ISC 2026 | CREST-2: the effect of treatment on cognitive function in asymptomatic carotid artery stenosis
Ronald M. Lazar, PhD, FAAN, FAHA, University of Alabama, Birmingham, AL, shares insights from the CREST-2 trial (NCT02089217) on the effect of treatment on cognitive function in patients with asymptomatic carotid artery stenosis. Prof. Lazar highlights that while carotid artery stenting was found to be better than medical therapy alone in preventing stroke, there was no difference in cognitive improvement between medical therapy and revascularization. This interview took place at the 2026 International Stroke Congress (ISC), held in New Orleans, LA.
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Transcript
So the CREST-2 trial took a look at trying to find out what the best therapy for treatment for asymptomatic carotid artery disease. The impetus for the trial is that medical management has greatly improved over many years. So the question was whether medical management alone was better in treating asymptomatic carotid artery disease in terms of preventing stroke versus best medical therapy plus a form of revascularization...
So the CREST-2 trial took a look at trying to find out what the best therapy for treatment for asymptomatic carotid artery disease. The impetus for the trial is that medical management has greatly improved over many years. So the question was whether medical management alone was better in treating asymptomatic carotid artery disease in terms of preventing stroke versus best medical therapy plus a form of revascularization. In one of the two parallel trials, they compared best medical therapy to best medical therapy plus carotid endarterectomy. And then the other parallel trial, they compared best medical therapy to best medical therapy plus carotid artery stenting. The results of that were presented back in November. And what they found was that carotid artery stenting was better than medical therapy alone. But there was no difference between the carotid endarterectomy revascularization arm and medical therapy. So this was an opportunity to take a look at the role of cognition. The reason for doing this particular secondary aim was because it’s pretty widely demonstrated that before revascularization takes place, cognitive function has diminished compared to the population as a whole. So with the success of reperfusion therapy in the setting of acute stroke, the thought was that revascularization might not only prevent stroke, but might improve cognition as well in these individuals. So cognition was tested at baseline before revascularization and then nearly thereafter, and a cognitive battery that was administered over the four years of their follow-up. And so what we found was that there was no difference in improvement of cognition between medical therapy and revascularization, either in the carotid endarterectomy trial and on the stent trial. And so the notion was that perhaps if you have a chronic stenosis of the carotid artery affecting the brain, that chronic brain injury may not be reversible as we once thought in the past.
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