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PubMed1984

Coping with transient intellectual dysfunction after coronary bypass surgery.

In summary, we believe that the impact of our findings on the patient and clinician includes recognition and acknowledgment that transient cognitive dysfunction frequently follows coronary bypass surgery. With this recognition comes the reassurance to the patient and his family that it is a temporary phenomenon that should resolve in time. To help the patient comply with his postoperative instructions during this difficult time period, there should be individual, slow-paced presentation of material with intentional repetition of information to help him remember the specific details of his postoperative instruction; the individual most involved with assisting in the patient's postoperative recovery should be included in all teaching sessions; and instructive audiovisual material should be used in postoperative home care.

Adaptation, Psychological↗
PubMed1999

Specific patterns of cognitive impairment in patients with idiopathic normal pressure hydrocephalus and Alzheimer's disease: a pilot study.

OBJECTIVES: Eleven patients with idiopathic normal pressure hydrocephalus (NPH) were selected from an initial cohort of 43 patients. The patients with NPH fell into two distinctive subgroups: preshunt, group 1 (n=5) scored less than 24 on the mini mental state examination (MMSE) and were classified as demented and group 2 (n=6) scored 24 or above on the MMSE and were classified as non-demented. METHODS: All patients were neuropsychologically assessed on two occasions: preshunt and then again 6 months postshunt. Group 1 completed the mini mental state examination (MMSE) and the Kendrick object learning test (KOLT). In addition to the MMSE and KOLT, group 2 completed further tasks including verbal fluency and memory and attentional tasks from the CANTAB battery. Nine of the 11 patients also underwent postshunt MRI. RESULTS: Group 1, who, preshunt, performed in the dementing range on both the MMSE and KOLT, showed a significant postoperative recovery, with all patients now scoring within the normal non-demented range. Group 2, although showing no signs of dementia according to the MMSE and KOLT either preshunt or postshunt, did show a specific pattern of impairment on tests sensitive to frontostriatal dysfunction compared with healthy volunteers, and this pattern remained postoperatively. Importantly, this pattern is distinct from that exhibited by patients with mild Alzheimer's disease. Eight of the nine patterns of structural damage corresponded well to cognitive performance. CONCLUSIONS: These findings are useful for three main reasons: (1) they detail the structural and functional profile of impairment seen in NPH, (2) they demonstrate the heterogeneity found in this population and show how severity of initial cognitive impairment can affect outcome postshunt, and (3) they may inform and provide a means of monitoring the cognitive outcome of new procedures in shunt surgery.

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PubMed2002

Neuropsychological alterations after coronary artery bypass graft surgery.

OBJECTIVE: To evaluate neuropsychological dysfunction in patients following elective coronary artery bypass graft surgery at Siriraj Hospital. PATIENTS AND METHOD: One hundred and ten patients who were scheduled for elective coronary artery bypass graft surgery were included in this study. We used the Thai Mental State Examination (TMSE) in order to detectthe presence of cognitive impairment aftercoronary artery bypass graft surgery. The examinations were conducted on two consecutive occasions; first preoperatively, the day before surgery, secondly on the third - fifth postoperative day. The patients' clinical characteristics were assessed perioperatively. RESULTS: The overall occurrence of neuropsychological deficit was 18.18 per cent. Predictors of neuropsychological dysfunction were older age and preexisting disease such as hypertension, hypercholesterolemia and renal insufficiency. Other risk factors such as gender, history of congestive heart failure, myocardial infarction, diabetes mellitus, dysrhythmia, cardiopulmonary bypass time, hemoglobin during cardiopulmonary bypass <7 g/dl, hemoglobin on admission to surgical cardiac care unit <10 g/dl, and atrial fibrillation arising after surgery were not significant. CONCLUSION: Neuropsychological impairments after coronary artery bypass graft surgery are relatively common. This study did not find an increased incidence with respect to gender as other studies have done. However, long-term follow-up of these patients would be very valuable.

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PubMed1994

A clinical and laboratory profile of symptomatic women with silicone breast implants.

