资料收集,通过简易智能量表(Mini-Mental State Examination, MMSE)和日常生活能力量表(Activities of Daily Living, ADL)来评价患者的认知功能。采用χ2test和逻辑回归分析寻找颈动脉硬化与认知损害的相关性。
结果：
1.基线特征分析
入组人数1367名，其中男性803人(58.7％)，女性564人(41.3%)，平均年龄70.4岁。颈动脉斑块组691名（50.5％），对照组676名（49.5％）。MCI患者116例（8.49%），痴呆患者46例（3.37%）。颈动脉斑块组与对照组在年龄、性别、受教育程度、血脂水平上无明显差异。斑块组高血压、糖尿病、心脏病的发病率较对照组明显增高。同时斑块组中当前吸烟与每日饮酒的人数较对照组明显增多（p<0.01）。斑块组的平均MMSE评分（25.9±1.7）较对照组（27.1±1.5）显著降低（p<0.01），且斑块组中MCI患者（74例vs42例，p<0.01）、痴呆患者（31例vs15例，p<0.05）较对照组明显增多。
2.斑块组中斑块性质、狭窄程度的性别、年龄分布特征
在691例颈动脉狭窄组患者中，男性406例（58.8%），女性285例（41.2%）。男性患者中，钙化斑147例（36.2%）比例最高，女性中混合斑106例（37.2%）更常见。重度狭窄患者中，男性50例（12.3%），女性51例（17.9%），提示女性重度狭窄率更高。从年龄分布看，在60-69岁人群中，混合斑比率最高（107例37.2%）。而70-79岁人群中非钙斑更常见（99例38.2%）。大于80岁138例患者中以钙化斑为主（52例37.7%），其中，重度狭窄患者23例（16.7%），提示高龄患者的狭窄率更高。
3颈动脉斑块性质、狭窄程度与老年认知损害的单因素分析
颈动脉斑块性质和狭窄程度、吸烟、饮酒与老年认知损害有着显著联系。混合斑和非钙斑相对于钙化斑和对照组更容易引起认知损害，斑块性质与MCI（χ2=7.02，P=0.012）和痴呆（χ2=7.26，P=0.0095）密切相关。颈动脉重度狭窄患者有着更高的发生MCI（χ2=7.43，P=0.009）和痴呆（χ2=7.87，P=0.0083）的风险相对于对照组和轻度狭窄患者。当前吸烟者较不吸烟和戒烟者发生认知损害（MCIχ2=6.33，p=0.035）、（痴呆χ2=6.16，p=0.042）的几率显著增高。每日饮酒者相对于每周、每月饮酒者及偶尔饮酒者更容易发生认知损害（MCIχ2=6.52，p=0.023）、（痴呆χ2=6.83，p=0.019）。另外，我们发现受教育程度、年龄、性别同样也是认知损害的危险因素。
4颈动脉斑块性质、狭窄程度与老年认知损害的多元逻辑回归分析
在排除吸烟、饮酒、颈动脉狭窄等其他危险因素后，非钙斑（MCI RR=2.78,95%CI=1.45-6.15）、（痴呆RR=2.62,95%CI=1.30-6.02）、混合斑（MCI RR=2.96,95%CI=1.56–6.33）、（痴呆RR=2.54,95%CI=1.42-5.99）、钙化斑（MCI RR=1.57,95%CI=1.04–2.86）、（痴呆RR=1.31,95%CI=1.10–3.21）依然与认知损害有显著联系和对照组相比。同样当排除其他危险因素后颈动脉狭窄和认知损害同样密切相关，相对于颈动脉轻度狭窄患者（MCI RR=1.59,95%CI=1.02-2.84）、（痴呆RR=1.73,95%CI=1.11-3.16），重度狭窄患者的认知损害风险更高,（MCA RR=3.72,95%CI=1.88–7.18）、（痴呆RR=3.82,95%CI=1.98–7.55）。在排除了年龄、性别、受教育程度、饮酒和颈动脉斑块、狭窄等危险因素后，同不吸烟者和戒烟者相比，当前吸烟同与认知损害（MCI RR=2.44,95%CI=1.49-4.08）、（痴呆RR=1.68,95%CI=1.06-2.73）有着显著联系。同样在排除了其他危险因素后，每日饮酒者较偶尔饮酒者发生MCI（RR=3.51,95%CI=1.91–6.84）和痴呆（RR=3.75,95%CI=1.96-7.05）的风险更高。而每周饮酒者认知损害的风险依然在上升MCI（RR=1.63,95%CI=1.07-2.77）、痴呆（RR=1.46,95%CI=1.03-2.44）。另外，当排除吸烟、饮酒、颈动脉斑块和狭窄后,认知损害与年龄、性别、受教育程度也有着密切联系。
结论：
1.颈动脉斑块组高血压、糖尿病、心脏病的发病率较对照组明显增高，斑块组中当前吸烟与每日饮酒的人数较对照组明显增多。斑块组的平均MMSE评分较对照组显著降低，斑块组中MCI患者、痴呆患者较对照组明显增多。
2.男性患者中钙化斑比例最高，女性中混合斑更常见，女性重度狭窄率更高。在60-69岁人群中，混合斑比率最高，而70-79岁人群中非钙斑更常见，大于80岁患者中以钙化斑为主，且重度狭窄率更高。
3.混合斑和非钙斑、颈动脉重度狭窄、当前吸烟、每日饮酒与老年认知损害密切相关。
4.在排除了年龄、性别、受教育程度等危险因素后，混合斑和非钙斑、颈动脉重度狭窄、当前吸烟、每日饮酒是老年认知损害的独立危险因素，而每周饮酒、钙化斑块和颈动脉轻度狭窄与认知损害依然有着显著的联系。
第二部分颈动脉支架介入治疗老年轻度认知功能损害的研究
目的：通过病例对照的前瞻性研究来观察颈动脉支架对颈动脉狭窄伴轻度认知功能损害患者认知功能的影响，明确颈动脉支架能否改善颈动脉狭窄伴轻度认知功能损害患者的认知功能。
对象和方法:连续性选择2011年1月-2012年10月期间在我科住院的诊断为颈动脉狭窄伴MCI病人，共登记240人。依据患者意愿分为支架治疗组和对照组。支架组1周内行CAS及强化药物治疗，对照组行强化药物治疗。两组患者（208例）完成了治疗前及治疗后6个月的神经心理学检查及CTA、CTP等影像学检查、随访。
结果：
1.基线特征分析
在登记的240例患者中有208例（支架组144例，对照组68例）完成了治疗及治疗后6个月的神经心理学检查。有120例（CAS组84例，药物组36例）接受了初始和6个月内的CTP随访检查。支架组手术成功率100%，术前颈动脉平均狭窄率为68%（50%～96%），其中左侧颈动脉狭窄占62.5%。支架术后平均狭窄为21%(0%–60%)。经术后6个月随访，支架组144例患者中有4例（2.8%）出现支架内血管腔再狭窄，同侧脑梗塞3例（2.1%），同侧TIA4例（2.8%）。对照组64例患者随访中，发生同侧脑梗塞2例（3.1%），同侧TIA3例（4.7%）。
治疗前两组患者在年龄、性别、受教育程度、血管危险因素、血管狭窄率、神经功能评分、认知功能评分等方面均无显著差异。
2．支架治疗对患者认知功能的影响
支架组患者术后6个月MMSE（before24.6±1.7versus after24.8±1.9P=0.016），MOCA（before23.7±1.7versus after24.1±2.0P=0.006），FOM（before13.8±2.2versus after14.0±2.3P=0.031）, WAIS-DS（before6.7±2.1versus after6.9±2.3P=0.040）,较术前有明显改善，其中MOCA改善最为显著。而RVR（before25.7±2.1versus after25.9±2.3P=0.201）也有改善的趋势。相比之下对照组患者6个月后神经心理学评分与基线数据比较有下降的趋势，虽然没有达到有统计学意义。两组病人6个月后NIHSS、ADL值较基线数据无明显变化。
3.脑灌注改善与认知功能改善的相关性
CAS组84例接受CTP随访的患者中有72例（86%）出现了术后同侧脑灌注改善，而对照组36例患者中无1例出现灌注改善。CAS组84例患者的CTP灌注改善与MMSE(r=0.574)、MOCA(r=0.574)评分改善之间有较为密切的联系，与WIAS-DS评分改变(r=0.464), RVR评分改变(r=0.449)，FOM评分改变(r=0.375)之间也有着适度的联系。
结论：
1.支架组手术成功率100%，术前平均狭窄率为68%，术后平均狭窄为21%。经术后6个月随访，支架内血管腔再狭窄（2.8%），同侧脑梗塞（2.1%），同侧TIA（2.8%）。提示支架治疗能成功解除患者颈动脉狭窄，且安全、有效。
2.支架组患者术后6个月的认知功能评分较术前有明显改善，而对照组患者6个月后神经心理学评分与治疗前比较有下降的趋势，提示支架治疗能改善MCI患者的认知功能。
3.支架治疗能改善患者同侧脑血流灌注，且患者的灌注改善与认知功能的改善密切相关。
