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Results for “Postoperative cognitive dysfunction”

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PubMed2002

Multi-modality neurophysiologic monitoring for cardiac surgery.

BACKGROUND: A high percentage of patients who undergo cardiac surgery experience persistent cognitive decline. The costs to insurers from brain injury associated with cardiac surgery is enormous. Furthermore, the same processes that injure the brain also appear to cause dysfunction of other vital organs. Therefore, there are great clinical and economic incentives to improve brain protection during cardiac surgery. This article discusses the methods of monitoring neurophysiologic function during heart surgery, including electroencephalography (EEG), near-infrared spectroscopy (NIRS), transcranial doppler (TCD) ultrasound, and cerebral oximetry, and analyzes the effectiveness of multi-modality neuromonitoring. METHODS: Neurophysiologic studies have implicated hypoperfusion and dysoxygenation as major causative factors for brain injury during cardiac surgery. Since these functional disturbances are often detectable and correctable, there is a new impetus to examine the role of neurophysiologic monitoring in brain protection. We have used a retrospective, single-surgeon case-control study to examine the influence on outcome following myocardial revascularization of multi-modality neuromonitoring, with modalities that include 4-channel EEG, bilateral cerebral oximetry, and single channel TCD. RESULTS: The majority of noteworthy functional disturbances detected by neuromonitoring can be corrected by simple adjustments in perfusion, oxygenation, or anesthetic administration. In more recalcitrant cases, pharmacological neuroprotection has proven effective. In addition to the substantial reductions in length of hospital stay, costs, and neurologic complications, the results of neuromonitoring suggest a possible benefit to other vital organ systems. Future studies of neuromonitoring efficacy should not overlook these important accessory benefits. CONCLUSION: This study provides the clearest evidence to date that multi-modality neuromonitoring for cardiac surgery is safe, clinically beneficial, and cost-effective. Although neuromonitoring involves negligible risk and modest costs, it's benefits for patient outcome and cost control are substantial.

Brain Diseases↗

PubMed1997

Neurobehavioral outcome in pediatric craniopharyngioma.

Neurobehavioral dysfunction occurs in children with craniopharyngioma, both before and after treatment, and its impact on outcome may not be fully appreciated. Also unclear is whether neurobehavioral outcome relates more to tumor location or surgical factors. We reviewed the records of 20 children with craniopharyngioma who were seen between 1983 and 1995. All children had subfrontal craniotomy and either partial (14 children) or gross total (6 children) resection of their tumors. In addition to traditional neuropsychological testing, we assessed social behavior and school performance using standardized ratings based on family interviews and school records. Over a mean follow-up period of 38 months, only 3 of 20 children had a good outcome in all three categories, and 12 of 20 had moderate or severe impairment in at least one category. Outcome did not differ between those who had partial and those with gross total resection. We conclude that neurobehavioral disorders are common and cause important morbidity in children after treatment for craniopharyngioma. To evaluate these impairments in future outcome studies, standard neuropsychological testing should be supplemented by specific behavioral assessments to capture the full range of neurobehavioral disability. In this series, partial versus gross total resection did not influence outcome, implying that tumor location in diencephalic and limbic regions is a more important factor.

Achievement↗

PubMed2004

Same old story? Do we need to modify our supportive care treatment of elderly cancer patients? Focus on antiemetics.

The incidence of cancer is highest among individuals > or =65 years of age. Physiological changes associated with aging, such as cognitive decline, renal and hepatic dysfunction, can often complicate treatment options, and the elderly represent a particular challenge to the oncologist because of the high incidence of comorbidity and polypharmacy. Effective supportive care is of particular importance in elderly cancer patients as they may recover less satisfactorily if adverse events are poorly controlled. Nevertheless, evidence suggests that supportive care agents, for example, antiemetics, are underutilised in this patient population. Chemotherapy and radiotherapy regimens are frequently associated with nausea and vomiting--symptoms that can have deleterious effects on vulnerable patients if not adequately managed. The serotonin 5-HT3-receptor antagonists represent a class of antiemetics that are currently regarded as the gold standard treatment for chemotherapy- and radiotherapy-induced nausea and vomiting. They are recommended as first-line treatment for patients at moderate-to-high risk of emesis. However, antiemetic guidelines do not differentiate between these agents and, more importantly, do not contain specific recommendations for the elderly. Pharmacological differences exist between the commonly available 5-HT3-receptor antagonists (dolasetron, granisetron, ondansetron, tropisetron and palonosetron), namely receptor sensitivity, duration of action, metabolism and tolerability profile. Of particular concern with prescriptions to elderly cancer patients is the convenience of once-daily administration, the low potential for drug-drug interactions and cardiovascular adverse effect profile. Moreover, the addition of the newly approved neurokinin NK1-receptor antagonist aprepitant to the choice of antiemetic regimen may complicate therapy and exacerbate the drug-drug interaction risk in elderly patients. Therefore, the use of antiemetics that are well tolerated and with the lowest risk of drug-drug interactions is imperative in this patient population and will enable even those patients with several comorbidities and a high level of polypharmacy to receive effective antiemetic therapy.

