Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Published online before print June 14, 2006, 10.1148/radiol.2402051043
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
2402051043v1
240/2/508    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mlekusch, W.
Right arrow Articles by Schillinger, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mlekusch, W.
Right arrow Articles by Schillinger, M.
(Radiology 2006;240:508-514.)
© RSNA, 2006

Neuroradiology

Is There Improvement of "Vascular Depression" after Carotid Artery Stent Placement?1

Wolfgang Mlekusch, MD, Irene Mlekusch, PhD, Erich Minar, MD, Markus Haumer, MD, Christoph W. Kopp, MD, Ramazanali Ahmadi, MD, Johannes Lehrner, PhD and Martin Schillinger, MD

1 From the Department of Internal Medicine II, Departments of Angiology (W.M., I.M., E.M., M.H., C.W.K., R.A., M.S.) and Neurology (J.L.), Vienna General Hospital, Medical School, Waehringer Guertel 18-20, A-1090 Vienna, Austria. Received June 21, 2005; revision requested August 18; revision received August 29; accepted September 21; final version accepted September 28. Address correspondence to W.M. (e-mail: wolfgang.mlekusch{at}meduniwien.ac.at).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 References
 
Purpose: To prospectively evaluate if high-grade (≥80% luminal narrowing) internal carotid artery stenosis is associated with depressive symptoms and if carotid artery stent placement (CAS) potentially improves depressive symptoms.

Materials and Methods: The study was approved by the local ethics committee, and informed consent was obtained from all subjects. One hundred forty-three patients (91 men, 52 women; interquartile range, 63–76 years) undergoing CAS because of asymptomatic high-grade (≥80% luminal narrowing) carotid artery stenosis and 102 control subjects (64 men, 38 women; interquartile range, 63–73 years) with advanced peripheral artery disease and without carotid artery stenosis undergoing lower-limb percutaneous transluminal angioplasty were included. Substantial depressive symptoms (defined as a Beck Depression Inventory score of 10 or higher) were recorded at baseline and at 4 weeks (follow-up) after the percutaneous procedures. The {chi}2 test, Mann-Whitney U test, McNemar test, Wilcoxon rank sum test, and two-group t test were used to check for statistical significance.

Results: A significantly higher prevalence of depressive symptoms was found in patients with carotid artery stenosis than in control subjects with peripheral artery disease at baseline (33.6% vs 16.7%, P = .003). At follow-up, a significant reduction of depressive symptoms was found in patients who underwent CAS (33.6% vs 9.8%, P < .001). The frequency of depressive symptoms remained unaffected in control subjects (16.7% vs 13.0%, P = .1).

Conclusion: High-grade carotid artery stenosis is associated with depressive symptoms in patients with atherosclerosis. CAS seems to exert beneficial effects on the course of depressive symptoms in these patients.

© RSNA, 2006


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 References
 
Depressive symptoms are common among elderly patients and may lead to severe lifestyle limitations (1). Studies revealed a 12%–15% prevalence of depressive symptoms in patients older than 50 years (2–5). In particular, depressive disorders may be causatively associated with degenerative processes based on cerebrovascular disease (6–9), a concept that is referred to as "vascular depression." The vascular depression hypothesis suggests that cerebrovascular disease may predispose to depressive symptoms (4). This concept has been derived from the association between ischemic lesions and distinct behavioral symptoms (4). Alternatively, various reports reveal that depressive symptoms among patients with severe vascular pathologic conditions are a response to the clinical sequelae of atherosclerotic disease (8,10). After acute ischemic events, such as myocardial infaction (10,11) or stroke (12–16), patients are more likely to develop depressive syndromes.

Atherosclerotic lesions of the extracranial carotid arteries are frequently found in elderly patients (17–19). Besides carotid stenosis creating a substantial risk for stroke (20), a strong association between carotid atherosclerotic lesions and the development of substantial depressive symptoms has been observed (8,21) in 20%–60% of patients (12–14). Currently, only few data are available on the course of depressive symptoms after successful carotid endarterectomy (22,23). These reports do not reveal a substantial change in the course of depressive symptoms. Recently, carotid artery stent placement (CAS) has emerged as an alternative therapeutic procedure to treat patients with carotid stenosis and may be the first choice for symptomatic patients with a high cardiovascular risk during carotid endarterectomy (24,25). Furthermore, a minimally invasive approach without the need for general anesthetic may offer certain advantages with respect to the course of depressive symptoms.