As China is entering aging society, the incidence of cognitive impairment in elderlypeople rises with increasing age and the study of cognitive impairment is being paid greatattention. Cognitive impairment can be classified into mild cognitive impairment (MCI) anddementia in two phases. MCI is the early stage of dementia and associated with anincreased risk for progression to Alzheimer diseases (AD)(10%to15%per year), which is10times that in normal population. Large numbers of scholars at home and abroadcommitted to research the risk factors for cognitive impairment in the elderly. MCI isatteached excessive concern as an early stage of dementia, so it is very important to studythe risk factors in the transformation process of MCI to dementia and cognitive dysfunctionof the patients with MCI. Carotid plaque and stenosis is not only considered as anindependent risk factor of ischemic stroke and cognitive impairment, but also known to bean independent risk factor in the transformation process of MCI to dementia. Therefore,understanding and treatment of carotid artery stenosis at the MCI stage may be an importantstrategy for preventing and delaying the progression to dementia.
The most common clinical type of elderly cognitive impairment are AD and vasculardementia (VaD). It is generally accepted previously that the VaD and AD are two types ofdiseases, which have different pathological basis and susceptible gene. But in recent yearsthe role of vascular factors in the pathogenesis of AD is gradually taken seriously. Manyrisk factors associated with vascular factors or hemodynamic can increase the risk of AD.Hypertension, diabetes, hyperlipidemia, current smoking habit, daily alcohol consumptionand Carotid atherosclerosis are considered as common vascular risk factors（VRFs) ofdementia. Carotid atherosclerosis is most popular among elderly people, which can causevascular intimal thickening, carotid plaque, vascular stenosis and occlusion. Carotidatherosclerosis plaque and stenosis often means atherosclerosis of total systemic vascularand encephalic, which maybe the direct causes of cognition decline. AsymptomaticSpontaneous cerebral emboli (SCE) and cerebral hemodynamics low perfusion are associated with an accelerated cognitive and functional decline in asymptomatic patients(>70%stenosis).
CEA (carotid endarterectomy) and CAS (carotid artery stenting) have a positive effecton severe carotid artery stenosis, which can improve cerebral perfusion and reducemicro-emboli derived from carotid atherosclerotic plaques and leukodystrophy. However,the effects of CAS on cognitive outcome in patients with carotid artery stenosis arecontroversial. A number of factors may lead to the variation in cognitive responsesobserved in the clinic, including differences in baseline cerebral perfusion status,detrimental effects on procedural emboli, temporary flow interruption and the beneficialeffect of improved cerebral hemodynamics. So a more objective evaluation of short-andlong-term standards, complete and detailed neuropsychological testing, scientificallyrigorous experimental design are required to evaluate the long-term curative effect of CASon the improvement of cognitive function in patients with carotid artery stenosis and MCI.
The research about relationship between carotid atherosclerosis and cognitiveimpairment and corresponding treatment of CAS include two parts:(1) To observerelationship between carotid atherosclerotic, smoking, alcohol Intake, and cognitiveimpairment in Chinese elderly people.(2) Using case-control design method and theprospective study, to investigate the effect of CAS on neurocognitive function in patientswith carotid artery stenosis and MCI.
