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PubMed1999

Prefrontal dysfunction following unilateral posteroventral pallidotomy in Parkinson's disease.

OBJECT: Pre- and postoperative cognitive function was evaluated in 25 patients with Parkinson's disease (PD) who underwent unilateral posteroventral pallidotomy (PVP) to clarify the effects of this operation on cognitive function. METHODS: Cognitive function was assessed before surgery and 1 month and 3 months afterward by using a battery of neuropsychological tests consisting of orientation, digit span (forward and backward), digit learning, 5-minute memory of five words, similarities, serial sevens, animal name listing, and the kana pick-out test, as well as the Japanese version of the Mini-Mental State. Preoperative evaluation revealed that patients experienced difficulties in performing the neuropsychological tasks of reasoning and abstraction, working memory of numerals, word fluency, and concept formation compared with 36 healthy volunteers (p < 0.05). A simple regression analysis showed strong relationships in a negative fashion between preoperative (r = 0.81, p = 0.002) and 1-month (r = 0.79, p = 0.0059) and 3-month (r = 0.85, p = 0.0016) postoperative gross-total scores and Hoehn and Yahr staging. Preoperative and postoperative scores at 1 month and 3 months were analyzed by analysis of variance, but only the Fisher's post hoc test revealed the source of difference. All tasks except orientation (p = 0.0292) were unchanged in the 10 patients who underwent surgery on the right side. The scores for this task at 1 month postsurgery were significantly lower (p = 0.0203) but improved to preoperative values by 3 months. In the 15 patients who underwent surgery on the left side significant differences among tasks were revealed for serial sevens (p = 0.0471) and animal naming (p = 0.0425). The scores for these tasks were significantly lower at 1 month postoperatively (p = 0.0431 for serial sevens and p = 0.0408 for animal naming), but improved by 3 months after the operation. CONCLUSIONS: The present data revealed that cognitive dysfunction in patients with PD relates to advancement of Hoehn and Yahr stage, but PVP is not associated with significant long-lasting cognitive deficits.

Aged↗

PubMed2005

Management of temperature during and after cardiac surgery.

Neurologic injury is a devastating complication of cardiac surgery. Cerebral cooling is an important aspect of hypothermic cardiopulmonary bypass in some patients, because hypothermia is the only reliable method of neuroprotection against injuries related to cerebral ischemia. Hypothermia may afford neuroprotection by a variety of mechanisms, including reduction in cerebral metabolic rate, decreased excitatory transmitter release, reduced ion influx, and reduced vascular permeability. Conversely, hyperthermia, even if mild (2-3 degrees C), is harmful; it aggravates ischemic neuronal injury and accelerates neuronal death. In patients with acute strokes, hyperthermia worsens prognosis with respect to stroke severity, infarct size, mortality, and outcome in survivors. The degree of temperature discrepancy among standard monitoring sites in individual patients is often striking. The differences between jugular bulb temperature and rectal or bladder temperature are particularly large. Blood temperature in the arterial line leading from the oxygenator may be the most consistently accurate indicator of cerebral temperature. When hypothermia is used to protect vital organs during cardiopulmonary bypass, the cooling phase should be adequate, and the rewarming phase must be carefully managed. Hyperthermia may be as hazardous during the postoperative period as during surgery, exacerbating the extent of tissue injury if an overt stroke has occurred. Postoperative hyperthermia correlates with a greater degree of cognitive dysfunction measured 6 weeks after cardiac surgery. In conclusion, cardiac anesthesiologists can reduce the risk of inadvertent hyperthermia by selecting the best sites for temperature monitoring, carefully controlling the rewarming process, and continuing temperature monitoring during the postoperative period.

Brain Ischemia↗

PubMed1996

Effect of asymptomatic carotid artery disease on cognitive outcome after cardiopulmonary bypass.

