Analysis of influencing factors on early neurological function improvement after carotid endarterectomy in patients with moderate to severe extracranial stenosis of unilateral internal carotid artery
Objective To explore the correlation between the characteristics of carotid artery plaques and the improvement of neurological function in patients with moderate to severe stenosis of the extracranial segment of the unilateral internal carotid artery after carotid endarterectomy(CEA).Methods A retrospective study was conducted on 145 patients who underwent CEA with complete follow-up data due to moderate to severe stenosis of the unilateral internal carotid artery in the Neurosurgery Department of the First Affiliated Hospital of Soochow University from January 2017 to June 2023.According to the difference between the National Institutes of Health stroke scale(NIHSS)score preoperative and NIHSS score at 24 hours post CEA(ΔNIHSS score),the patients are divided into a group with improved neurological function(ΔNIHSS score≥2 points or postoperative 24 hours NIHSS score was 0 point)and group with no improvement in neurological function(ΔNIHSS score＜2 points).Collect clinical and imaging data from all patients and compare them between groups.Clinical data include age,gender,hypertension,diabetes,history of coronary heart disease,smoking history,preoperative clinical manifestations(transient ischemic attack,stroke,asymptomatic),preoperative systolic blood pressure,diastolic blood pressure,dyslipidemia,blood biochemical indicators(high-density lipoprotein cholesterol,low-density lipoprotein cholesterol,triacylglycerol,total cholesterol,fasting blood glucose,hypersensitive C-reactive protein).Patient information regarding CEA preoperative and 24-hour postoperative NHISS scores,as well as preoperative modified Rankin scale(mRS)scores were collected.The imaging data includes preoperative carotid artery ultrasound and CT angiography evaluation of the degree of carotid artery stenosis(moderate stenosis with a stenosis rate of 50%to 69%,severe stenosis with a stenosis rate of 70%to 99%),plaque echo(mainly low echo,mainly medium echo,mainly high echo),fibrous cap integrity(complete or incomplete),whether it is an ulcerative plaque,whether it is calcified,and the location of calcification(surface and base)and the hemodynamic parameters of the affected middle cerebral artery(MCA)measured by transcranial Doppler ultrasound before surgery,1 week,1 month,and 3 months after surgery(mean blood flow velocity[Vm],vascular pulsatility index[PI]).The hemodynamic parameters of the affected MCA at different time points before and after surgery within the group were compared.Univariate analysis on two sets of clinical and imaging data was performed,and parameters with P＜0.05 were incorporated into multivariate Logistic regression analysis to explore the influencing factors of early neurological function improvement after CEA surgery.A simplified predictive model was established based on the P＜0.05 parameter in the results of multiple Logistic regression analysis.The working characteristic curve of the subjects was plotted,and the area under the curve(AUC)was calculated to determine the relevant risk factors.The predictive model was used to evaluate the predictive efficacy of early neurological function improvement in patients with moderate to severe stenosis of the unilateral extracranial carotid artery undergoing CEA.Results Among 145 patients with moderate to severe stenosis of the extracranial segment of the unilateral internal carotid artery undergoing CEA,there were 117 cases in the group with improved neurological function 24 hours after surgery and 28 cases in the group without improved neurological function.(1)Compared with the group with improved neurological function,patients in the group without improved neurological function had higher preoperative systolic blood pressure([139±13]mmHg vs.[129±7]mmHg),preoperative NIHSS scores(3[2,4]scores vs.1[0,2]scores)and NIHSS scores 24 hours after surgery(2[1,3]scores vs.0[0,1]scores),and the differences were statistically significant(all P＜0.01);there was no statistically significant difference in other clinical baseline data between the two groups(all P＞0.05).(2)Compared with the group with improved neurological function,patients in the group without improved neurological function had a higher incidence of ulcerative plaques(64.3%vs.33.3%),the difference was statistically significant(P＜0.01),while there was no statistically significant difference in the degree of carotid artery stenosis,fiber cap integrity,plaque echo,and plaque calcification location between the two groups(all P＞0.05).(3)The overall effect results showed that there was a statistically significant difference in MCA Vm in both groups between various time points before and after CEA surgery(Finteraction = 7.307,P = 0.008;Fgroup = 13.621,P＜0.01;Ftime = 248.065,P＜0.01);there was a statistically significant difference in MCA PI at each time point before and after CEA surgery in each group(Wald χ2time =134.110,P＜0.01),while there was no statistically significant difference in MCA PI at each time point between two groups(Wald χ2group =0.562,P =0.453).Compared with preoperative,the MCA Vm and MCA PI on the affected side of the two groups of patients increased at 1 week,1 month,and 3 months after surgery,and the differences were statistically significant(all P＜0.01);there was no statistically significant difference in MCA Vm and MCA PI in both groups between 1 month and 3 months after surgery and 1 week after surgery(all P＞0.05).The inter group comparison results showed that the preoperative MCA Vm in the group with no improvement in neurological function was lower than that in the group with improved neurological function,and the difference was statistically significant(P＜0.05),and there was no statistically significant difference in MCA Vm between two groups at the remaining time point(all P＞0.05).(4)Multivariate Logistic regression analysis showed that preoperative systolic blood pressure(OR,0.880,95%CI 0.822-0.943,P＜0.01),preoperative NIHSS score(OR,0.105,95%CI 0.023-0.473,P = 0.003),ulcerative plaques(OR,4.060,95%CI 1.202-13.711,P =0.024),and preoperative MCA Vm(OR,1.285,95%CI 1.144-1.443,P＜0.01)were the influencing factors for early neurological function improvement in CEA patients.(5)The joint prediction model predicted an AUC of 0.972(95%CI 0.885-0.969,P＜0.01)for early postoperative neurological improvement in patients with moderate to severe extracranial stenosis of the unilateral internal carotid artery after CEA,which was higher than the predictive power of a single factor.Conclusion Preoperative systolic blood pressure,NIHSS score,ulcerative plaques,and MCA Vm are influencing factors for postoperative symptoms and early neurological function improvement in CEA patients.
Carotid artery stenosisCharacteristics of atherosclerotic plaqueCarotid endarterectomyEarly neurological function improvement
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