Section1
Study of the relationship between carotid atherosclerotic and cognitiveimpairment among elderly people
Objects: the incidence of cognitive impairment is increasing; and its risk factors isattached with great importance. This report focuses on investigating the relationshipbetween carotid atherosclerosis, smoking, alcohol Intake, and cognitive impairment inChinese elderly people.
Methods：From January2011to October2012,1367patients aged60years old andover were enrolled from Daping hospital of Chongqing. Screening with high-resolutionB-mode ultrasound,691paitents with carotid atherosclerosis plaque were assigned toplaque group, rest of676cases of plaque-free into the control group. In plaque group,Computerized Tomography angiography (CTA) by a Light Speed VCT64-slice scanner or (DSA)were scheduled to assess the plaque characteristics and carotid artery stenosis.Cognitive function was measured by the Mini-Mental State Examination (MMSE) andActivities of Daily Living (ADL). The χ~2test and logistic regression was used to find therelationship between carotid atherosclerosis, smoking, alcohol intake, and cognitiveimpairment.
Results：
1.Baseline characterictics in overall patients: In total,803men(58.7％) and564women(41.3%) were registered in this study (mean age of70.4years old),691cases inplaque group（50.5％） and676cases in control group （49.5％）. Of1367patients,116cases had MCI,46cases had dementia. The patients in the two groups did not differ withregard to age, gender, education level and hyperlipidemia. The incidence of hypertension,diabetes mellitus and cardiac disease of plaque group were significantly higher than that ofcontrol group. Meanwhile, the number of current smokers and daily drinking of plaquegroup were much more than control group（p<0.01）. The MMSE score of plaque group（25.9±1.7）were significantly lower than that of the control group（27.1±1.5）（p<0.01）,and patients with MCI（74vs42，p<0.01）,dementia（31vs15，p<0.05）were obvious muchmore than control group.
2．Plaque characteristic, degree of stenosis, gender and age distribution in plaquegroup: of691cases in plaque group,406were male（58.8%），285were female（41.2%）.In male patients,147cases（36.2%）had calcified plaque which had the highest percentage,while mixed plaque106（37.2%） were more common in female. Among patients withsevere stenosis,50cases were male（12.3%）,51cases were female（17.9%）, prompting thatfemale had higher rate of severe carotid stenosis than male. From the perspective of agedistribution, mixed plaque had the highest rate in people aged60-69（107cases,37.2%）,while noncalcified plaque was more common in people aged70-79（99cases,38.2%）. Of138patients age above80, calcified plaque had the highest percentage（52cases,37.7%）,among which,23cases with severe stenosis, which means the older the more severestenosis.
3. Univariate associations of smoking, drinking, plaque characteristic and stenosis withcognitive impairment
There was a significant trend for an association of cigarette smoking, alcohol drinking, plaque characteristic and stenosis with cognitive impairment. Current smokers were morelikely to be cognitive impairment (MCI χ~2=6.33，p=0.035),(dementia χ~2=6.16，p=0.042)than past smokers and those who had never smoked. Those who drank every day had ahigher risk for MCI (χ~2=6.52，p=0.023) and dementia（χ~2=6.83，p=0.019）than those whodrank every week, every month and occasional. Patients with mixed plaque andnoncalcified plaque were more likely to be MCI and dementia than patients with calcifiedplaque and control group. Plaque characteristic was associated with MCI（χ~2=7.02，P=0.012） and dementia（χ~2=7.26，P=0.0095）. Patients who with severe carotid stenosishad a higher risk for MCI（χ~2=7.43，P=0.009） and dementia（χ~2=7.87，P=0.0083） thanthose with moderate stenosis and control group. In addition, we found that education level,age and sex were also risk factors for cognitive impairment.
4. Multivariate associations of smoking, drinking, plaque characteristic and stenosiswith cognitive impairment: After excluding the risk factors of age, sex, education level,alcohol drinking and carotid plaque, there was still a significant association between currentsmoking with cognitive impairment（MCI RR=2.44,95%CI=1.49-4.08）、（dementiaRR=1.68,95%CI=1.06-2.73） than those who had never smoked and past smokers.Meanwhile, after excluding other risk factors, those who drank every day had asignificantly higher risk of MCI（RR=3.51,95%CI=1.91–6.84）and dementia（RR=3.75,95%CI=1.96-7.05）than occasional drinkers. There was a significant risk in those who drankevery week, MC（IRR=1.63,95%CI=1.07-2.77）、dementia（RR=1.46,95%CI=1.03-2.44）.After excluding other risk factors, there were still a significant association betweencognitive impairment with noncalcified plaque（MCI RR=2.78,95%CI=1.45-6.15）,（dementia RR=2.62,95%CI=1.30-6.02）, mixed plaque （MCI RR=2.96,95%CI=1.56–6.33）,（Dementia RR=2.54,95%CI=1.42-5.99）, and calcified plaque（MCIRR=1.57,95%CI=1.04–2.86）,（Dementia RR=1.31,95%CI=1.10–3.21）compared withcontrol group. While excluding other risk factors, there was a significant association withcognitive impairment and carotid artery stenosis. Compared with those with moderatestenosis（MCI RR=1.59,95%CI=1.02-2.84）、（dementia RR=1.73,95%CI=1.11-3.16）,patients with severe stenosis had higher risk of cognitive impairment（MCI RR=3.72,95%CI=1.88–7.18）、（dementia RR=3.82,95%CI=1.98–7.55）. In addition, after excludingsmoking, drinking, carotid plaque and stenosis, we found an association of cognitive impairment with age, sex and education.
Conclusions：
1. The incidence of hypertension, diabetes mellitus and cardiac disease of plaquegroup were significantly higher than that of control group. Meanwhile, the number ofcurrent smokers and daily drinking of plaque group were much more than control group.The MMSE score of plaque group were significantly lower than control group, and patientswith MCI and dementia were obvious more than control group.
2. In male patients, calcified plaque had the highest percentage, while mixed plaquewere more common in female. Female had higher rate of severe stenosis than male. Fromthe perspective of age distribution, mixed plaque had the highest rate in people aged60-69.while noncalcified plaque was more common in people aged70-79. Of patients age above80, calcified plaque had the highest percentage, who also had the more severe stenosis.
