Revascularization in Asymptomatic Carotid Artery Stenosis With Hemodynamic Impairment and Cognitive Outcomes: The CREST-H Substudy of the CREST-2 Randomized Clinical Trial.

Revascularization plus intensive medical management showed no 1-year cognitive benefit over intensive medical management alone across cerebral hemodynamic impairment levels in asymptomatic ICA stenosis.

• Why it matters: Cerebral hemodynamic impairment is linked to reduced cognition in asymptomatic internal carotid artery stenosis, but it was uncertain whether revascularization could improve cognitive dysfunction.
• What they did: In CREST-2 (61 North American sites), 291 participants with complete data were randomized to revascularization (endarterectomy or stenting) plus IMM versus IMM alone, with baseline hemodynamic impairment measured by delayed perfusion time-to-peak.
• The result: Among 51 participants with baseline reduced cognition (cognitive z score ≤-1.0 SD), the adjusted 1-year cognitive z score difference was -0.15 SD (95% CI, -0.54 to 0.24), and the treatment-by-hemodynamic interaction was not significant (β=0.018; P=.40).