One hundred seventy-six patients with breast prosthetic implants were evaluated. All women were symptomatic and were referred by either attorneys (152) or physicians (24) for rheumatic evaluation. The women ranged in age from 24 to 72 with a mean of 45 years. Indications for surgery were cosmetic (128), cancer (34), and other (14). Implants had been in place for 7 years or more in 120 patients and < 2 years in only 8. Eighty-three women required explantation of their original prostheses, and 63 had new implants inserted of which 47 were silicone and 16 were saline. Capsular contractures were present in 128 women, and documented implant rupture occurred in 67. Sixty-four women underwent manual closed capsulotomies. Of the 63 revisions, 37 resulted in contractures of the new implant. The most frequent symptoms seen in the women were chronic fatigue (77%) cognitive dysfunction (65%), arthralgia (56%), dry mouth (53%), dry eye (50%), alopecia (40%), and dysphagia (35%). The most common findings on physical examination were telangiectasias (60%), erythema of the chest wall (56%), carpal tunnel syndrome (47%), petechiae (46%), lacrimal gland enlargement (26%), thyroid tenderness (22%), thyroid enlargement (21%), and parotid enlargement (18%). Laboratory findings included elevated cholesterol (59%), elevated erythrocyte sedimentation rate (32%), elevated serum immunoglobulin (28%), and positive autonuclear antibody (25%) seen most often. Despite clinical features suggesting Sjögren's syndrome, antibodies to Ro (SSA) were seen in only 2 patients, and antibodies to La (SSB) were seen in only 4 patients. Siliconosis is a novel systemic disease with symptoms of chronic fatigue, cognitive dysfunction, sicca syndrome, and arthralgia.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Cognitive function after open-heart surgery: are postoperative neuropsychological deficits caused by cardiopulmonary bypass?

Despite the many technological developments in arterial perfusion and cardiac surgical procedures, open-heart surgery is still believed to pose a significant risk for cerebral injury. There are several potential causes of brain damage during open-heart surgery, including prolonged or severe arterial hypotension, as well as emboli emanating from the cardiopulmonary bypass circuit or the operative field. This article reviews the available neuropsychological studies of outcome following cardiac valve replacement and coronary artery bypass grafting. Because both procedures are life-saving operations, the research in this area has been quasi-experimental and fraught with methodological problems. Nonetheless, the findings converge to suggest that cognitive dysfunction occurs after open-heart surgery, and that the deficits are attributable, at least in part, to factors specific to the operation or to the patient being maintained on cardiopulmonary bypass. Preliminary findings suggest that embolization is the primary cause of perioperative deficits in uncomplicated operations. Studies have also consistently found preoperative deficits in this population, suggesting that neuropsychological dysfunction is caused by severe chronic cardiac disease as well as open-heart surgery.

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PubMed2007

Predicting the outcome of shunt surgery in normal pressure hydrocephalus.

We studied retrospectively the effectiveness of the repeated lumbar CSF tap test (RTT), lumbar external CSF drainage (LED) and radioisotope cisternography (RIC) in predicting the outcome of shunt surgery, as well as the diagnostic and prognostic value of periventricular hyperintensity (PVH) and of the classic clinical triad in normal pressure hydrocephalus. Two hundred and seventy patients were referred to the Departments of Neurosurgery, in Nancy, France and in Istanbul, Turkey. The decision to perform surgery was based on the clinical presentation (all patients had at least two symptoms of the classic clinical triad), neuroimaging examinations and the results of the RTT (taps were performed on three consecutive days and at each tap a minimum of 30 to 40 cc of CSF was removed), the LED (drainage was performed for 3 days and the volume of CSF drained daily was a minimum of 150 to 250 cc) or the RIC. After all shunt procedures, postoperative assessments verified improvements in 88% of the RTT group, 91% of the LED group and 66% of the RIC group. Gait disturbance had improved in 90% at the end of the second and twelfth month follow-up. Cognitive dysfunction had improved in 79% at the second and in 77% at the twelfth month follow-up. Urinary incontinence had improved in 66% at the second and in 62% at the twelfth month follow-up. From the surgical point of view, the greatest difficulty is not to make the diagnosis, but rather to identify the appropriate patients to operate on. The decision to perform shunt surgery should be based on strict clinical findings associated with CT and MRI criteria and especially with positive RTT or LED test results.

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PubMed1997

Impact of anesthesia on the cognitive functioning of the elderly.

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longerterm cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.

Aged↗
PubMed2004

"Other" neurologic complications after cardiac surgery.

Compared to the neurologic morbidity of stroke and cognitive dysfunction, "other" neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.

Blindness, Cortical↗
PubMed1996

Evaluating neuroprotective agents for clinical anti-ischemic benefit using neurological and neuropsychological changes after cardiac surgery under cardiopulmonary bypass. Methodological strategies and results of a double-blind, placebo-controlled trial of GM1 ganglioside.