3. Current smoking, daily drinking, mixed plaque and noncalcified plaque had asignificant association with cognitive impairment.
4. After excluding the risk factors of age, sex and education level, current smoking,daily drinking, carotid plaque characteristic (noncalcified plaque, mixed plaque) and severecarotid stenosis is closely related to MCI and dementia in Chinese elderly people. Whiledrinking every week, calcified plaque and moderate carotid stenosis still have moderatecorrelations with cognitive impairment.
Section2
Study of carotid artery stenting on cognitive function in elderly people with mildcognitive impairment
Objects：Using case-control design method and prospective study, to investigate theeffect of CAS on neurocognitive function in patients with carotid stenosis and MCI.
Methods：A total of240inpatients with carotid stenosis and MCI were consecutively selected from the Department of Neurology, Daping Hospital, Chongqing from January2011to October2011. They were assigned to a treatment group (CAS+drugs therapy,167cases) or a control group (simple drug therapy,73cases) according to patient preference.CAS was performed in the week after the patients were assigned to the treatment group.Patients in the control group were treated with the same oral medication as the treatmentgroup.208patients finished the neuropsychological examinations (NPEs) and CTA,Computerized Tomography Perfusion (CTP) examination before treatment and6months offollow-up.
Results:
1. Analysis of baseline characteristics:
Among the240patients registered in this study,208patients (144in the CAS groupand64in the control group) finished the NPEs and analysis of cognitive scores aftertreatment and6months of follow-up. The pretreatment CTP examinations were performedin155of the218patients and the post-treatment scan in120patients (58%). Technicalsuccess was achieved in all patients in the CAS group. Following stent placement, theseverity of carotid stenosis decreased to21%vs68%preoperatively. The stenosis wasleft-sided in62.5%of patients. In the6month follow-up, we observed stent restenosis in4patients (2.8%), ipsilateral cerebral infarction in3patients (2.1%) and ipsilateral transientischemic attack (TIA) in4patients (2.8%). Of the64patients in the control group,2patients (3.1%) had ipsilateral cerebral infarction and3patients (4.7%) had ipsilateral TIA.
The patients in the two groups did not differ with regard to baseline characteristics,educational level, VRFs and NPEs prior to the procedure.
2. Neurocognitive and neurologic functions at baseline and6months after in the CASand control groups: In the CAS group, we observed significant improvements in the MMSE(before,24.6±1.7vs after,24.8±1.9; P=0.016), Montreal Cognitive Assessment (MOCA)(before,23.7±1.7vs after,24.1±2.0; P=0.006), Fuld Object Memory Evaluation (FOM)(before,13.8±2.2vs. after,14.0±2.3; P=0.031) and Wechsler Adult IntelligenceScale-digital span (WAIS-DS)(before,6.7±2.1vs. after,6.9±2.3; P=0.040). The change inMOCA was the most significant and rapid verbal retrieval (RVR)(before,25.7±2.1vs.after,25.9±2.3; P=0.201) also exhibited an increasing trend. In comparison, all testparameters were decreased at follow up in the control group, however the reductions were not statistically significant. National Institutes of Health Stroke Scale (NIHSS) and ADLvalues were similar in the two groups at the6month follow-up compared with baselineresults.
3. Correlation coefficients between perfusion change and changes in NPE scores: Ofthe84patients in the CAS group who received CTP follow-up,72(86%) demonstratedimprovements in ipsilateral brain perfusion following the procedure; however, noimprovements were identified in the control group. There are close correlations between thechange in perfusion and the change in MMSE (r=0.575) and MOCA (r=0.574), as well asmoderate correlations between the change in perfusion and the change in WIAS-DS(r=0.464), RVR (r=0.449) and FOME (r=0.375).
Conclusions：
1. Technical success was achieved in all patients in the CAS group. Following stentplacement, the severity of carotid stenosis decreased to21%vs68%preoperatively. In the6month follow-up, we observed stent restenosis in4patients (2.8%), ipsilateral cerebralinfarction in3patients (2.1%) and ipsilateral TIA in4patients (2.8%).Which means CAScan not only remove the patients with carotid artery stenosis, but also safe and effective.
2. In the CAS group, we observed significant improvements of NEPs after6monthsthan baseline. In comparison, all test parameters were decreased at follow up in the controlgroup, however the reductions were not statistically significant. Which indicates that CASincreases the neuropsychological tests scores in MCI patients.
3. CAS can improve ipsilateral brain perfusion and there were close correlationsbetween the improvements in perfusion and improvements in cognitive score.