This prospective study reinvestigates the effect of asymptomatic carotid artery disease on the cognitive outcome after cardiopulmonary bypass (CPB) (Harrison et al., 1989). Patients (N = 104) scheduled for cardiac surgery using CPB were classified in one of two groups based on the results of a preoperative duplex B mode Doppler scan of the internal carotid arteries. All patients received a neuropsychological examination before surgery, 8 days after surgery, and 6 months after surgery (n = 79). When group data are considered, patients showed evidence of selective cognitive dysfunction early after surgery. These dysfunctions were resolved by the sixth postoperative month. We found no indications that the presence of asymptomatic carotid artery disease increased the incidence of cognitive disturbances after CPB or differentially affected the postoperative performance. We conclude that mild to moderate asymptomatic carotid artery disease does not appear to play a major role in the genesis of postoperative neuropsychological sequelae.

Aged↗

PubMed2003

Regional anaesthesia in ambulatory surgery.

PURPOSE OF REVIEW: The purpose of this review is to present recent research into the clinical use of regional anaesthesia techniques in ambulatory surgery. Further, to put into an ambulatory perspective some of the issues recently discussed on the basis and practice of regional anaesthesia in general. RECENT FINDINGS: Early discharge with long-acting peripheral nerve blockade seems safe, and discharge of patients who have not voided after surgery is possible under specified terms. The spinal anaesthesia technique may be improved in terms of better and faster recovery characteristics if the dose of local anaesthesia is reduced by adding a small dose of opioid. SUMMARY: Loco-regional techniques are well suited for ambulatory surgery due to less postoperative nausea and pain and possibly less cognitive dysfunction. The different techniques are continuously being refined in order to provide fast discharge readiness, while still maintaining the benefits.

Journal Article↗

PubMed2005

Cerebral ischemic injury and cognitive impairment after off-pump and on-pump coronary artery bypass grafting surgery.

BACKGROUND: Off-pump coronary artery bypass grafting surgery reduces the intraoperative cerebral embolic load and may therefore cause less brain injury. The main aim of this study was to compare off-pump and on-pump surgery with regard to the frequency of new postoperative cerebral ischemic lesions and the prevalence of postoperative cognitive impairment. We also assessed whether preoperative cerebral ischemic injury predicts the risk for cognitive dysfunction after surgery. METHODS: One hundred twenty patients with ischemic coronary artery disease were prospectively randomized to undergo off-pump or on-pump surgery. A detailed neuropsychological assessment and a cerebral magnetic resonance imaging examination were performed on the day before and at 3 months postoperatively. The neuropsychological assessment was repeated at 12 months. RESULTS: There was no significant (p = 0.17) difference between off-pump (8.2%) and on-pump (17.3%) surgery with regard to new postoperative cerebral lesions. The prevalence of cognitive impairment after surgery was also similar in the two groups (3 months: off-pump 20.4%, on-pump 23.1%, p = 0.74; 12 months: off-pump 24.1%, on-pump 23.1%, p = 0.90). The degree of preoperative cerebral ischemic injury was significantly associated with cognitive dysfunction after on-pump (p = 0.02) but not after off-pump (p = 0.22) surgery. None of the patients with normal preoperative radiologic findings were found to have cognitive impairment at 3 months postoperatively (p = 0.04). CONCLUSIONS: Long-term cognitive function and magnetic resonance imaging evidence of brain injury were similar after off-pump and on-pump coronary artery bypass grafting surgery. Preoperative cerebral magnetic resonance imaging can be used to predict the risk for cognitive dysfunction after coronary artery bypass grafting surgery.

Adult↗

PubMed2005

Elevations in preoperative monocyte count predispose to acute neurocognitive decline after carotid endarterectomy for asymptomatic carotid artery stenosis.

BACKGROUND AND PURPOSE: Although the incidence of major stroke attributable to carotid endarterectomy (CEA) is low (1% to 2%), approximately 25% of patients experience subtle postoperative neurocognitive dysfunction. This study examines whether preoperative leukocyte profiles predict cognitive outcome in asymptomatic CEA patients. METHODS: Sixty-nine asymptomatic CEA patients underwent neuropsychometric testing preoperatively and on postoperative day 1 (POD1). Preoperative white blood cell counts and differentials were obtained. Logistic regression was performed for risk factors for neurocognitive decline. Variables achieving univariate P<0.10 were included in multivariate analysis. RESULTS: Eighteen (26%) patients experienced neurocognitive decline on POD1; multivariate analysis demonstrated that preoperative monocyte count (P=0.011) and age (P=0.02) independently predicted outcome. CONCLUSIONS: Preoperative monocyte count and age are independently associated with acute neurocognitive decline after CEA for asymptomatic stenosis.

