Central nervous system injury associated with cardiac surgery

Department of Anesthesiology, Duke University, Durham, North Carolina, United States
The Lancet (Impact Factor: 45.22). 09/2006; 368(9536):694-703. DOI: 10.1016/S0140-6736(06)69254-4
Source: PubMed


Millions of individuals with coronary artery or valvular heart disease have been given a new chance at life by heart surgery, but the potential for neurological injury is an Achilles heel. Technological advancements and innovations in surgical and anaesthetic technique have allowed us to offer surgical treatment to patients at the extremes of age and infirmity-the group at greatest risk for neurological injury. Neurocognitive dysfunction is a complication of cardiac surgery that can restrict the improved quality of life that patients usually experience after heart surgery. With a broader understanding of the frequency and effects of neurological injury from cardiac surgery and its implications for patients in both the short term and the long term, we should be able to give personalised treatments and thus preserve both their quantity and quality of life. We describe these issues and the controversies that merit continued investigation.

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Available from: Daniel Laskowitz, Jan 13, 2014
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    • "With 7 million cardiovascular and 21 million non-cardiovascular surgeries performed annually in the US [3] and similar numbers in Europe (extrapolated from data from the Netherlands [4]), annual deaths are calculated to be in excess of 180,000 on these two continents alone. Those left with the debilitating consequences of perioperative stroke/encephalopathy number an order of magnitude higher [5], [6]. Treatment of perioperative stroke accounts for a quarter of the resources spent annually for stroke treatment in the USA [5]. "
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    ABSTRACT: Stroke is a major complication of cardiovascular surgery, resulting in over 100,000 deaths and over a million postoperative encephalopathies annually in the US and Europe. While mitigating damage from stroke after it occurs has proven elusive, opportunities to reduce the incidence and/or severity of stroke prior to surgery in at-risk individuals remain largely unexplored. We tested the potential of short-term preoperative dietary restriction to provide neuroprotection in rat models of focal stroke. Rats were preconditioned with either three days of water-only fasting or six days of a protein free diet prior to induction of transient middle cerebral artery occlusion using two different methods, resulting in either a severe focal stroke to forebrain and midbrain, or a mild focal stroke localized to cortex only. Infarct volume, functional recovery and molecular markers of damage and protection were assessed up to two weeks after reperfusion. Preoperative fasting for 3 days reduced infarct volume after severe focal stroke. Neuroprotection was associated with modulation of innate immunity, including elevation of circulating neutrophil chemoattractant C-X-C motif ligand 1 prior to ischemia and suppression of striatal pro-inflammatory markers including tumor necrosis factor α, its receptor and downstream effector intercellular adhesion molecule-1 after reperfusion. Similarly, preoperative dietary protein restriction for 6 days reduced ischemic injury and improved functional recovery in a milder cortical infarction model. Our results suggest that short-term dietary restriction regimens may provide simple and translatable approaches to reduce perioperative stroke severity in high-risk elective vascular surgery.
    PLoS ONE 04/2014; 9(4):e93911. DOI:10.1371/journal.pone.0093911 · 3.23 Impact Factor
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    • "The incidence of cerebral injury during surgery, especially cardiac surgery, has been a concern to clinicians and researchers for decades. The etiology of perioperative stroke, encephalopathy, and cognitive decline has been the subject of extensive reviews (Newman et al., 2006; Lombard and Mathew, 2010; van Dijk et al., 2000). Current opinion is that these cerebral insults arise from a multifactorial process, involving hypoperfusion, alterations in neuronal metabolism, inflammation, and embolization (Carrascal and Guerrero, 2010; Hogue et al., 2006). "
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    ABSTRACT: Cerebral air emboli occur as a complication of invasive medical procedures. The sensitivity of cerebral monitoring methods for the detection of air emboli are not known. This study investigates the utility of electroencephalography and non-invasively measured cerebral oxygen saturation in the detection of intracerebrovascular air. In 12 pigs oxygen saturation was continuously measured using transcranial near-infrared spectroscopy and oxygen tension was continuously measured using intraparenchymal probes. Additionally, quantitative electroencephalography and microdialysis were performed. Doses of 0.2, 0.4, 0.8, and 1.6ml of air were injected into the cerebral arterial vasculature through a catheter. Oxygen saturation and electroencephalography both reacted almost instantaneously on the air emboli, but were less sensitive than the intraparenchymal oxygen tension. There was reasonable correlation (ρ ranging from 0.417-0.898) between oxygen saturation, oxygen tension, electroencephalography and microdialysis values. Our study is the first to demonstrate the effects of cerebral air emboli using multimodal monitoring, specifically on oxygen saturation as measured using near-infrared spectroscopy. Our results show that non-invasively measured oxygen saturation and quantitative electroencephalography can detect the local effects of air emboli on cerebral oxygenation, but with reduced sensitivity as compared to intraparenchymal oxygen tension. Prospective human studies using multimodal monitoring incorporating electroencephalography and oxygen saturation should be performed.
    Journal of Neuroscience Methods 03/2014; 228. DOI:10.1016/j.jneumeth.2014.03.009 · 2.05 Impact Factor
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    • "In recent years, near-infrared spectroscopy (NIRS) is increasingly used to monitor regional cerebral oxygen saturation (rSO2) during cardiac surgery [1,2,3,4]. In fact, neurologic injury is still a common complication after cardiac surgery, with rates of postoperative neurocognitive decline (PONCD) and stroke of up to 50% and 1-3%, respectively [5]. Moreover, stroke after cardiac surgery results in a 10-fold increase in mortality and in a 3-fold increase in hospital stay [6]. "
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    ABSTRACT: Introduction Several near-infrared spectroscopy oximeters are commercially available for clinical use, with lack of standardization among them. Accordingly, cerebral oxygen saturation thresholds for hypoxia/ischemia identified in studies conducted with INVOSTM models do not necessarily apply to other devices. In this study, the measurements made with both INVOSTM and EQUANOXTM oximeters on the forehead of 10 patients during conventional cardiac surgery are directly compared, in order to evaluate the interchangeability of these two devices in clinical practice. Methods Cerebral oxygen saturation measurements were collected from both INVOSTM 5100C and EQUANOXTM 7600 before anesthetic induction (baseline), two minutes after tracheal intubation, at cardiopulmonary bypass onset/offset, at aortic cross-clamping/unclamping, at the end of surgery and whenever at least one of the two devices measured a reduction in cerebral oxygen saturation equal to or greater than 20% of the baseline value. Bland-Altman analysis was used to compare the bias and limits of agreement between the two devices. Results A total of 140 paired measurements were recorded. The mean bias between INVOSTM and EQUANOXTM was -5.1%, and limits of agreement were ±16.37%. Considering the values as percent of baseline, the mean bias was -1.43% and limits of agreement were ±16.47. A proportional bias was observed for both absolute values and changes from baseline. Conclusions INVOSTM and EQUANOXTM do not seem to be interchangeable in measuring both absolute values and dynamic changes of cerebral oxygen saturation during cardiac surgery. Large investigations, with appropriate design, are needed in order to identify any device-specific threshold.
    03/2014; 6(3):197-203.
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