痴呆最常见的类型就是阿尔茨海默病(Alzheimer’s disease, AD)和血管性痴呆（Vascular dementia, VaD）。以往大家认为AD与VaD是两类不同性质的疾病，有不同的发病机制和病理基础。近年来血管因素在AD发病中的作用不断受到重视，许多与血管因素或血流动力学相关的危险因素均能增大AD的患病风险。高血压、糖尿病、吸烟、饮酒和颈动脉硬化被认为是痴呆的常见血管危险因素（vascular risk factors，VRFs)。动脉硬化是老年人最常见的疾病之一。它是由多个血管危险因素造成的，导致内中膜厚度增加、斑块形成、颈动脉硬化性狭窄甚至闭塞的病理过程。颈动脉粥样硬化性斑块形成和狭窄不仅意味着颅内或者全身的动脉粥样硬化，而且也可能是导致认知功能减退的直接原因。颈动脉斑块引起的微栓子栓塞和脑血流动力学低灌注可能是无症状颈动脉狭窄导致认知功能损害的两个重要机制。
颈动脉内膜切除术(carotid endarterectomy，CEA)或颈动脉支架成形术(carotidartery stenting，CAS)是目前治疗颈动脉斑块和狭窄的常用手段。颈动脉血管成形术（CEA和CAS）主要通过改善脑组织血流灌注、减少斑块脱落引起的脑栓塞事件、减轻脑白质病变等机制来改善颈动脉狭窄患者的认知功能。然而颈动脉血管成形术对认知功能的影响仍然充满争议。很多因素会导致患者术后认知功能产生差异，包括患者基线的灌注状态，术中的微栓塞，短暂的血流阻断和血流动力学改善后患者的获益程度等等。因此有必要制定更加客观的近期和远期评价标准，采用完善、细化的神经心理学测试，科学严谨的实验设计，结合影像学检查对CAS术后不同时期的认知功能变化进行评估。
本课题开展了颈动脉硬化与中国老年人认知损害的相关性研究,并针对其行CAS治疗的疗效观察，共分为两个部分：(1)通过对重庆市老年人认知功能的现状调查来揭示颈动脉硬化、吸烟、饮酒与中国老年人的认知损害的相关性。(2)采用病例对照的前瞻性研究，对颈动脉狭窄的MCI病人分别行CAS和药物治疗，并在治疗前后分别进行认知功能评价和随访，探讨CAS对颈动脉狭窄的MCI患者认知功能的影响。
第一部分颈动脉硬化对老年人认知功能损害的研究
目的：在中国，老年人认知损害的发生率日益提高，与其有关的危险因素研究备受重视。本研究主要通过现状调查研究明确颈动脉硬化、吸烟、饮酒与中国老年人的认知损害的相关性。
对象和方法：连续性选择2011年1月－2012年10月期间来自重庆大坪医院神经内科的1367例60岁以上病人进行了现状调查研究。通过B超及64排CT筛查，691例有颈动脉斑块的病人纳入斑块组，676例无斑块的纳入对照组。斑块组患者通过64排CT血管造影(Computerized Tomography angiography，CTA)或数字减影血管造影(digital subtraction angiography，DSA)检查确定狭窄程度和斑块类型,并进行一般临床资料收集,通过简易智能量表(Mini-Mental State Examination, MMSE)和日常生活能力量表(Activities of Daily Living, ADL)来评价患者的认知功能。采用χ2test和逻辑回归分析寻找颈动脉硬化与认知损害的相关性。
结果：
1.基线特征分析
入组人数1367名，其中男性803人(58.7％)，女性564人(41.3%)，平均年龄70.4岁。颈动脉斑块组691名（50.5％），对照组676名（49.5％）。MCI患者116例（8.49%），痴呆患者46例（3.37%）。颈动脉斑块组与对照组在年龄、性别、受教育程度、血脂水平上无明显差异。斑块组高血压、糖尿病、心脏病的发病率较对照组明显增高。同时斑块组中当前吸烟与每日饮酒的人数较对照组明显增多（p<0.01）。斑块组的平均MMSE评分（25.9±1.7）较对照组（27.1±1.5）显著降低（p<0.01），且斑块组中MCI患者（74例vs42例，p<0.01）、痴呆患者（31例vs15例，p<0.05）较对照组明显增多。
2.斑块组中斑块性质、狭窄程度的性别、年龄分布特征
在691例颈动脉狭窄组患者中，男性406例（58.8%），女性285例（41.2%）。男性患者中，钙化斑147例（36.2%）比例最高，女性中混合斑106例（37.2%）更常见。重度狭窄患者中，男性50例（12.3%），女性51例（17.9%），提示女性重度狭窄率更高。从年龄分布看，在60-69岁人群中，混合斑比率最高（107例37.2%）。而70-79岁人群中非钙斑更常见（99例38.2%）。大于80岁138例患者中以钙化斑为主（52例37.7%），其中，重度狭窄患者23例（16.7%），提示高龄患者的狭窄率更高。
3颈动脉斑块性质、狭窄程度与老年认知损害的单因素分析
颈动脉斑块性质和狭窄程度、吸烟、饮酒与老年认知损害有着显著联系。混合斑和非钙斑相对于钙化斑和对照组更容易引起认知损害，斑块性质与MCI（χ2=7.02，P=0.012）和痴呆（χ2=7.26，P=0.0095）密切相关。颈动脉重度狭窄患者有着更高的发生MCI（χ2=7.43，P=0.009）和痴呆（χ2=7.87，P=0.0083）的风险相对于对照组和轻度狭窄患者。当前吸烟者较不吸烟和戒烟者发生认知损害（MCIχ2=6.33，p=0.035）、（痴呆χ2=6.16，p=0.042）的几率显著增高。每日饮酒者相对于每周、每月饮酒者及偶尔饮酒者更容易发生认知损害（MCIχ2=6.52，p=0.023）、（痴呆χ2=6.83，p=0.019）。另外，我们发现受教育程度、年龄、性别同样也是认知损害的危险因素。
4颈动脉斑块性质、狭窄程度与老年认知损害的多元逻辑回归分析
在排除吸烟、饮酒、颈动脉狭窄等其他危险因素后，非钙斑（MCI RR=2.78,95%CI=1.45-6.15）、（痴呆RR=2.62,95%CI=1.30-6.02）、混合斑（MCI RR=2.96,95%CI=1.56–6.33）、（痴呆RR=2.54,95%CI=1.42-5.99）、钙化斑（MCI RR=1.57,95%CI=1.04–2.86）、（痴呆RR=1.31,95%CI=1.10–3.21）依然与认知损害有显著联系和对照组相比。同样当排除其他危险因素后颈动脉狭窄和认知损害同样密切相关，相对于颈动脉轻度狭窄患者（MCI RR=1.59,95%CI=1.02-2.84）、（痴呆RR=1.73,95%CI=1.11-3.16），重度狭窄患者的认知损害风险更高,（MCA RR=3.72,95%CI=1.88–7.18）、（痴呆RR=3.82,95%CI=1.98–7.55）。在排除了年龄、性别、受教育程度、饮酒和颈动脉斑块、狭窄等危险因素后，同不吸烟者和戒烟者相比，当前吸烟同与认知损害（MCI RR=2.44,95%CI=1.49-4.08）、（痴呆RR=1.68,95%CI=1.06-2.73）有着显著联系。同样在排除了其他危险因素后，每日饮酒者较偶尔饮酒者发生MCI（RR=3.51,95%CI=1.91–6.84）和痴呆（RR=3.75,95%CI=1.96-7.05）的风险更高。而每周饮酒者认知损害的风险依然在上升MCI（RR=1.63,95%CI=1.07-2.77）、痴呆（RR=1.46,95%CI=1.03-2.44）。另外，当排除吸烟、饮酒、颈动脉斑块和狭窄后,认知损害与年龄、性别、受教育程度也有着密切联系。
结论：
1.颈动脉斑块组高血压、糖尿病、心脏病的发病率较对照组明显增高，斑块组中当前吸烟与每日饮酒的人数较对照组明显增多。斑块组的平均MMSE评分较对照组显著降低，斑块组中MCI患者、痴呆患者较对照组明显增多。
2.男性患者中钙化斑比例最高，女性中混合斑更常见，女性重度狭窄率更高。在60-69岁人群中，混合斑比率最高，而70-79岁人群中非钙斑更常见，大于80岁患者中以钙化斑为主，且重度狭窄率更高。
3.混合斑和非钙斑、颈动脉重度狭窄、当前吸烟、每日饮酒与老年认知损害密切相关。
4.在排除了年龄、性别、受教育程度等危险因素后，混合斑和非钙斑、颈动脉重度狭窄、当前吸烟、每日饮酒是老年认知损害的独立危险因素，而每周饮酒、钙化斑块和颈动脉轻度狭窄与认知损害依然有着显著的联系。
第二部分颈动脉支架介入治疗老年轻度认知功能损害的研究
目的：通过病例对照的前瞻性研究来观察颈动脉支架对颈动脉狭窄伴轻度认知功能损害患者认知功能的影响，明确颈动脉支架能否改善颈动脉狭窄伴轻度认知功能损害患者的认知功能。