We hypothesized that clinically important depressive symptoms in patients with carotid artery stenosis of 80% or more luminal narrowing may improve after successful endovascular revascularization therapy. Therefore, the aim of the present study was to prospectively evaluate if high-grade (≥80%) carotid stenosis is associated with depressive symptoms and if CAS potentially improves depressive symptoms.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 References
 
Study Design
The study was designed as a prospective cohort study. The entire study complied with the Declaration of Helsinki and was approved by the local ethic committee. All patients and control subjects gave written informed consent. From January to December 2002, we enrolled 143 consecutive patients (91 men, 52 women; interquartile range [IQR], 63–76 years) who were scheduled to undergo elective CAS because of asymptomatic high-grade (≥80% luminal narrowing) internal carotid artery stenosis. The control group consisted of 102 consecutive patients (64 men, 38 women; IQR, 63–73 years) hospitalized from January to April 2002 because of peripheral artery disease and scheduled to undergo percutaneous transluminal angioplasty (PTA). The control subjects underwent duplex ultrasonography (US) of the carotid arteries to exclude coexisting high-grade (≥80% luminal narrowing) carotid stenosis. All patients were evaluated for depressive symptoms by using the Beck Depression Inventory (BDI) (26,27) before (within 3 days) the planned treatment (baseline) and 4 weeks after the planned treatment (follow-up).

Inclusion and Exclusion Criteria
All patients with high-grade and asymptomatic stenosis (≥80% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria [20]) and who were scheduled to undergo CAS during the study period were eligible. Patients were not eligible and finally excluded if they were permanently disabled after a prior stroke or had dementia. Furthermore, patients unwilling or unable to complete the BDI were excluded from this study, and patients with recent initiation (<6 months) of antidepressive therapy were also excluded.

Patient Data
At admission, medical history and current medication of each patient were recorded with a standardized questionnaire by two independent observers (W.M., M.S.). Special attention was paid to the following cardiovascular risk factors and comorbidities: age, sex, smoking habits, hyperlipidemia, arterial hypertension, diabetes mellitus, coronary artery disease, and history of myocardial infarction and stroke. Data were reviewed for agreement between the two observers on the day the patient was discharged; when a discrepancy occurred, data were reviewed by both observers until a consensus was reached.

Definitions
The diagnosis of peripheral artery disease was assessed with clinical evaluation and ankle-brachial index measurements. Coronary artery disease was categorized according to the Canadian Cardiovascular Society classification. Duplex US of the internal carotid artery stenosis was performed by an investigator (I.M. with 8 years of experience) using either a model 128 XP 10 system (Acuson, Mountain View, Calif) with a 5-MHz linear probe or a model System 5 (Wingmed Sound, now General Electric, Horton, Norway) with a 10-MHz linear probe. Duplex grading was performed as described previously with measurement of the peak systolic and end-diastolic velocities in the internal and common carotid arteries (28). Diabetes mellitus, hyperlipidemia, and arterial hypertension were diagnosed according to previously published criteria (29).

Mood Assessment
Assessment of depressive symptoms was performed by using the BDI (26,27), which has been compared with other questionnaires that screen for depression and was proposed to be an acceptable tool (30). The BDI is a self-reporting 21-item questionnaire that describes sadness, pessimism, sense of failure, dissatisfaction, guilt, expectation of punishment, dislike of self, self-accusation, suicidal ideation, episodes of crying, irritability, social withdrawal, indecisiveness, change of body image, retardation, insomnia, fatigability, loss of appetite, loss of weight, somatic preoccupation, and low level of energy.

