MILD COGNITIVE IMPAIRMENT IN PATIENTS WITH CAROTID DISEASE

1. 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

2. Conflict of Interest DisclosureIrena 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.

3. 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 (>70%) and /or occlusion of the internal carotid artery (ICA) – ICA s/o • Associated with silent cerebral infarctions

4. Narrowing or occlusion of carotid arteries (ICA) State of increased risk for cerebrovascular incident Increased risk for cognitive decline ASYMPTOMATIC CAROTID DISEASE

5. 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

7. 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)

8. 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)

9. DEMOGRAPHIC & VASCULAR RISK DATA * sign. difference (z-test) ** t-test

10. INCLUSION CRITERIA PATIENTS: Asymptomatic (stroke/TIA free) patients; right-handed CAT scan normal Diagnosed with severe ICA stenosis (>70%) or with ICA occlusion CONTROLS Asymptomatic (stroke/TIA free) patients; right-handed Without severe ICA stenosis (>70%) 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 CRITERIA FOR THE STUDY

11. 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)

12. CAROTID PATHOLOGY: THE SIDE & THE DEGREE OF STENOSIS

13. COGNITIVE IMPAIRMENT:patients vs. controls * z-test Proportion of abnormal scores (indicating cognitive impairment) in patients and controls when tested by MMSE and MoCA

14. TOTAL COGNITIVE TESTING SCORES: patients vs. controls Patients and controls did not differ significantly in MMSE scores. Median total MoCA scores were significantly lower in patients.

15. MoCA SUBTESTS SCORES: patients vs. controls

16. COGNITIVE IMPAIRMENT & VASCULAR RISK 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

17. COGNITIVE IMPAIRMENT & VASCULAR RISK • Patients with ICA s/o AND diabetes performed worse (p <0.001) at delayed recall • Patients with ICA s/o AND increased BMI performed worse at delayed recall (p=0.02)* • Patients with diabetes had lower attention (p=0.065)* and naming (p=0.06)* MoCA subtests scores • Hyperlipemic patients scored worse at attention (p=0.064)* • Patients with hypertension scored lower at naming MoCA subtests (p=0.04)* • The side of stenosis was not associated with lower performance on MoCA subtests * Differences not statistically significant

18. 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 ?

19. 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!)

20. 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!)

21. 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)

22. 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

23. THANK YOU!