对象和方法:连续性选择2011年1月-2012年10月期间在我科住院的诊断为颈动脉狭窄伴MCI病人，共登记240人。依据患者意愿分为支架治疗组和对照组。支架组1周内行CAS及强化药物治疗，对照组行强化药物治疗。两组患者（208例）完成了治疗前及治疗后6个月的神经心理学检查及CTA、CTP等影像学检查、随访。
结果：
1.基线特征分析
在登记的240例患者中有208例（支架组144例，对照组68例）完成了治疗及治疗后6个月的神经心理学检查。有120例（CAS组84例，药物组36例）接受了初始和6个月内的CTP随访检查。支架组手术成功率100%，术前颈动脉平均狭窄率为68%（50%～96%），其中左侧颈动脉狭窄占62.5%。支架术后平均狭窄为21%(0%–60%)。经术后6个月随访，支架组144例患者中有4例（2.8%）出现支架内血管腔再狭窄，同侧脑梗塞3例（2.1%），同侧TIA4例（2.8%）。对照组64例患者随访中，发生同侧脑梗塞2例（3.1%），同侧TIA3例（4.7%）。
治疗前两组患者在年龄、性别、受教育程度、血管危险因素、血管狭窄率、神经功能评分、认知功能评分等方面均无显著差异。
2．支架治疗对患者认知功能的影响
支架组患者术后6个月MMSE（before24.6±1.7versus after24.8±1.9P=0.016），MOCA（before23.7±1.7versus after24.1±2.0P=0.006），FOM（before13.8±2.2versus after14.0±2.3P=0.031）, WAIS-DS（before6.7±2.1versus after6.9±2.3P=0.040）,较术前有明显改善，其中MOCA改善最为显著。而RVR（before25.7±2.1versus after25.9±2.3P=0.201）也有改善的趋势。相比之下对照组患者6个月后神经心理学评分与基线数据比较有下降的趋势，虽然没有达到有统计学意义。两组病人6个月后NIHSS、ADL值较基线数据无明显变化。
3.脑灌注改善与认知功能改善的相关性
CAS组84例接受CTP随访的患者中有72例（86%）出现了术后同侧脑灌注改善，而对照组36例患者中无1例出现灌注改善。CAS组84例患者的CTP灌注改善与MMSE(r=0.574)、MOCA(r=0.574)评分改善之间有较为密切的联系，与WIAS-DS评分改变(r=0.464), RVR评分改变(r=0.449)，FOM评分改变(r=0.375)之间也有着适度的联系。
结论：
1.支架组手术成功率100%，术前平均狭窄率为68%，术后平均狭窄为21%。经术后6个月随访，支架内血管腔再狭窄（2.8%），同侧脑梗塞（2.1%），同侧TIA（2.8%）。提示支架治疗能成功解除患者颈动脉狭窄，且安全、有效。
2.支架组患者术后6个月的认知功能评分较术前有明显改善，而对照组患者6个月后神经心理学评分与治疗前比较有下降的趋势，提示支架治疗能改善MCI患者的认知功能。
3.支架治疗能改善患者同侧脑血流灌注，且患者的灌注改善与认知功能的改善密切相关。
As China is entering aging society, the incidence of cognitive impairment in elderlypeople rises with increasing age and the study of cognitive impairment is being paid greatattention. Cognitive impairment can be classified into mild cognitive impairment (MCI) anddementia in two phases. MCI is the early stage of dementia and associated with anincreased risk for progression to Alzheimer diseases (AD)(10%to15%per year), which is10times that in normal population. Large numbers of scholars at home and abroadcommitted to research the risk factors for cognitive impairment in the elderly. MCI isatteached excessive concern as an early stage of dementia, so it is very important to studythe risk factors in the transformation process of MCI to dementia and cognitive dysfunctionof the patients with MCI. Carotid plaque and stenosis is not only considered as anindependent risk factor of ischemic stroke and cognitive impairment, but also known to bean independent risk factor in the transformation process of MCI to dementia. Therefore,understanding and treatment of carotid artery stenosis at the MCI stage may be an importantstrategy for preventing and delaying the progression to dementia.
The most common clinical type of elderly cognitive impairment are AD and vasculardementia (VaD). It is generally accepted previously that the VaD and AD are two types ofdiseases, which have different pathological basis and susceptible gene. But in recent yearsthe role of vascular factors in the pathogenesis of AD is gradually taken seriously. Manyrisk factors associated with vascular factors or hemodynamic can increase the risk of AD.Hypertension, diabetes, hyperlipidemia, current smoking habit, daily alcohol consumptionand Carotid atherosclerosis are considered as common vascular risk factors（VRFs) ofdementia. Carotid atherosclerosis is most popular among elderly people, which can causevascular intimal thickening, carotid plaque, vascular stenosis and occlusion. Carotidatherosclerosis plaque and stenosis often means atherosclerosis of total systemic vascularand encephalic, which maybe the direct causes of cognition decline. AsymptomaticSpontaneous cerebral emboli (SCE) and cerebral hemodynamics low perfusion are associated with an accelerated cognitive and functional decline in asymptomatic patients(>70%stenosis).