Age Factors↗

PubMed2004

[Neuropsychological outcomes after coronary artery bypass grafting].

OBJECTIVE: Neuropsychological (cognitive) dysfunction has been described as an important complication, affecting up to 80% of patients early after cardiac surgery. Also it has been shown that cognitive abnormalities persist in a later postoperative follow up. The aim of our study was to determine incidence of cognitive complications early after isolated coronary artery bypass grafting using cardiopulmonary bypass, and to identify predictive factors, associated with perioperative cerebral dysfunction. MATERIAL AND METHODS: Eighty-six patients (63 men and 23 women; mean age 66.1+/-6.7 year) with identified isolated coronary artery disease were enrolled into prospective study using Case Report data collection document. Neuropsychological status was examined using Symbol Digit Modalities Test with additional Euro QOL test. All tests were performed at baseline (1 day before operation), at the 5(th) to 7(th) postoperative day and one month after operation. RESULTS: Neuropsychological dysfunction (as compared with baseline) occurred in 59 patients (68.6%) at the 5(th)-7(th) postoperative day and persisted in 19 patients (22.1%) after one month. Patients who suffered postoperative cerebral dysfunction more often had history of prior cerebrovascular morbidity (p<0.05), poor left ventricular ejection fraction (<or=35%) (p<0.05) and higher incidence of left main coronary artery disease (p<0.05). CONCLUSIONS: Cognitive dysfunction is still important complication after coronary artery bypass grafting persisting during the early follow-up in some patients. Symbol Digit Modalities Test was sensitive instrument for diagnostics of postoperative neuropsychological complications reasons.

Age Factors↗

PubMed2000

Subtle brain damage cannot be detected by measuring neuron-specific enolase and S-100beta protein after carotid endarterectomy.

OBJECTIVE: To assess whether subtle brain damage after carotid endarterectomy could be detected using serum levels of neuron-specific enolase (NSE) or S-100beta protein. DESIGN: Prospective noninterventional study. SETTING: University hospital. PARTICIPANTS: Twenty-two patients undergoing carotid endarterectomy and 16 patients undergoing repair of abdominal aortic aneurysm. INTERVENTIONS: Serum levels of NSE and S-100beta protein were measured in all patients before surgery and postoperatively at 12, 24, 36, and 48 hours. In patients undergoing carotid endarterectomy, neuropsychologic testing was performed before surgery and postoperatively at discharge from the hospital and after 3 months using a neuropsychologic test battery. MEASUREMENTS AND MAIN RESULTS: Compared with abdominal aortic surgery patients, the preoperative serum concentration of NSE was significantly higher in carotid artery surgery patients. Postoperatively, the NSE serum level decreased significantly after uncomplicated carotid artery surgery, and the level was then similar to that in the aortic surgery patients. Before operation, the S-100beta protein levels were similar in the two groups, but a significant increase was seen in aortic surgery patients postoperatively. Neuropsychologic testing after uncomplicated carotid artery surgery revealed cognitive dysfunction in 2 of 20 (10%) of the patients after 5 days and 3 of 16 (19%) of the patients after 3 months. There was no correlation between the change in cognitive function and the changes in blood levels of either NSE or S-100 protein. CONCLUSIONS: Subtle brain damage after carotid artery surgery could not be detected by measuring blood levels of NSE and S-100beta protein. The NSE level was significantly higher before carotid artery surgery and decreased postoperatively to the level observed in aortic surgery.

Aged↗

PubMed2005

The effects on cognitive performance of tailored resection in surgery for nonlesional mesiotemporal lobe epilepsy.

