Carotid Revascularization Does Not Improve Cognition in Asymptomatic Severe Carotid Stenosis

In patients with severe asymptomatic carotid artery stenosis, carotid revascularization—either carotid artery stenting (CAS) or carotid endarterectomy (CEA)—added to intensive medical management (IMM) did not significantly improve cognitive function compared with IMM alone over up to 4 years. The CREST-2 randomized clinical trials included 2,366 US patients, of whom 2,165 underwent cognitive assessments using five tests covering learning, memory, executive function, attention, and processing speed. At 4 years, the adjusted difference in composite cognitive scores between CAS + IMM and IMM alone was 0.03 SD, while the difference between CEA + IMM and IMM alone was 0.02 SD, with no significant benefit in any individual cognitive domain. A separate CREST-2 substudy further examined whether patients with impaired cerebral blood flow might benefit more from revascularization. Among participants with reduced baseline cognition, revascularization provided no significant cognitive advantage over IMM alone, and the degree of baseline cerebral hemodynamic impairment did not modify the treatment effect. Together, these findings suggest that, in chronic asymptomatic severe carotid stenosis, revascularization does not improve cognitive function, even among patients with evidence of cerebral hemodynamic impairment. Source: https://jamanetwork.com/