CEA (carotid endarterectomy) and CAS (carotid artery stenting) have a positive effecton severe carotid artery stenosis, which can improve cerebral perfusion and reducemicro-emboli derived from carotid atherosclerotic plaques and leukodystrophy. However,the effects of CAS on cognitive outcome in patients with carotid artery stenosis arecontroversial. A number of factors may lead to the variation in cognitive responsesobserved in the clinic, including differences in baseline cerebral perfusion status,detrimental effects on procedural emboli, temporary flow interruption and the beneficialeffect of improved cerebral hemodynamics. So a more objective evaluation of short-andlong-term standards, complete and detailed neuropsychological testing, scientificallyrigorous experimental design are required to evaluate the long-term curative effect of CASon the improvement of cognitive function in patients with carotid artery stenosis and MCI.
The research about relationship between carotid atherosclerosis and cognitiveimpairment and corresponding treatment of CAS include two parts:(1) To observerelationship between carotid atherosclerotic, smoking, alcohol Intake, and cognitiveimpairment in Chinese elderly people.(2) Using case-control design method and theprospective study, to investigate the effect of CAS on neurocognitive function in patientswith carotid artery stenosis and MCI.
Section1
Study of the relationship between carotid atherosclerotic and cognitiveimpairment among elderly people
Objects: the incidence of cognitive impairment is increasing; and its risk factors isattached with great importance. This report focuses on investigating the relationshipbetween carotid atherosclerosis, smoking, alcohol Intake, and cognitive impairment inChinese elderly people.
Methods：From January2011to October2012,1367patients aged60years old andover were enrolled from Daping hospital of Chongqing. Screening with high-resolutionB-mode ultrasound,691paitents with carotid atherosclerosis plaque were assigned toplaque group, rest of676cases of plaque-free into the control group. In plaque group,Computerized Tomography angiography (CTA) by a Light Speed VCT64-slice scanner or (DSA)were scheduled to assess the plaque characteristics and carotid artery stenosis.Cognitive function was measured by the Mini-Mental State Examination (MMSE) andActivities of Daily Living (ADL). The χ~2test and logistic regression was used to find therelationship between carotid atherosclerosis, smoking, alcohol intake, and cognitiveimpairment.
Results：
1.Baseline characterictics in overall patients: In total,803men(58.7％) and564women(41.3%) were registered in this study (mean age of70.4years old),691cases inplaque group（50.5％） and676cases in control group （49.5％）. Of1367patients,116cases had MCI,46cases had dementia. The patients in the two groups did not differ withregard to age, gender, education level and hyperlipidemia. The incidence of hypertension,diabetes mellitus and cardiac disease of plaque group were significantly higher than that ofcontrol group. Meanwhile, the number of current smokers and daily drinking of plaquegroup were much more than control group（p<0.01）. The MMSE score of plaque group（25.9±1.7）were significantly lower than that of the control group（27.1±1.5）（p<0.01）,and patients with MCI（74vs42，p<0.01）,dementia（31vs15，p<0.05）were obvious muchmore than control group.
2．Plaque characteristic, degree of stenosis, gender and age distribution in plaquegroup: of691cases in plaque group,406were male（58.8%），285were female（41.2%）.In male patients,147cases（36.2%）had calcified plaque which had the highest percentage,while mixed plaque106（37.2%） were more common in female. Among patients withsevere stenosis,50cases were male（12.3%）,51cases were female（17.9%）, prompting thatfemale had higher rate of severe carotid stenosis than male. From the perspective of agedistribution, mixed plaque had the highest rate in people aged60-69（107cases,37.2%）,while noncalcified plaque was more common in people aged70-79（99cases,38.2%）. Of138patients age above80, calcified plaque had the highest percentage（52cases,37.7%）,among which,23cases with severe stenosis, which means the older the more severestenosis.
3. Univariate associations of smoking, drinking, plaque characteristic and stenosis withcognitive impairment
There was a significant trend for an association of cigarette smoking, alcohol drinking, plaque characteristic and stenosis with cognitive impairment. Current smokers were morelikely to be cognitive impairment (MCI χ~2=6.33，p=0.035),(dementia χ~2=6.16，p=0.042)than past smokers and those who had never smoked. Those who drank every day had ahigher risk for MCI (χ~2=6.52，p=0.023) and dementia（χ~2=6.83，p=0.019）than those whodrank every week, every month and occasional. Patients with mixed plaque andnoncalcified plaque were more likely to be MCI and dementia than patients with calcifiedplaque and control group. Plaque characteristic was associated with MCI（χ~2=7.02，P=0.012） and dementia（χ~2=7.26，P=0.0095）. Patients who with severe carotid stenosishad a higher risk for MCI（χ~2=7.43，P=0.009） and dementia（χ~2=7.87，P=0.0083） thanthose with moderate stenosis and control group. In addition, we found that education level,age and sex were also risk factors for cognitive impairment.