Aged↗

PubMed1998

Cognitive dysfunction in patients with pituitary tumour who have been treated with transfrontal or transsphenoidal surgery or medication.

OBJECTIVE: This study was carried out to examine the neuropsychological status of patients treated for pituitary tumour by transfrontal surgery, transphenoidal surgery or medical treatment only, with or without radiotherapy. DESIGN AND MEASUREMENTS: Three groups of 23 patients who had been treated for pituitary tumour were compared with 23 healthy controls on a range of neuropsychological measures. The surgical patients were also subdivided into two groups and compared. The neuropsychological measures were standardized psychological tests designed to assess aspects of attention, memory and executive function. PATIENTS: The patients were those who had been treated with transfrontal surgery (n = 23), transsphenoidal surgery (n = 23) and medication only (n = 23). The groups did not differ with respect to age, education or premorbid ability level as assessed by the National Adult Reading Test. All participants were free of known sources of cognitive impairment other than pituitary tumour. RESULTS: Comparison of the four groups revealed that nearly half of the transfrontal, one-third of the transsphenoidal and one-quarter of the non-surgical group had three or more neuropsychological tests scores below the 10th percentile compared to less than 5% of the controls. Impairments in memory and executive function were found in both surgical groups. The non-surgical patients appeared to have problems only on tasks requiring high levels of cognitive processing. Differences were found between the two surgical groups with respect to the severity of the cognitive impairment, the transfrontal patients having more severe impairment than the transsphenoidal. No significant negative effects on cognitive functioning were associated with radiotherapy; however, transfrontal surgery patients who had not been treated with radiotherapy were found to be more impaired than other patients. This was thought to be related to radical surgery. CONCLUSIONS: Many patients with treated pituitary tumour suffer significant cognitive impairment. The severity and nature of impairment differs between treatment groups, although the cause of this could not be addressed by this study. Recommendations are made for future research and clinical practice.

Adult↗

PubMed2000

Downstream turbulence and high intensity transient signals (HITS) following aortic valve replacement with Medtronic Hall or St. Jude Medical valve substitutes.

OBJECTIVE: High intensity transient signals (HITS) representing microembolization to the brain have been found to contribute to cognitive impairment and psychoneurological dysfunction in patients carrying a mechanical aortic valve. It is unknown, whether HITS represent gaseous or solid emboli. This animal study evaluates the impact of valve orientation on HITS for two different mechanical valves with both valves implanted in their best and worst orientation, which has been defined in previous studies with respect to downstream turbulence. METHODS: In four pigs a rotation device carrying either a Medtronic Hall (MH) or St. Jude Medical (SJM) valve size 23 mm was implanted. The device allowed rotation of the implanted valves without reopening of the aorta. Approximately 30 min after weaning from extracorporeal circulation, a Doppler probe was placed on both common carotid arteries. In different orientations of the implanted valves (best and worst position), HITS were detected by the Doppler probe and recorded for ten min by a transcranial Doppler sonography device (Medilab Inc., Estenfeld, Germany). RESULTS: HITS showed significant change with rotation for both valve designs. With the major orifice of the MH oriented towards the non-coronary leaflet (optimum position) very low HITS-counts (0.8-1.7/min) were observed. In the worst orientation HITS rose to 43-66/min. For the SJM the HITS count in the optimum position was 23.4-24/min and in the worst orientation 38-48/min. CONCLUSIONS: Valve orientation has an important impact on microembolization to the brain. In the optimum orientation (large orifice facing the non-coronary leaflet) the Medtronic Hall valve showed negligible incidence of HITS. The St. Jude Medical bileaflet valve showed less variation but demonstrated significant HITS counts at any orientation. As the MH in the worst position shows significantly higher turbulent stresses than the SJM but no higher incidence of HITS, a strong correlation between turbulence and HITS was not demonstrated by this study.

Animals↗

PubMedDate not supplied

[Assessment of short-term neuropsychologic changes after normothermic versus hypothermic coronary artery bypass grafting].