The highest score on each of these 21 questions is three. The numeric values of zero, one, two, or three are assigned to each statement to indicate the degree of severity from neutral (zero) to maximum (three). The highest possible score for this continuous variable is 63, and the lowest possible score is zero. A score of 10 or higher is the general accepted threshold for the presence of clinically important depressive symptoms (30–32). Therefore, we categorized the patients and control subjects into two groups according to BDI score. BDI scores lower than 10 denote no relevant depressive symptoms. Scores of 10 or higher indicated relevant depressive symptoms.

The testing was performed by an independent investigator (I.M.) with 4 years of experience in psychologic testing. We compared the change of the BDI score from that at baseline to that at follow-up between patients and control subjects by calculating a standardized change score (BDIfu – BDIb/SD, where BDIfu is the BDI score at follow-up, BDIb is the BDI score at baseline, and SD is standard deviation of BDIb). The investigator of the BDI score was not the interventionist and was not blinded with respect to the treatment regimen (CAS or lower-limb PTA).

Study End Points
The primary study end point was the presence of depressive mood symptoms (yes vs no) according to a previously validated score obtained with the BDI (29–31) before and after a percutaneous intervention in patients and in control subjects. The secondary end point was the respective BDI scores as metric measures.

CAS Procedure
Technical details of the procedure are described elsewhere (33). Briefly, an independent physician (R.A.) with more than 10 years of experience performed diagnostic four-vessel angiography in all patients prior to the intervention in order to document the grade of stenosis. Procedures were begun with the administration of local anesthetic (Xylocain; Astra Zeneca, Wedel, Germany) and with transfemoral access with an 8-F sheath (Introducer; Terumo, Tokyo, Japan). The first 27 patients (18.9%) were treated without the use of a mechanical cerebral protection device. The remaining patients were treated with the use of a filter-type (Filterwire; Boston Scientific, Natick, Mass) cerebral protection device. After stent placement, selective repeat angiography was performed to assess the local result. The first intervention was considered successful when the residual diameter reduction was less than 30%.

Statistical Analysis
Continuous data are presented as the median and IQR (25th–75th percentile). Discrete data are given as number of patients and percentages. The {chi}2 test was used to compare groups of categorical data. The Mann-Whitney U test was used to compare groups of continuous unpaired data. Paired categorical data were compared by using the McNemar test, and paired continuous data were compared with the Wilcoxon rank sum test. The change of the BDI score was evaluated with a two-group t test. Furthermore, we reanalyzed the change of the BDI score by using a parametric approach with repeated measurements analysis of variance that were adjusted for variables which were imbalanced between the two groups; the reanalyzed change was indicated with a P value <.1. A two-sided P value <.05 was considered to indicate a statistically significant difference. Calculations were performed with statistical software (SPSS for Windows version 11.0; SPSS, Chicago, Ill).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 ADVANCES IN KNOWLEDGE
 References
 
Patient Data
During the study period, 178 patients underwent technically successful CAS. Of these, 35 patients were not eligible because of a symptomatic internal carotid artery stenosis in 27 patients and eight patients were not eligible because they refused to give their consent. One hundred eleven consecutive control subjects scheduled to undergo lower-limb PTA next underwent duplex US of the carotid arteries to help rule out a high-grade stenosis. A carotid artery stenosis of 80% or more luminal narrowing was found in eight of these patients and one patient refused to participate in the study, which left 102 control subjects for inclusion. The remaining 143 patients (91 men, 52 women; [IQR], 63–76 years) with high-grade carotid stenosis and 102 control subjects (64 men, 38 women; IQR, 63–73 years) with peripheral artery disease were included in the final analysis. All CAS procedures were technically successful; in five patients (3.5%) a procedure-related stroke (two major and three minor strokes) was observed. Demographic data and clinical characteristics of patients and control subjects are given in Table 1. Patients and control subjects were balanced with regard to age, sex, arterial hypertension, hyperlipidemia, coronary artery disease, and history of myocardial infarction and stroke. Control subjects with peripheral artery disease exhibited a higher prevalence of diabetes mellitus (P < .001) (Table 1).