4. Multivariate associations of smoking, drinking, plaque characteristic and stenosiswith cognitive impairment: After excluding the risk factors of age, sex, education level,alcohol drinking and carotid plaque, there was still a significant association between currentsmoking with cognitive impairment（MCI RR=2.44,95%CI=1.49-4.08）、（dementiaRR=1.68,95%CI=1.06-2.73） than those who had never smoked and past smokers.Meanwhile, after excluding other risk factors, those who drank every day had asignificantly higher risk of MCI（RR=3.51,95%CI=1.91–6.84）and dementia（RR=3.75,95%CI=1.96-7.05）than occasional drinkers. There was a significant risk in those who drankevery week, MC（IRR=1.63,95%CI=1.07-2.77）、dementia（RR=1.46,95%CI=1.03-2.44）.After excluding other risk factors, there were still a significant association betweencognitive impairment with noncalcified plaque（MCI RR=2.78,95%CI=1.45-6.15）,（dementia RR=2.62,95%CI=1.30-6.02）, mixed plaque （MCI RR=2.96,95%CI=1.56–6.33）,（Dementia RR=2.54,95%CI=1.42-5.99）, and calcified plaque（MCIRR=1.57,95%CI=1.04–2.86）,（Dementia RR=1.31,95%CI=1.10–3.21）compared withcontrol group. While excluding other risk factors, there was a significant association withcognitive impairment and carotid artery stenosis. Compared with those with moderatestenosis（MCI RR=1.59,95%CI=1.02-2.84）、（dementia RR=1.73,95%CI=1.11-3.16）,patients with severe stenosis had higher risk of cognitive impairment（MCI RR=3.72,95%CI=1.88–7.18）、（dementia RR=3.82,95%CI=1.98–7.55）. In addition, after excludingsmoking, drinking, carotid plaque and stenosis, we found an association of cognitive impairment with age, sex and education.
Conclusions：
1. The incidence of hypertension, diabetes mellitus and cardiac disease of plaquegroup were significantly higher than that of control group. Meanwhile, the number ofcurrent smokers and daily drinking of plaque group were much more than control group.The MMSE score of plaque group were significantly lower than control group, and patientswith MCI and dementia were obvious more than control group.
2. In male patients, calcified plaque had the highest percentage, while mixed plaquewere more common in female. Female had higher rate of severe stenosis than male. Fromthe perspective of age distribution, mixed plaque had the highest rate in people aged60-69.while noncalcified plaque was more common in people aged70-79. Of patients age above80, calcified plaque had the highest percentage, who also had the more severe stenosis.
3. Current smoking, daily drinking, mixed plaque and noncalcified plaque had asignificant association with cognitive impairment.
4. After excluding the risk factors of age, sex and education level, current smoking,daily drinking, carotid plaque characteristic (noncalcified plaque, mixed plaque) and severecarotid stenosis is closely related to MCI and dementia in Chinese elderly people. Whiledrinking every week, calcified plaque and moderate carotid stenosis still have moderatecorrelations with cognitive impairment.
Section2
Study of carotid artery stenting on cognitive function in elderly people with mildcognitive impairment
Objects：Using case-control design method and prospective study, to investigate theeffect of CAS on neurocognitive function in patients with carotid stenosis and MCI.
Methods：A total of240inpatients with carotid stenosis and MCI were consecutively selected from the Department of Neurology, Daping Hospital, Chongqing from January2011to October2011. They were assigned to a treatment group (CAS+drugs therapy,167cases) or a control group (simple drug therapy,73cases) according to patient preference.CAS was performed in the week after the patients were assigned to the treatment group.Patients in the control group were treated with the same oral medication as the treatmentgroup.208patients finished the neuropsychological examinations (NPEs) and CTA,Computerized Tomography Perfusion (CTP) examination before treatment and6months offollow-up.
Results:
1. Analysis of baseline characteristics:
Among the240patients registered in this study,208patients (144in the CAS groupand64in the control group) finished the NPEs and analysis of cognitive scores aftertreatment and6months of follow-up. The pretreatment CTP examinations were performedin155of the218patients and the post-treatment scan in120patients (58%). Technicalsuccess was achieved in all patients in the CAS group. Following stent placement, theseverity of carotid stenosis decreased to21%vs68%preoperatively. The stenosis wasleft-sided in62.5%of patients. In the6month follow-up, we observed stent restenosis in4patients (2.8%), ipsilateral cerebral infarction in3patients (2.1%) and ipsilateral transientischemic attack (TIA) in4patients (2.8%). Of the64patients in the control group,2patients (3.1%) had ipsilateral cerebral infarction and3patients (4.7%) had ipsilateral TIA.
The patients in the two groups did not differ with regard to baseline characteristics,educational level, VRFs and NPEs prior to the procedure.
2. Neurocognitive and neurologic functions at baseline and6months after in the CASand control groups: In the CAS group, we observed significant improvements in the MMSE(before,24.6±1.7vs after,24.8±1.9; P=0.016), Montreal Cognitive Assessment (MOCA)(before,23.7±1.7vs after,24.1±2.0; P=0.006), Fuld Object Memory Evaluation (FOM)(before,13.8±2.2vs. after,14.0±2.3; P=0.031) and Wechsler Adult IntelligenceScale-digital span (WAIS-DS)(before,6.7±2.1vs. after,6.9±2.3; P=0.040). The change inMOCA was the most significant and rapid verbal retrieval (RVR)(before,25.7±2.1vs.after,25.9±2.3; P=0.201) also exhibited an increasing trend. In comparison, all testparameters were decreased at follow up in the control group, however the reductions were not statistically significant. National Institutes of Health Stroke Scale (NIHSS) and ADLvalues were similar in the two groups at the6month follow-up compared with baselineresults.
3. Correlation coefficients between perfusion change and changes in NPE scores: Ofthe84patients in the CAS group who received CTP follow-up,72(86%) demonstratedimprovements in ipsilateral brain perfusion following the procedure; however, noimprovements were identified in the control group. There are close correlations between thechange in perfusion and the change in MMSE (r=0.575) and MOCA (r=0.574), as well asmoderate correlations between the change in perfusion and the change in WIAS-DS(r=0.464), RVR (r=0.449) and FOME (r=0.375).
Conclusions：
1. Technical success was achieved in all patients in the CAS group. Following stentplacement, the severity of carotid stenosis decreased to21%vs68%preoperatively. In the6month follow-up, we observed stent restenosis in4patients (2.8%), ipsilateral cerebralinfarction in3patients (2.1%) and ipsilateral TIA in4patients (2.8%).Which means CAScan not only remove the patients with carotid artery stenosis, but also safe and effective.
2. In the CAS group, we observed significant improvements of NEPs after6monthsthan baseline. In comparison, all test parameters were decreased at follow up in the controlgroup, however the reductions were not statistically significant. Which indicates that CASincreases the neuropsychological tests scores in MCI patients.
3. CAS can improve ipsilateral brain perfusion and there were close correlationsbetween the improvements in perfusion and improvements in cognitive score.
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