BACKGROUND AND PURPOSE: Many neuroprotective agents (NPAs) are effective in acute experimental cerebral ischemia in animals. None have proven effective in human stroke trials. Even short treatment delays cause substantial efficacy loss. Cardiac surgery under cardiopulmonary bypass (CS-CPB) causes cerebral ischemia with cognitive impairment at a predeterminable time point and should permit efficient screening of NPAs for stroke benefit. We sought to develop sensitive methods to assess dysfunction from CS-CPB in a double-blind trial of the NPA GM1 ganglioside. METHODS: Eighteen GM1 and 11 Control patients received GM1 300 mg or placebo, two doses intravenously, before nonemergency CS-CPB. Independent examiners administered structured neurological examinations and neuropsychological test batteries at Baseline and 1 day (Acute Postop; neurological only), 1 week (Early F/U), and > or = 6 months (Long-term F/U) postoperatively; using defined procedures they employed ordinal Clinical Change Scores (CCSs) to quantify neurological cerebral, neurological noncerebral, and neuropsychological performance changes. Several methods to analyze CCSs and neuropsychological test score changes were evaluated. RESULTS: The most sensitive indicators were the mean Acute Postop Neurologist's CCS-Cerebral (P < 10(-5)) and the mean Early F/U Neuropsychologist's CCS (P < .01), with statistically nonsignificant differences favoring GM1. No significant mean changes in Neurologist's CCS-Noncerebral or any Long-term F/U CCSs occurred. CCS distributions and neuropsychological test score mean changes showed similar temporal patterns, with less sensitivity to change. When, as usual in prior CS-CPB studies, impairment was defined by neuropsychological test score declines (increases ignored), results were spurious. CONCLUSIONS: The strokelike cerebral dysfunction (maximal acutely, with eventual recovery) that occurs after CS-CPB is useful to screen NPAs for clinical efficacy. CCSs based on detailed neurological examination and neuropsychological testing are sensitive measures; refinement of this approach should enhance the efficiency of the CS-CPB model. Further testing of GM1 is warranted.

Adult↗
PubMed2004

Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery.

OBJECTIVE: To evaluate the relationship between cerebral oxygen saturation and neuropsychological dysfunction after cardiac surgery. DESIGN: Prospective and observational study. SETTING: Operating room and cardiac floor of a university hospital. PARTICIPANTS: One hundred one patients undergoing elective cardiac surgery with cardiopulmonary bypass INTERVENTION: Bilateral noninvasive cerebral oxygen saturations were monitored over the forehead. The anesthetic and surgical techniques were performed as usual, and no interventions were attempted based on the monitor. Neuropsychological outcome was assessed by the Mini-Mental State Examination (MMSE) and the antisaccadic eye movement test (ASEM). MEASUREMENTS AND MAIN RESULTS: Preoperative baseline values of cerebral oxygen saturation (rSO(2)) were 58.6% +/- 10.2%. Patients with the nadir rSO(2) <35% had significantly higher incidences of postoperative ASEM and MMSE impairments than those with rSO(2) always above 35% (44% and 33% v 12% and 9%, respectively). Patients with areas of rSO(2) <40% for more than 10 minutes . % presented with a significantly higher incidence of postoperative ASEM and MMSE impairments than those with areas of rSO(2) <40% for less than 10 minutes . % (42% and 32% v 13% and 10%, respectively). Patients with postoperative ASEM or MMSE impairment had significantly lower nadir rSO(2) and significantly larger areas of rSO(2) <40%, <45%, and <50% than those with normal postoperative neuropsychological outcome. However, multivariate logistic regression analysis showed that areas of rSO(2) <40% were the only predictor for both postoperative ASEM and MMSE impairments. CONCLUSIONS: Intraoperative cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery with cardiopulmonary bypass. However, it remains to be determined whether interventions to maintain adequate cerebral oxygenation may improve neuropsychological outcome.

Aged↗
PubMed2006

Clinically silent cerebral ischemic events after cardiac surgery: their incidence, regional vascular occurrence, and procedural dependence.