View this table:
[in this window]
[in a new window]

  		Table 1. Demographic Data and Clinical Characteristics of 143 Patients with High-Grade Carotid Artery Stenosis and 102 Control Subjects with Peripheral Artery Disease

 
Depressive Symptoms
Patients with high-grade internal carotid artery stenosis more frequently exhibited substantial depressive symptoms compared with control subjects without relevant internal carotid artery stenosis (Table 1). According to the accepted threshold in the BDI score, 48 (33.6%) patients with high-grade internal carotid artery stenosis and 17 (16.7%) control subjects with peripheral artery disease had depressive symptoms (P = .003) (Table 1). Demographic data and clinical characteristics were equally balanced between subjects with and subjects without substantial depressive symptoms (Table 2).


View this table:
[in this window]
[in a new window]

  		Table 2. Demographic Data and Clinical Characteristics in Patients with and Patients without Substantial Depressive Symptoms

 
Depressive Symptoms after CAS
The BDI score of patients with high-grade internal carotid artery stenosis at 4 weeks after CAS decreased significantly from the BDI score at baseline (6 vs 2 [median BDI score], P < .001) (Fig 1). The frequency of depressive symptoms also decreased significantly (33.6% vs 9.8%, P < .001) (Fig 2). Furthermore, the standardized change score in BDI score at follow-up was significantly different in patients compared with that in control subjects (–0.4 vs 0 [median standardized change score], P < .001) (Fig 3). Increasing age did not have a statistically significant effect on the prevalence of depressive symptoms (Table 2).


Figure 1
View larger version (19K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1a: Graph of course of BDI score before and after respective percutaneous intervention. (a) BDI score in 143 patients before and after CAS. (b) BDI score in 102 control subjects before and after PTA. Significant decrease of BDI score as measure of depression was found in 143 patients at 4 weeks after successful CAS. No significant change of BDI score was observed in 102 control subjects after PTA. Bar displays median, boxes represent IQR, and whiskers display total range.

 

Figure 1
View larger version (18K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1b: Graph of course of BDI score before and after respective percutaneous intervention. (a) BDI score in 143 patients before and after CAS. (b) BDI score in 102 control subjects before and after PTA. Significant decrease of BDI score as measure of depression was found in 143 patients at 4 weeks after successful CAS. No significant change of BDI score was observed in 102 control subjects after PTA. Bar displays median, boxes represent IQR, and whiskers display total range.

 

Figure 2
View larger version (33K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2: Graph of percentage and number of patients with clinically substantial depressive symptoms before and 4 weeks after CAS compared with those of control subjects with peripheral artery disease before and 4 weeks after PTA. Significant decrease in frequency of depressive symptoms was found in 143 patients after successful CAS. No significant change in frequency of depressive symptoms was observed in 100 control subjects after PTA. Bars represent percentages and 95% confidence intervals.

 

Figure 3
View larger version (32K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3: Graph of standardized change in BDI score 4 weeks after CAS in patients and PTA in control subjects. Patients showed improvement of BDI score after CAS; control subjects after PTA showed virtually no change. Bar displays median, boxes represent IQR, and whiskers display total range.

 
Four weeks after successful intervention, no statistically significant difference in frequency of depressive symptoms was found between patients with former high-grade carotid artery stenosis after CAS and control subjects with peripheral artery diesese (9.8% vs 13.0%, P = .49) (Fig 2). The control group had no significant difference in BDI score from baseline to 4 weeks after PTA. Unfortunately, two control subjects were lost to follow-up.

The first 27 patients who underwent CAS were treated without the use of a cerebral protection device. The number of patients with substantial depressive symptoms after CAS did not differ between patients who underwent CAS with the use of a cerebral protection device and those without the use of a cerebral protection device (7.4% vs 11.1%, P = .63).

In 29 patients who underwent CAS, the BDI score was reassessed 4 months after the procedure. Neither the frequency of substantial depressive symptoms (11.1% vs 13.8%, P = .36) nor the BDI score changed significantly (4 vs 5 [median BDI score], P = .16).

