Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial - Hemodynamics (CREST-H) (CREST-H)
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|ClinicalTrials.gov Identifier: NCT03121209|
Recruitment Status : Recruiting
First Posted : April 20, 2017
Last Update Posted : July 28, 2020
We aim to determine whether cognitive impairment attributable to cerebral hemodynamic impairment in patients with high-grade asymptomatic carotid artery stenosis is reversible with restoration of flow. To accomplish this aim CREST-H will add on to the NINDS-sponsored CREST-2 trial (parallel, outcome-blinded Phase 3 clinical trials for patients with asymptomatic high-grade carotid artery stenosis which will compare carotid endarterectomy plus intensive medical management (IMM) versus IMM alone (n=1,240), and carotid artery stenting plus IMM versus IMM alone (n=1,240) to prevent stroke and death).
CREST-H addresses the intriguing question of whether cognitive impairment can be reversed when it arises from abnormal cerebral hemodynamic perfusion in a hemodynamically impaired subset of the CREST-2 -randomized patients. We will enroll 500 patients from CREST-2, all of whom receive cognitive assessments at baseline and yearly thereafter. We anticipate identifying 100 patients with hemodynamic impairment as measured by an inter-hemispheral MRI perfusion "time to peak" (TTP) delay on the side of stenosis. Among those who are found to be hemodynamically impaired and have baseline cognitive impairment, the cognitive batteries at baseline and at 1 year will determine if those with flow failure who are randomized to a revascularization arm in CREST-2 will have better cognitive outcomes than those in the medical-only arm compared with this treatment difference for those who have no flow failure.
We hypothesize that hemodynamically significant "asymptomatic" carotid disease may represent one of the few examples of treatable causes of cognitive impairment. If cognitive decline can be reversed in these patients, then we will have established a new indication for carotid revascularization independent of the risk of recurrent stroke.
|Condition or disease|
|Internal Carotid Artery Stenosis Cognitive Impairment|
|Study Type :||Observational|
|Estimated Enrollment :||500 participants|
|Official Title:||Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial - Hemodynamics|
|Actual Study Start Date :||January 18, 2018|
|Estimated Primary Completion Date :||March 2022|
|Estimated Study Completion Date :||March 2022|
- Change in cognitive score [ Time Frame: 1 year ]Among those with flow failure (PWI TTP>2 sec) and cognitive impairment (>1.0 SD below age-matched norms) at baseline, cognitive change at 1 year will be compared between those receiving revascularization (CEA or CAS) versus those receiving IMM alone in CREST-2. This treatment group difference in cognitive outcome will be compared with treatment group difference among patients with the same baseline cognitive impairment, but without flow failure at baseline. Primary outcome will be adjusted for age, baseline cognitive performance, depression, prior cerebral infarcts, subsequent silent infarction, WMH volume and microbleeds.
- Silent infarcts [ Time Frame: 1 year ]MRI-determined silent infarcts present at 1 year that were not present at baseline, comparing by treatment group
- White matter hyperintensity (WMH) volume [ Time Frame: 1 year ]change in confluent white matter hyperintensity volume at 1 year, comparing by treatment group
- Change in cognitive score at 2, 3, and 4 years [ Time Frame: 2-4 years ]Z-scored cognitive battery at 2, 3, and 4 years minus baseline, addressing the same comparisons as with the primary outcome at 1 year above.
- Correlation between change in cognition and change in perfusion [ Time Frame: 1 year ]Among those with baseline cognitive and hemodynamic impairment, degree of improvement in cognition will correlate with degree of improvement in TTP among those undergoing revascularization
- Use of alternative perfusion measures as criteria for Change in cognitive score at 1 year [ Time Frame: 1-4 years ]We will assess additional imaging markers including TTP delay >4sec, circle of willis collateral pattern, mean transit time, Tmax, CBF, and cerebral blood volume to determine if these have greater specificity for Z-scored cognitive battery change at 1-4 years
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03121209
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