BACKGROUND: The reported frequency of stroke after coronary artery bypass grafting varies between 1.5% and 6%, approaches 10% after aortic valve replacement, and may occur in between 40 to 70% in high-risk groups. Clinically silent infarction may be far more frequent and could contribute to long-term cognitive dysfunction in patients after cardiac procedures. Using diffusion-weighted magnetic resonance imaging we document the occurrence, vascular distribution, and procedural dependence of silent infarction after cardiac surgery with cardiopulmonary bypass. We also document the association of preexisting white matter lesions with new postoperative ischemic lesions. METHODS: Thirty-four patients underwent T2-weighted fluid attenuated inversion recovery and diffusion-weighted magnetic resonance imaging before and after cardiac surgery with cardiopulmonary bypass for coronary artery bypass grafting, aortic valve replacement, and mitral valve repair or replacement surgery. Images were evaluated by experienced neuroradiologists for number, size, and vascular distribution of lesions. RESULTS: Mean age of participants was 67 +/- 15 years. Imaging occurred before and 6 +/- 2 days after surgery. New cerebral infarctions were evident in 6 of 34 patients (18%), were often multiple, and in 67% of patients were clinically silent. The occurrence of new infarctions by surgical procedure was as follows: aortic valve replacement (2 of 6), coronary artery bypass grafting and aortic valve replacement (3 of 8), aortic valve replacement with root replacement (1 of 1), coronary artery bypass grafting and mitral valve repair or replacement (0 of 4), mitral valve repair or replacement (0 of 2), and isolated coronary artery bypass grafting (0 of 13). New infarction occurred in 6 of 15 (40%) of all procedures involving aortic valve replacement. The severity of preexisting white matter lesions trended toward predicting the occurrence of new lesions (p = 0.055). CONCLUSIONS: Diffusion-weighted imaging reveals new cerebral infarctions in nearly 40% of patients after aortic valve replacement.

Aged↗
PubMed1996

Cerebral emboli and cognitive outcome after cardiac surgery.

There have been major advancements in cardiac surgery over the past two decades, with a concomitant decrease in mortality and major morbidity. However, several recent studies have demonstrated that cardiac surgery poses significant risk for negative neurologic and neuropsychologic outcome. Although very few patients die as a result of cardiac surgery, more than two thirds of the patients demonstrate evidence of neuropsychologic dysfunction postoperatively. The mechanisms contributing to post-cardiopulmonary bypass neuropsychologic deficits are uncertain. However, two major interrelated etiologic factors, hypoperfusion and emboli, are suggested as probable culprits. It is important to define the relationship between these two putative mechanisms and postoperative neuropsychologic outcome in order to either prevent the problem or treat the effects of emboli or hypoperfusion. For example, if embolism is the cause of the deficits, increasing cerebral perfusion would deliver more emboli and increase the amount of severity of injury. Conversely, if hypoperfusion is the cause of the injury, then decreasing brain blood flow would increase the likelihood of injury. If both are important, their relative significance must be established, then one prevented and the effects of the other treated. This report discusses the methodology for detecting cerebral emboli during cardiac surgery. The incidence and severity of neuropsychologic deficits after cardiac surgery are discussed, as well as emboli in relation to composition and time of occurrence and their effect on neuropsychologic outcome.

Cardiac Surgical Procedures↗
PubMed2006

Neuronal injury after repeated brief cardiac arrests during internal cardioverter defibrillator implantation is associated with deterioration of cognitive function.

To determine the degree of neurocognitive dysfunction after placement of internal cardioverter defibrillators (ICD) and its relationship to the extent of neuronal injury, we studied 42 patients undergoing ICD (n = 21) or pacemaker (PM) insertion (control patients, n = 21). The Mini Mental State Examination, the Trailmaking A test and the forward and backward Digit Span tests were used and P300 latencies were determined preoperatively and postoperatively. Serum neuron-specific enolase (NSE) was determined before and at the end of, as well as 2, 6, and 24 h after surgery. Preoperatively, PM patients scored worse in the Digit Span backward and the Trailmaking tests and showed prolonged P300 latencies. Postoperatively, the Digit Span backward scores declined and NSE levels increased only in the ICD group (P < or = 0.05). The difference between preoperative and postoperative Digit Span backward scores correlated with the increase in serum NSE levels (r2 = 0.3, P < or = 0.05). Moreover, P300 latencies increased in 13 of 17 ICD patients, but decreased in 7 of 10 PM patients (P < or = 0.05). PM patients even improved in the Trailmaking test (P < or = 0.05). Neuronal injury from even brief periods of global brain ischemia seems to be associated with deteriorating neurocognitive function.

Aged↗