By using repeated measurements analysis of variance, we found a significant difference in the course of the BDI score from baseline to follow-up (P = .033); adjustment was made for diabetes, presence of a high-grade carotid stenosis, and severe claudication.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
ADVANCES IN KNOWLEDGE
 References
 
We found an increased frequency of relevant depressive symptoms in patients with high-grade internal carotid artery stenosis compared with that in control subjects with severe atherosclerosis. Patients had a significant reduction in depressive symptoms after successful carotid recanalization, whereas control subjects who underwent PTA had no change in the frequency of depressive symptoms. These data suggest a potential benefit of CAS on the mood state.

Depressive symptoms are frequently found in elderly patients with hemodynamically relevant stenosis of the carotid arteries, other vascular pathologic conditions, or both (14). The concept of vascular depression suggests a causal relationship between cerebrovascular disease and depressive symptoms (4,17). The accumulation of vascular disease, traditional vascular risk factors, and chronic cerebral hypoperfusion presumably cause vascular changes in the brain (4,9,17,34). Consistently, we found that patients with high-grade internal carotid artery stenosis exhibited a higher prevalence of depressive symptoms compared with that of control subjects. It cannot be derived from our data with certainty whether there is a direct causal relationship between carotid stenosis or cerebral malperfusion and depression or whether depression rather is the consequence of the sequelae of cerebrovascular atherosclerotic disease.

Patients with advanced peripheral artery disease who require peripheral revascularization frequently exhibit concomitant coronary and cerebrovascular atherosclerosis. According to the vascular depression hypothesis, these patients with generalized atherosclerosis seem to be at a particularly high risk for depressive symptoms and therefore may be a reasonable control group for the study purpose. In this context, it has been observed that approximately 20% of patients with severe claudication exhibited depressive symptoms (35). Consistently, in our cohort, the prevalence of depressive symptoms was approximately 17% among control subjects with symptomatic peripheral artery disease and, as expected, remained widely unchanged after PTA.

Few studies have compared the course of depressive symptoms before with that after endarterectomy of carotid artery stenosis (22,23). These studies did not find a statistically significant postoperative change in depressive symptoms. The lack of positive association in surgical patients may be based on the fact that neuropsychologic performance experiences a statistically significant decrease after the administration of general anesthetic (36). In contrast, our findings suggest that improvement of cerebral perfusion by removing the stenosis with a minimally invasive technique with the use of local anesthetic is associated with significant improvement of depressive symptoms.

The age distribution of patients and control subjects was similar. We further analyzed a potential interaction among age, depression, and CAS because age is an independent predictor of depressive disorders. When we focused on the comparison between patients with and patients without relevant depressive symptoms, however, we found age did not affect the prevalence of depressive symptoms in our patients.

Although CAS has gained acceptance in the treatment of carotid stenosis, particularly in high-risk surgical patients, periinterventional microembolism remains a major drawback (29). At least in the present patient series with a low frequency of clinical neurologic complications, microembolism did not translate into worsening of depressive mood symptoms; in contrast, the BDI score significantly improved after revascularization. Although a higher rate of microemboli was depicted at transcranial Doppler US after CAS compared with surgical endarterectomy, no neuropsychologic differences were found in a small randomized trial (24). This finding also suggests that primarily the hemodynamic improvement after revascularization accounts for the potential beneficial effect of revascularization. Further larger prospective trials, however, are needed to address this issue.

Our study had limitations. We are well aware that the follow-up period of the present study was fairly short. It seems long enough, however, to document a positive effect on the course of depressive symptoms in patients who underwent CAS compared with that in control subjects who underwent PTA. BDI scores at 4 months after CAS were available in 29 patients and showed no significant changes compared with the scores at 4 weeks.

Furthermore, the selection of adequate control subjects is a critical issue and has to be considered when interpreting our findings. There may be differences in psychologic stress for the patient before carotid or lower-limb PTA, and these differences may affect the BDI score.

In conclusion, high-grade internal carotid artery stenosis is associated with depressive symptoms in patients with atherosclerosis, and CAS seems to exert beneficial effects on the course of depressive symptoms in these patients.