BACKGROUND: Coronary artery bypass grafting (CABG) is one of the main methods of treatment of coronary artery disease. Neuropsychological testing is a sensitive method for quantitative assessment of cognitive dysfunctioning following cardiopulmonary bypass. The aim of the present clinical study was to evaluate the neuropsychologic changes in CABG patients, operated with normothermic or hypothermic cardiopulmonary bypass (CPB). METHODS: Neuropsychological changes were assessed in 33 first-time CABG patients before and 3-10 days after surgery. Patients underwent CABG with hypothermic (Gr. H, n = 17) or normothermic (Gr. N, n = 16) CPB with standard anesthesia. Neuropsychological performance was assessed using a well-established battery of 10 tests. A neuropsychological test battery includes: Digit Span-subtest of WAIS-R (PL), the Trail Making Test, Raven Test, Benton, Bourdon, Verbal Fluency (F,A,S), Turm von Hanoi, Rey Auditory Verbal Learning Test, Supermarket, WAIS-R (PL) Digit Symbol-subtest of WAIS-R (PL). All patients completed the test for perception, attention, immediate and delayed verbal and visual memory, visual and verbal learning, problem-solving strategies, abstraction, recognition, word fluency, visual- motor coordination and psychomotor speed. For comparison, the incidence of decline using the 1.5 standard deviation (at least in 2 tests) also was calculated. RESULTS: Comparing the reliable change and SD methods, statistically significant differences in the incidence of decline were observed in 6 of the 10 neuropsychological measures. Patients' scores showed a significant deterioration in concentration of attention, immediate verbal memory, psychomotor speed, visuoconstructive tasks and verbal learning. Neuropsychological deficits were found in 66.7% of patients after surgery. Post-operative deficits were not associated with the method used (normothermia or hypothermia).

Adult↗

PubMed1995

Microemboli during coronary artery bypass grafting. Genesis and effect on outcome.

Cerebral dysfunction after coronary artery bypass operations represents some of the most serious and costly complications of cardiac surgery. We used transcranial Doppler ultrasonography to detect and quantify the number of microemboli in the right middle cerebral artery of patients undergoing elective first coronary bypass operations (n = 117) and second coronary bypass operations (n = 10). We hypothesized that total microemboli were related to clinical outcome. A 2 MHz transducer was positioned in front of the ear above the zygomatic arch and depth gated to 50 mm. Microemboli were recorded as perturbations of the blood flow velocity in the middle cerebral artery and aurally monitored. Each episode of microembolism was specified both by clock time and as a perfusion or surgical event. Forty-one patients (32%) completed neuropsychologic evaluation with a battery of tests for cognitive function. Anxiety states and traits were also assessed. The distribution of microembolism showed that there were three groups of patients: < 30 microemboli (n = 83); 30 to 59 (n = 24); and > 60 (n = 20). Seven of 10 patients with cerebral complications (stroke, coma, delirium, aberrant behavior) were in the > 60 microemboli group. Those with cerebral complications had 20.7 +/- 4.5 microemboli from perfusion and 57.4 +/- 15.6 from surgical events. The 13 patients in the > 60 microemboli group without central nervous system symptoms had 95.5 +/- 19.5 microemboli from perfusion and 36.0 +/- 6.9 from surgical events. Neuropsychologic scores were most often depressed for memory (73%), comprehension (49%), attention (46%), and constructional ability (44%). The greatest change was in total score in the > 60 microemboli group (-3.3 +/- 0.6) compared with -1.1 +/- 0.2 and -1.9 +/- 0.2 for the 30 to 59 and < 30 groups, respectively. The incidences of cardiac and pulmonary complications and mortality were different between those patients with < 60 microemboli versus those with > 60 microemboli. Cardiac and pulmonary complications and mortality percentages were 4.7%, 3.7%, and 0.9%, respectively, for the < 60 microemboli group and 20%, 20%, and 15%, respectively, for the > 60 microemboli group. We concluded that transcranial Doppler ultrasonography is a useful technique to quantify and detect the source of microemboli during coronary artery bypass operations and may be useful in assessing new operative strategies, the quality of the perfusion, and potentially as an indicator for pharmacologic therapy in the operating room in patients with high microemboli counts.

Cardiopulmonary Bypass↗

PubMed2002

Radiosurgery for residual or recurrent nonfunctioning pituitary adenoma.

OBJECT: Nonfunctioning pituitary adenomas comprise approximately 30% of all pituitary tumors. The purpose of this retrospective study is to evaluate the efficacy and role of gamma knife radiosurgery (GKS) in the management of residual or recurrent nonfunctioning pituitary adenomas. METHODS: A review was conducted of the data obtained in 42 patients who underwent adjuvant GKS at the University of Pittsburgh between 1987 and 2001. Prior treatments included transsphenoidal resection, craniotomy and resection, or conventional radiotherapy. Endocrinological, ophthalmological, and radiological responses were evaluated. The duration of follow-up review varied from 6 to 102 months (mean 31.2 months). Fifteen patients were observed for more than 40 months. The mean radiation dose to the tumor margin was 16 Gy. Conformal radiosurgery planning was used to restrict the dose to the optic nerve and chiasm. Tumor control after GKS was achieved in 100% of patients with microadenomas and 97% of patients with macroadenomas. Gamma knife radiosurgery was equally effective in controlling adenomas with cavernous sinus invasion and suprasellar extension. No patient developed a new endocrinological deficiency following GKS. One patient's tumor enlarged with an associated decline in visual function. Another patient experienced a deterioration of visual fields despite a decrease in tumor size. CONCLUSIONS: Gamma knife radiosurgery can achieve tumor control in virtually all residual or recurrent nonfunctioning pituitary adenomas. Dose sparing facilitates tumor management even when the adenoma is close to the optic apparatus or invades the cavernous sinus.

Adenoma↗