PURPOSE: Mesiotemporal lobe epilepsy (MTLE) can be treated with different surgical approaches. In tailored resections, neocortex is removed beyond "standard" margins when spikes are present in the electrocorticogram. We hypothesized that these larger resections are justified because spiking neocortex is dysfunctional. This would imply that in patients with spikes (a) postoperative cognitive performance is not affected, and (b) preoperative performance is worse than without spikes. METHODS: We studied 80 operated-on MTLE patients with pathologically confirmed nonlesional hippocampal sclerosis. All patients were left-sided language dominant and underwent cognitive tests 6 months pre- and postoperatively. A repeated measures analysis of variance (ANOVA) was performed, looking for within- and between-subjects interactions with presence of intraoperative neocortical spikes. RESULTS: Intraoperatively, neocortical spikes were present in 61% of patients. Improved postoperative cognitive outcome was seen only in left-sided patients with spikes. Their performance IQ (PIQ) increased by 8.1 points (95% confidence interval, 3.8-12.3; p = 0.02), and visual naming latency by 12.8 s (95% CI, 2.1-23.5; p = 0.07). Conversely, in left-sided patients without spikes, naming latency declined by 7.5 s (95% CI, -2.3-17.2; p = 0.07). Preoperative scores were comparable except for a 15.3-point (95% CI, 0.1-30.5; p = 0.02) lower VIQ in left-sided patients without spikes. CONCLUSIONS: Tailoring does not harm cognitive performance and is, in left-sided MTLE, associated with postoperative improvement. Left-sided MTLE without neocortical spikes has lower verbal scores, which tend to decline after standard resection and may represent a special pathophysiologic entity.

Adult↗

PubMed2006

Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial.

BACKGROUND: It has been suggested that the risk of cerebral dysfunction is less with off-pump coronary artery bypass grafting (OPCAB) than with conventional coronary artery bypass grafting (CCAB). However, evidence for this statement is preliminary, and additional insight is needed. METHODS AND RESULTS: The study was a substudy of the randomized Best Bypass Surgery trial that compared OPCAB with CCAB treatment with respect to intraoperative and postoperative mortality and morbidity in patients with a moderate to high level of predicted preoperative risk. The outcome was cognitive function. A total of 120 elderly patients (mean age 76 years, SD 4.5 years) underwent psychometric testing before surgery and at a mean of 103 (SD 15) days postoperatively with a neuropsychological test battery that included 7 parameters from 4 tests. Cognitive dysfunction was defined as the occurrence of at least 2 of the 7 possible deficits. Secondary analysis was performed on the basis of the definition of a 20% decline in cognitive scores compared with baseline, and with z score analysis. Cognitive dysfunction was identified in 4 of the 54 patients (7.4%, 95% confidence interval [CI] 2.1% to 17.9%) in the OPCAB group and 5 of the 51 patients (9.8%, 95% CI 3.3% to 21.4%) in the CCAB group. We found no difference in incidence of cognitive dysfunction between the groups regardless of the definition applied. CONCLUSIONS: In elderly high-risk patients, no significant difference was found in the incidence of cognitive dysfunction 3 months after either OPCAB or CCAB.

Aged↗

PubMed2005

A preliminary study of transient confusional states following bilateral subthalamic stimulation for Parkinson's disease.

Transient postoperative confusion (POC) occurs in 5-25% of patients following bilateral subthalamic nucleus stimulation. We retrospectively reviewed data on 96 patients who underwent bilateral subthalamic nucleus deep brain stimulation for Parkinson's disease. Nine percent of patients developed POC. There was no significant correlation between age/perioperative factors and POC. The POC group had a significantly higher incidence of depression and frontal-subcortical dysfunction on preoperative evaluation than patients without POC. Postoperative neuropsychological evaluations revealed declines on measures of general cognitive function and memory in the POC group. We provide preliminary evidence that patients with depression and frontal-subcortical dysfunction are more likely to develop POC, and that POC is more often associated with cognitive decline following surgery.

Aged↗

PubMed2002

[Central nervous system complications after coronary artery bypass grafting].

OBJECTIVE: The aim of this prospective study was to review incidence of neurological and cognitive complications after coronary artery bypass graft surgery and find out predictive factors, associated with perioperative cerebral dysfunction. MATERIAL AND METHODS: A prospective pilot study of 35 (27 men and 8 women, mean age 64.5+/-4.3 year) patients with identified coronary artery disease was conducted using Case Report data collection document. All patients underwent isolated elective CABG procedure at Cardiac center of Kaunas University of Medicine Hospital. RESULTS: There were two cases (5.7%) of postoperative transient ischemic attack, two cases (5.7%) of restless agitation with delirium, characterised as an postoperative encephalopathy and eight patients (22.8%) with cognitive abnormalities. CONCLUSIONS: The Canadian Stroke Scale and The Confusion Assessment Scale are sensitive and objective methods for diagnostics of postoperative neurological dysfunction. To characterize the incidence and severity of neuropsychological dysfunction, a concise battery of neuropsychologic tests that provides reliable evidence of subtle brain trauma should be used.