   ADVANCES IN KNOWLEDGE
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
References
 


   FOOTNOTES
 

Abbreviations: BDI = Beck Depression Inventory • CAS = carotid artery stent placement • IQR = interquartile range • PTA = percutaneous transluminal angioplasty

Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, W.M., I.M.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, W.M., I.M.; clinical studies, W.M.; statistical analysis, W.M., I.M.; and manuscript editing, all authors


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 References
 

  1. Barzega G, Maina G, Venturello S, Bogetto F. Dysthymic disorder: clinical characteristics in relation to age at onset. J Affect Disord 2001;66:39–46.[CrossRef][Medline]
  2. Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry 1999;174:307–311.[Abstract/Free Full Text]
  3. Stek ML, Gussekloo J, Beekman AT, van Tilburg W, Westendorp RG. Prevalence, correlates and recognition of depression in the oldest old: the Leiden 85-plus study. J Affect Disord 2004;78:193–200.[CrossRef][Medline]
  4. Alexopoulos GS, Meyers BS, Young RC, Campbell S, Silbersweig D, Charlston M. "Vascular depression" hypothesis. Arch Gen Psychiatry 1997;54:915–922.[Abstract/Free Full Text]
  5. Beekman AT, Deeg DJ, van Tilburg T, Smit JH, Hooijer C, van Tilburg W. Major and minor depression in later life: a study of prevalence and risk factors. J Affect Disord 1995;36:65–75.[CrossRef][Medline]
  6. Van den Berg MD, Oldehinkel AJ, Bouhuys AL, Brilman EI, Beekman AT, Ormel J. Depression in later life: three etiologically different subgroups. J Affect Disord 2001;65:19–26.[CrossRef][Medline]
  7. Baldwin RC, Tomenson B. Depression in later life: a comparison of symptoms and risk factors in early and late onset cases. Br J Psychiatry 1995;167:649–652.[Abstract/Free Full Text]
  8. Haas DC, Davidson KW, Schwartz DJ, et al. Depressive symptoms are independently predictive of carotid atherosclerosis. Am J Cardiol 2005;95:547–550.[CrossRef][Medline]
  9. Kales HC, Maixner DF, Mellow AM. Cerebrovascular disease and late-life depression. Am J Geriatr Psychiatry 2005;13:88–98.[CrossRef][Medline]
  10. Rudisch B, Nemeroff CB. Epidemiology of comorbid coronary artery disease and depression. Biol Psychiatry 2003;54:227–240.[CrossRef][Medline]
  11. Bush DE, Ziegelstein RC, Tayback M, et al. Even minimal symptoms of depression increase mortality risk after acute myocardial infarction. Am J Cardiol 2001;88:337–341.[CrossRef][Medline]
  12. Stenager EN, Madsen C, Stenager E, Boldsen J. Suicide in patients with stroke: epidemological study. BMJ 1998;316:1206.[Free Full Text]
  13. Pohjasvaara T, Leppavuori A, Siira I, Vataja R, Kaste M, Erkinjuntti T. Frequency and clinical determinants of post-stroke depression. Stroke 1998;29:2311–2317.[Abstract/Free Full Text]
  14. Rao R, Jackson S, Howard R. Depression in older people with mild stroke, carotid stenosis and peripheral vascular disease: a comparison with healthy controls. Int J Geriatr Psychiatry 2001;16:175–183.[CrossRef][Medline]
  15. Zito M, Muscari A, Marini E, Di Iorio A, Puddu GM, Abate G. Silent lacunar infarcts in elderly patients with chronic non valvular atrial fibrillation. Aging (Milano) 1996;8:341–346.[Medline]
  16. Fujikawa T, Yamawaki S, Touhouda Y. Incidence of silent cerebral infarction in patients with major depression. Stroke 1993;24:1631–1634.[Abstract/Free Full Text]
  17. Krishnan KR, Hays JC, Blazer DG. MRI-defined vascular depression. Am J Psychiatry 1997;154:497–501.[Abstract]
  18. Josse MO, Touboul PJ, Mas JL, Laplane D, Bousser MG. Prevalence of asymptomatic internal carotid artery stenosis. Neuroepidemiology 1987;6:150–152.[Medline]