Aged↗

PubMed2005

Patient-controlled analgesia.

Using a portable infusion pump, intravenous opioid patient-controlled analgesia (PCA) permits a patient to self-deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals, largely because it can provide equivalent or better analgesia than conventional nurse-administered opioid analgesia, and patients are more satisfied with its use. There is no decisive pharmacological or clinical argument for the choice of one opioid rather than another. Thus, morphine remains the most frequently used opioid in PCA. The adjunction of non-opioid drugs to morphine in the PCA reservoir is still very controversial. A new investigational PCA transdermal system using iontophoresis to deliver fentanyl seems to provide an adequate pain control with the advantages of needle-free, preprogrammed, self-contained device. Whatever drug or device used, the overall success of the PCA technique relies mainly on the expert supervision of nurses or anesthesiologists in an Acute Pain Service. Indeed, PCA is effective and significant only on the condition that there is careful preoperative patient education and strict postoperative monitoring. In addition, preoperative patient selection allows to exclude patients with evidence of cognitive dysfunction or physical disabilities, making the use of the patient-controlled device impossible. Caution is required among patients with respiratory or renal insufficiency. In the future, the indispensable improvement in the management of postoperative pain should lead to a greater expansion of PCA. However, more pharmaco-economic evaluations will be needed on the cost-effectiveness issue.

Analgesia, Patient-Controlled↗

PubMed2000

Fatal toxic effect of bleomycin on brain tissue after intracystic chemotherapy for a craniopharyngioma: case report.

OBJECTIVE AND IMPORTANCE: Craniopharyngiomas are benign neoplasms of epithelial origin that arise from the remnants of Rathke's pouch and are located in the sellar, parasellar, and third ventricular regions. Despite major advances in microsurgical techniques, total removal of these tumors is associated with a high risk of death, long-term endocrinological dependence, cognitive dysfunction, and behavioral disorders. For patients with monocystic craniopharyngiomas, encouraging postoperative survival rates and high rates of cyst regression after intracavitary administration of bleomycin have been reported. Moreover, only a few side effects have been reported for this treatment method. We report a patient with a cystic craniopharyngioma who was treated using intracavitary bleomycin administration and died as a result of the direct toxic effects of bleomycin on deep brain structures and the brainstem. CLINICAL PRESENTATION AND INTERVENTION: A 47-year-old woman with a cystic craniopharyngioma underwent stereotactic insertion of a catheter attached to a subcutaneous reservoir. Five months after the procedure, positive-contrast computed tomographic cystography was performed to confirm the absence of fluid leakage. Daily intracavitary injections of bleomycin were administered through the reservoir into the cyst, until a total dose of 56 mg had been administered in 8 days. After the treatment, the cystic cavity regressed but the patient exhibited neurological deterioration; magnetic resonance imaging scans revealed diffuse edema in the diencephalon and brainstem. The patient died 45 days after completion of the treatment. CONCLUSION: Intracavitary administration of bleomycin is not a treatment protocol without risks or side effects, even if there is no fluid leakage into the cerebrospinal fluid. Although this is known to be an effective treatment for cystic craniopharyngiomas, previous reports cannot be used to establish a standard treatment method, and more research is needed to yield a safer effective protocol.

Antimetabolites, Antineoplastic↗

PubMed2005

Delayed surgical fixation of fractured hips in older people: impact on mortality.

AIM: The aim of this project was to ascertain whether increasing delays from admission to surgical repair of hip fractures showed a direct relationship to mortality within the first postoperative year. BACKGROUND: It has been recommended that surgical repair of hip fractures should be performed within 24 hours of admission in an effort to reduce postoperative mortality. A literature review of articles relevant to this directive revealed that previous research is conflicting in its findings, and fails to provide conclusive evidence on which to base this recommendation. METHODS: Using a retrospective correlational design, Cox Multivariate Regression was used to analyse data from a sample of 381 patients admitted with hip fractures between September 2000 and March 2002. Exclusions from the total accessible population were made in an effort to control bias because of other factors that could contribute to mortality, resulting in 381 patients (64% of total population) being included in the study. All patients in the sample had an American Society of Anaesthesiologists score of 2 or less, were fit for immediate surgery, had an intracapsular or trochanteric fracture, had not had contralateral hip fracture in the previous 2 years, and had presented exclusively with a hip fracture. RESULTS: There was no relationship between delayed surgery and postoperative mortality (P>0.05) when all other independent variables were controlled. Cognitive dysfunction and reduced prefracture mobility were both good prognostic indicators of increased mortality within the first operative year. CONCLUSION: It is important that patients are adequately prepared and resuscitated before surgery is carried out. The nursing contribution to this is paramount. The findings also identify useful information for preparing patient's relatives in relation to prognosis.

Aged↗

PubMed2006

Evidence-based perianesthesia care: accelerated postoperative recovery programs.

Prolonged stress response after surgery can cause numerous adverse effects, including gastrointestinal dysfunction, muscle wasting, impaired cognition, and cardiopulmonary, infectious, and thromboembolic complications. These events can delay hospital discharge, extend convalescence, and negatively impact long-term prognosis. Recent advances in perioperative management practices have allowed better control of the stress response and improved outcomes for patients undergoing surgery. At the center of the current focus on improved outcomes are evidence-based fast-track surgical techniques and what is commonly referred to as "accelerated postoperative recovery programs." These programs require a multidisciplinary, coordinated effort, and nurses are essential to their successful implementation.

Convalescence↗

PubMed2001

Is there a relationship between cognitive dysfunction and systemic inflammatory response after cardiopulmonary bypass?

BACKGROUND: The systemic inflammatory reaction (SIR) is assumed to be one of the factors that causes cerebral dysfunction after cardiopulmonary bypass (CPB). The aim of the present study was to evaluate the relationship between the SIR and postoperative cognitive performance at 5 days and 3 months. METHODS: One hundred patients undergoing coronary artery bypass grafting were studied. Inflammatory markers and markers of coagulation and fibrinolysis were determined at several time points during and after the operation. Correlation analysis between maximum levels of the different markers and early and late performance was performed. RESULTS: No overall association was found between the maximum levels of the inflammatory markers and early and late function. CONCLUSIONS: Notwithstanding limitations of statistical power established markers of systemic inflammatory reaction showed no relationship with outcome at 5-day or 3-month follow-up in this subset of patients.

Aged↗

PubMed1995

A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery. II. Neurologic and cognitive outcomes.

UNLABELLED: This double-blind, randomized comparison of pulsatile or nonpulsatile perfusion and alpha-stat or pH-stat management during cardiopulmonary bypass was designed to assess postoperative central nervous system outcomes. METHODS: Neurologic and cognitive testing was conducted before the operation and 7 days and 2 months after the operation in 316 patients having coronary artery bypass and in a reference cohort of 40 patients having major vascular and thoracic operations. RESULTS: As detailed in part I of this study, mortality in patients having coronary bypass was 2.8%. The incidence of stroke was 2.5% and did not differ among bypass groups. Mortality was 2.5% for the major surgery cohort. The incidence of cognitive (p = 0.003) and either neurologic or cognitive dysfunction (p = 0.0002) was higher at 7 days for the coronary bypass group than for the major surgery cohort. The incidence of neurologic dysfunction remained higher (p = 0.050) at 2 months in the coronary bypass group. Cognitive dysfunction at 2 months was less prevalent after 90 minutes of cardiopulmonary bypass in patients managed with alpha-stat than with pH-stat strategy (27% versus 44%, p = 0.047). CONCLUSIONS: Postoperative central nervous system dysfunction is more prevalent in patients having coronary bypass than in those having major operations. Pulsatility has no effect on central nervous system outcomes, but alpha-stat management is associated with a decreased incidence of cognitive dysfunction in patients undergoing prolonged cardiopulmonary bypass.

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