  19. Colgan MP, Strode GR, Sommer JD, Gibbs JL, Sumner DS. Prevalence of asymptomatic carotid disease: results of duplex scanning in 348 unselected volunteers. J Vasc Surg 1988;8:674–678.[CrossRef][Medline]
  20. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445–453.[Abstract]
  21. Lovett JK, Rothwell PM. Suicide in a patient with symptomatic carotid occlusion. J R Soc Med 2002;95:93–94.[Free Full Text]
  22. Crawley F, Stygall J, Lunn S, Harrison M, Brown MM, Newman S. Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke 2000;31:1329–1334.[Abstract/Free Full Text]
  23. De Leo D, Serraiotto L, Pellegrini C, Magni G, Franceschi L, Deriu GP. Outcome from carotid endarterectomy: neuropsychological performance, depressive symptoms and quality of life—8-month follow-up. Int J Psychiatry Med 1987;17:317–325.[Medline]
  24. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004;351:1493–1501.[Abstract/Free Full Text]
  25. Ouriel K. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Perspect Vasc Surg Endovasc Ther 2005;17:63–64.[Medline]
  26. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–571.[Abstract/Free Full Text]
  27. Richter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity of the Beck Depression Inventory: a review. Psychopathology 1998;31:160–168.[CrossRef][Medline]
  28. Sabeti S, Schillinger M, Mlekusch W, et al. Quantification of internal carotid artery stenosis with duplex US: comparative analysis of different flow velocity criteria. Radiology 2004;232:431–439.[Abstract/Free Full Text]
  29. Schillinger M, Exner M, Mlekusch W, et al. Vascular inflammation and percutaneous transluminal angioplasty of the femoropopliteal artery: association with restenosis. Radiology 2002;225:21–26.[Abstract/Free Full Text]
  30. Aben I, Verhey F, Lousberg R, Lodder J, Honig A. Validity of the Beck Depression Inventory, Hospital Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as screening instruments for depression in stroke patients. Psychosomatics 2002;43:386–393.[Abstract/Free Full Text]
  31. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: 25 years of evaluation. Clin Psychol Rev 1988;8:77–100.
  32. Söderman E, Lisspers J, Sundin Ö. Depression as a predictor of return to work in patients with coronary artery disease. Soc Sci Med 2003;56:193–202.[CrossRef][Medline]
  33. Ahmadi R, Schillinger M, Lang W, Mlekusch W, Sabeti S, Minar E. Carotid artery stenting in older patients: is age a risk factor for poor outcome? J Endovasc Ther 2002;9:559–565.[CrossRef][Medline]
  34. Steffens DC, Taylor WD, Krishnan KR. Progression of subcortical ischemic disease from vascular depression to vascular dementia. Am J Psychiatry 2003;160:1751–1756.[Free Full Text]
  35. McDermott MM, Greenland P, Guralnik JM, et al. Depressive symptoms and lower extremity functioning in men and women with peripheral artery disease. J Gen Intern Med 2003;18:461–467.[CrossRef][Medline]
  36. Townes BD, Dikmen SS, Bledsoe SW, Hornbein TF, Martin DC, Janesheski JA. Neuropsychological changes in a young, healthy population after controlled hypotensive anesthesia. Anesth Analg 1986;65:955–959.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Am. J. Neuroradiol.Home page
F. Gaudiello, V. Colangelo, F. Bolacchi, M. Melis, R. Gandini, F.G. Garaci, V. Cozzolino, R. Floris, and G. Simonetti
Sixty-Four-Section CT Cerebral Perfusion Evaluation in Patients with Carotid Artery Stenosis before and after Stenting with a Cerebral Protection Device
AJNR Am. J. Neuroradiol., May 1, 2008; 29(5): 919 - 923.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
2402051043v1
240/2/508    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mlekusch, W.
Right arrow Articles by Schillinger, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mlekusch, W.
Right arrow Articles by Schillinger, M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE