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Long-term cognitive impairment after acute respiratory distress syndrome: A review of clinical impact and pathophysiological mechanisms


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Abstract Acute respiratory distress syndrome (ARDS) survivors experience a high prevalence of cognitive impairment with concomitantly impaired functional status and quality of life, often persisting months after hospital discharge. In this review, we explore the pathophysiological mechanisms underlying cognitive impairment following ARDS, the interrelations between mechanisms and risk factors, and interventions that may mitigate the risk of cognitive impairment. Risk factors for cognitive decline following ARDS include pre-existing cognitive impairment, neurological injury, delirium, mechanical ventilation, prolonged exposure to sedating medications, sepsis, systemic inflammation, and environmental factors in the intensive care unit, which can co-occur synergistically in various combinations. Detection and characterization of pre-existing cognitive impairment imparts challenges in clinical management and longitudinal outcome study enrollment. Patients with brain injury who experience ARDS constitute a distinct population with a particular combination of risk factors and pathophysiological mechanisms: considerations raised by brain injury include neurogenic pulmonary edema, differences in sympathetic activation and cholinergic transmission, effects of positive end-expiratory pressure on cerebral microcirculation and intracranial pressure, and sensitivity to vasopressor use and volume status. The blood-brain barrier represents a physiological interface at which multiple mechanisms of cognitive impairment interact, as acute blood-brain barrier weakening from mechanical ventilation and systemic inflammation can compound existing chronic blood-brain barrier dysfunction from Alzheimer’s-type pathophysiology, rendering the brain vulnerable to both amyloid-beta accumulation and cytokine-mediated hippocampal damage. Although some contributory elements, such as the presenting brain injury or pre-existing cognitive impairment, may be irreversible, interventions such as minimizing mechanical ventilation tidal volume, minimizing duration of exposure to sedating medications, maintaining hemodynamic stability, optimizing fluid balance, and implementing bundles to enhance patient care help dramatically to reduce duration of delirium and may help prevent acquisition of long-term cognitive impairment.
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R E V I E W Open Access
Long-term cognitive impairment after
acute respiratory distress syndrome: a
review of clinical impact and
pathophysiological mechanisms
Cina Sasannejad
, E. Wesley Ely
and Shouri Lahiri
Acute respiratory distress syndrome (ARDS) survivors experience a high prevalence of cognitive impairment with
concomitantly impaired functional status and quality of life, often persisting months after hospital discharge. In this
review, we explore the pathophysiological mechanisms underlying cognitive impairment following ARDS, the
interrelations between mechanisms and risk factors, and interventions that may mitigate the risk of cognitive
impairment. Risk factors for cognitive decline following ARDS include pre-existing cognitive impairment, neurological
injury, delirium, mechanical ventilation, prolonged exposure to sedating medications, sepsis, systemic inflammation,
and environmental factors in the intensive care unit, which can co-occur synergistically in various combinations.
Detection and characterization of pre-existing cognitive impairment imparts challenges in clinical management and
longitudinal outcome study enrollment. Patients with brain injury who experience ARDS constitute a distinct
population with a particular combination of risk factors and pathophysiological mechanisms: considerations raised by
brain injury include neurogenic pulmonary edema, differences in sympathetic activation and cholinergic transmission,
effects of positive end-expiratory pressure on cerebral microcirculation and intracranial pressure, and sensitivity to
vasopressor use and volume status. The blood-brain barrier represents a physiological interface at which multiple
mechanisms of cognitive impairment interact, as acute blood-brain barrier weakening from mechanical ventilation and
systemic inflammation can compound existing chronic blood-brain barrier dysfunction from Alzheimers-type
pathophysiology, rendering the brain vulnerable to both amyloid-beta accumulation and cytokine-mediated
hippocampal damage. Although some contributory elements, such as the presenting brain injury or pre-
existing cognitive impairment, may be irreversible, interventions such as minimizing mechanical ventilation
tidal volume, minimizing duration of exposure to sedating medications, maintaining hemodynamic stability,
optimizing fluid balance, and implementing bundles to enhance patient care help dramatically to reduce
duration of delirium and may help prevent acquisition of long-term cognitive impairment.
Keywords: ARDS, Cognitive impairment, Outcomes, ICU delirium, Blood-brain barrier, Inflammation, Mechanical
ventilation, Pathophysiological mechanisms
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* Correspondence:
Division of Neurocritical Care, Department of Neurology, Cedars-Sinai
Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103,
Los Angeles, CA 90048, USA
Division of Neurocritical Care, Department of Neurosurgery, Cedars-Sinai
Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103,
Los Angeles, CA 90048, USA
Full list of author information is available at the end of the article
Sasannejad et al. Critical Care (2019) 23:352
Cognitive decline following acute respiratory distress syn-
drome (ARDS) complicates recovery from critical illness,
particularly among elderly patients with pre-existing cogni-
tive impairment. Although the exact pathophysiological
mechanisms are unknown, it is widely believed that neuro-
logical injury due to acute systemic inflammatory dysregu-
lation or impairments in cerebrovascular hemodynamics
contribute to cognitive decline after ARDS. In this article,
we review epidemiology, risk factors, putative pathophysio-
logical mechanisms, and possible therapeutic approaches to
minimize cognitive decline after ARDS.
Background and epidemiology
Cognitive impairment in survivors of acute respiratory
distress syndrome: clinical burden and long-term
Acute respiratory distress syndrome (ARDS) affects
200,000 patients per year in the USA, accounting for
10.4% of ICU admissions and 2540% mortality risk [1,
2]. ARDS survivors experience a high prevalence of
cognitive impairment: 70100% at hospital discharge,
4680% at 1 year, and 20% at 5 years [3,4]. ARDS sur-
vivors score significantly lower on standardized quality
of life assessments compared to severity-matched con-
trols at 6- and 12-month follow-up [5,6]. ARDS survi-
vors also experience higher overall healthcare costs,
exercise limitations, and persistent psychological and
physical disability despite lung function recovery at 5-
year follow-up [7]. Upon 1-year follow-up, survivors
demonstrate impaired executive function and short-
term memory and increased rates of anxiety and de-
pression [1,8], in addition to post-traumatic stress dis-
order [9]. Neurocognitive testing of ARDS survivors at
2-year follow-up reveals residual emotional and cogni-
tive sequelae in nearly half of patients [10]. In addition
to depression and anxiety, testing shows impairments
in executive function, learning, and memory, with 50%
of those affected performing below the 6th percentile
on multiple instruments [10]. Selected clinical studies
relevant to the understanding of post-ARDS cognitive
impairment are summarized in Table 1.
Ascertaining the true cognitive impact of ARDS requires
distinction between patients with pre-ARDS cognitive im-
pairment and patients who develop new cognitive symptoms
after ARDS. Although established instruments, such as the
Mini-Mental State Examination (MMSE), identify general
memory impairment at a single point in time, two limitations
arise in ICU populations: incomplete patient participation
and the inability to distinguish between delirium, dementia,
or the simultaneous presence of both [11]. These limitations
led to the development of instruments more sensitive in
discerning between different types and timescales of cogni-
tive impairment. The Confusion Assessment Method for
Intensive Care Unit patients (CAM-ICU) shows high sensi-
tivity and specificity in detecting delirium in mechanically
ventilated patients, incorporating questions addressing the
onset of mental status change, inattention, disorganized
thinking, and changes in the patients level of consciousness
[12]. Other instruments have been developed to evaluate for
pre-existing cognitive deficits: the Modified Blessed Demen-
tia Rating Scale (mBDRS) and the Informant Questionnaire
on Cognitive Decline in the Elderly (IQCODE) [13]. These
instruments more sensitively detect pre-existing cognitive
impairment by incorporating questions about activities of
daily living and practical examples of learning or memory in
the patients pre-morbid daily life experiences, thereby redu-
cing the burden of direct participation expected from the pa-
tient or allowing completion by proxy [11,14]. The mBDRS
assesses for dementia across 11 items encompassing mem-
ory, money management, navigation, activities of daily living,
and personality changes, while the IQCODE measures longi-
tudinal cognitive decline across 16 items encompassing
memory, tool utilization, learning, decision-making, and
problem solving [11,13]. While these instruments show high
overall agreement, the IQCODE demonstrates greater sensi-
tivity, while the mBDRS is less dependent on access to a
proxy [11,13]. In the long-term follow-up of survivors of
ARDS, the MMSE shows poor sensitivity in detecting cogni-
tive impairment and weak-to-moderate correlation with
neuropsychological testing [15]. Implementation and devel-
opment of specialized cognitive assessment tools may help
better guide decisions regarding capacity and medications, in
addition to improving our understanding of the significant
impact of cognitive decline after ARDS.
ARDS in brain injury
ARDS in the context of acute brain injury constitutes a
distinct clinical scenario from other types of ARDS, char-
acterized by earlier sympathetic activation and potential
interactions between positive pressure ventilation, cerebral
autoregulatory, and microcirculatory function [16]. ARDS
independently predicts mortality and poor neurological
outcome in patients with acute brain injury, particularly in
traumatic brain injury or intracerebral hemorrhage [17].
Stevens and Puybasset posited a brain-lung-brain axisby
which severe neurological injury from traumatic brain in-
jury, subarachnoid hemorrhage, or status epilepticus can
provoke concurrent pulmonary injury, in turn worsening
overall neurocognitive outcomes [18]. Up to 25% of pa-
tients with severe brain injury develop ARDS and up to
50% develop pulmonary edema, the former increasing the
likelihood of death or vegetative state threefold [19,20].
Patients with brain injury incur the greatest risk for devel-
oping ARDS in the initial 23 days after injury and ap-
proximately 1 week after injury [21,22]. Sympathetic
activation, systemic inflammation, pulmonary insuffi-
ciency, and shock contribute to the risk of ARDS early in
Sasannejad et al. Critical Care (2019) 23:352 Page 2 of 12
hospitalization [21,22]. The second peak of ARDS risk re-
flects ventilator-associated pneumonia and sepsis [21,22]:
comatose patients experience an increased frequency of
pneumonia between hospital days 47andareatriskfor
aspiration of oropharyngeal secretions during and after in-
tubation [23]. An observational study of patients with
severe traumatic brain injury identified cerebral midline
shift exceeding 5 mm and prior drug abuse as risk factors
for ARDS [19]. Furthermore, patients with concurrent
ARDS and brain injury who experienced worse long-term
cognitive outcome tended to demonstrate lower systemic
blood pressure, higher intracranial pressure, and lower
Table 1 Selected clinical studies investigating post-ARDS cognitive impairment
Author(s) Year Methodology Results/conclusions
Davidson et al. 1999 Prospective cohort (n= 146) Patients who survived ARDS experience significantly reduced quality of life following
discharge compared to critically ill patients without ARDS
Hopkins et al. 1999 Prospective cohort (n= 62) Survivors of ARDS demonstrate cognitive impairments in memory, attention,
concentration, and processing speed: 100% at discharge and 78% at 1 year after
Contant et al. 2001 Observational (n= 161) ARDS following severe head injury results in severe intracranial hypertension. Targeting
intracranial pressure rather than cerebral blood flow improves outcomes
et al.
2001 Prospective interventional (n= 20) In patients with acute stroke receiving mechanical ventilation, changes in cerebral
perfusion pressure are mediated by mean arterial pressure rather than by positive end-
expiratory pressure. Positive end-expiratory pressure does not increase intracranial pres-
sure as long as hemodynamic stability is maintained
Holland et al. 2003 Prospective cohort (n= 137) In patients with traumatic brain injury, ARDS independently predicts mortality and is
associated with worse long-term neurological outcome
Ely et al. 2004 Prospective cohort (n= 275) Delirium independently predicts higher mortality and longer hospital stay among
patients treated with mechanical ventilation
Mascia et al. 2005 Prospective interventional (n= 12) Positive end-expiratory pressure does not affect intracranial pressure when inducing al-
veolar recruitment, but does lead to significant increases in PaCO
and intracranial pres-
sure when inducing alveolar hyperinflation
Muench et al. 2005 Prospective interventional (n= 10) In hemodynamically unstable patients with severe subarachnoid hemorrhage, increases
in positive end-expiratory pressure disturb cerebrovascular autoregulation, resulting in
significant decreases in mean arterial pressure and regional cerebral blood flow
Mascia et al. 2007 Observational (n= 82) High-tidal-volume mechanical ventilation is associated with the development of ARDS
after severe brain injury
Fong et al. 2009 Secondary analysis of prospective
cohort (n= 408)
Delirium accelerates cognitive decline in patients with probable or possible Alzheimers
Taccone et al. 2009 Observational (n= 21) Septic shock impairs cerebral autoregulation in patients with septic shock, particularly
with concurrent hypercapnia
Janz et al. 2010 Retrospective cohort (n= 7 from
database of 379)
Brain autopsy of patients with ICU delirium shows hypoxic ischemic damage in the
hippocampus, suggesting a link between ICU delirium and long-term cognitive
van den
Boogard et al.
2011 Exploratory observational (n=
The underlying mechanism of delirium may differ in patients with systemic inflammation
versus patients without systemic inflammation and is mediated by different cytokines for
each mechanism
Mikkelsen et al. 2012 Prospective cohort (n= 102) Survivors of ARDS 1 year following discharge demonstrate a confluence of cognitive
impairment, psychiatric sequelae, and diminished quality of life. Hypoxemia and
conservative fluid management are associated with these long-term impairments
Elmer et al. 2013 Retrospective cohort (n= 697) High-tidal-volume mechanical ventilation in patients with intracerebral hemorrhage is
associated with the development of ARDS and increased mortality
et al.
2013 Prospective cohort (n= 821) At 12-month follow-up after discharge, 1/4 of patients who had been critically ill demon-
strate cognitive impairment similar in severity to that seen in mild Alzheimers disease,
and 1/3 similar in severity to that seen in traumatic brain injury
Needham et al. 2014 Prospective cohort (n= 203) At 6- and 12-month follow-up, ARDS survivors demonstrated impairments in 6-min walk
distance and physical function outcomes. Minimizing the duration of intensive care and
corticosteroid use may reflect modifiable risk factors
Girard et al. 2018 Prospective cohort (n= 1040
enrolled, n= 586 follow-up)
Patients with ARDS, septic shock, or both experience multiple subtypes of delirium
associated with long-term cognitive impairment at 3- and 12-month follow-up, including
hypoxic, septic, unclassified, and sedative-associated delirium. The durations of these de-
lirium subtypes predict worse cognitive function at 12-month follow-up, particularly
sedative-associated delirium
Sasannejad et al. Critical Care (2019) 23:352 Page 3 of 12
cerebral perfusion pressure [19]. Among patients with in-
tracerebral hemorrhage, 27% develop ARDS, with high-
tidal-volume mechanical ventilation constituting the
greatest risk factor, followed by positive fluid balance and
blood transfusion [24]. Despite this, existing prognostic
models for acute brain injury largely do not include ARDS
as a variable that may independently limit the extent of
neurocognitive recovery.
Risk factors for cognitive decline
Risk factors for long-term cognitive impairment com-
prise a combination of irreversible clinical factors, po-
tentially modifiable clinical complications of provider
interventions, and pathophysiological events that may
occur in the natural history of ARDS in brain injury. Fig-
ure 1illustrates the confluence of these factors and how
they may culminate in an adverse long-term cognitive
outcome. The heterogeneity of ARDS etiology and sever-
ity can expose patients to varying balances of these fac-
tors: for instance, ARDS of a pulmonary etiology may
expose patients to more severe hypoxemia, whereas
ARDS related to sepsis may expose patients to more se-
vere inflammatory activation, while overall disease sever-
ity can impact length of stay.
Pre-existing cognitive impairment and the interface of
delirium and dementia
Pre-existing cognitive impairment is a risk factor for
cognitive decline after critical illness [25,26], though
data are limited by under-recognition of pre-existing
cognitive impairment [14] or exclusion of patients with
pre-existing cognitive impairment from longitudinal
follow-up studies [1,6]. Alzheimers disease, character-
ized by cerebral accumulation and deposition of the
amyloid-βpeptide, is the most common type of cogni-
tive impairment [27,28]. Although one third of elderly
patients admitted to the intensive care unit have pre-
existing cognitive impairment, this history is often un-
known to their medical teams [14], in turn precluding
comparisons of pre-morbid versus longitudinal cognitive
performance. Among patients confirmed not to have
pre-existing dementia, one study found hospitalization
itself significantly associated with a greater likelihood of
developing dementia, along a temporal pattern of abrupt,
rather than gradual, cognitive decline [29].
Delirium during critical illness predicts long-term
cognitive decline after ARDS [1,4,26], and longer
durations of delirium in critically ill patients predict
more severe cognitive impairment at 1-year follow-up
[30]. The closely intertwined relationship between de-
lirium and pre-existing cognitive impairment raises a
physiological question: does long-term cognitive im-
pairment following ARDS reflect a reduction in the
threshold for developing delirium due to underlying
dependently to this end? It is known that pre-existing
cognitive impairment is a key underlying risk factor
for delirium, which affects as many as 7087% of crit-
ically ill patients [31,32]. Particularly among the eld-
erly, ICU delirium can persist during hospitalization
following transfer from the ICU in 4050% of pa-
tients, commonly with incomplete resolution by dis-
charge [33]. A meta-analysis of long-term sequelae of
delirium in elderly patients found increased risk of
developing dementia within 35 years of discharge,
with an odds ratio of 12.52 (95% CI 1.8684.21) [34].
Patients with Alzheimers disease, when hospitalized,
to experience delirium; cognitive deficits can persist
up to 5 years after discharge [25]. Clinically, patients
with Alzheimers disease who experience delirium suf-
fer accelerated cognitive decline beyond the natural
course of dementia alone, with twofold increases in
the slope of decline [35]. Recent pathology-based
studies corroborate delirium-associated acceleration of
cognitive decline independent of pre-existing demen-
tia pathology [36].
Delirium subtypes and pathways
Studies of the pathophysiology of short- and long-term
cognitive impairment reflect similarities and differences
between delirium and dementia pathways, in which pre-
existing pathophysiology diminishes the reserve with
which to face acute insults. Shared mechanistic features
of dementia and delirium include synaptic disconnection
resulting from the loss of presynaptic terminals, dimin-
ished cholinergic activity leading to impaired arousal
and inattention, and microglial activation perpetuating
systemic inflammation [37]. Girard et al. classify the
phenotypes of delirium in the intensive care unit into
five subtypes: sedative-associated, hypoxic, septic/inflam-
matory, metabolic, and unclassified [30]. Among these,
the duration of metabolic delirium is not associated with
long-term adverse cognitive outcomes [30]. Pathophysio-
logically, MacLullich et al. classify the etiologies of delir-
ium into two categories: direct brain insultsprimary
insults such as hemorrhage, hypoxia, hypoperfusion, or
drugsversus aberrant stress responsesthe dysfunc-
tion of ordinarily adaptive responses to acute systemic
stressors such as infection or trauma [38]. Differences in
serum markers between patients with inflammatory ver-
sus non-inflammatory delirium suggest activation of
multiple possible pathways: a systemic inflammation
pathway associated with IL-8 elevation among patients
with inflammation, and an alternative pathway charac-
terized by elevation of amyloid-βand IL-10 in patients
without inflammation, suggesting activation of existing
pathways of underlying cognitive impairment [39].
Sasannejad et al. Critical Care (2019) 23:352 Page 4 of 12
Individual pathophysiological mechanisms may be asso-
ciated with multiple delirium subtypes in which a single
phenotype dominates, and these relationships remain an
active area of investigation.
ARDS and hypoxemia: short-term and long-term effects
Profound hypoxemia is one of the cardinal features of
ARDS. While, in the short-term, this can predispose pa-
tients to hypoxic delirium phenotypes [30], lower PaO
levels are associated with long-term cognitive impair-
ment at 12-month follow-up, particularly in the domains
of executive function and psychomotor tasks [1,40].
Inflammation and septic delirium
The production of cytokines TNF-α, IL-6, IL-1α, and IL-
1βcan produce a constellation of behaviors termed
sickness behavior,comprising impaired concentration,
malaise, diminished motivation, psychomotor retard-
ation, and depression [41], corresponding with septic de-
lirium. In one study, this state was found to be
associated with recruitment of additional brain struc-
tures in order to maintain the same level of cognitive
performance during systemic inflammation [42]. Existing
brain injury enhances vulnerability to inflammation: in
mouse models of neurodegenerative disease, lipopolysac-
charide in brain-injured versus control mice induces
Fig. 1 Confluence of clinical risk factors and pathophysiological events culminating in cognitive impairment following ARDS and brain injury.
Combinations of irreversible clinical risk factors, pathophysiological events, and modifiable clinical risk factors, each occurring to varying extents,
produce an aggregate sum of risk for long-term cognitive impairment. Cognitive outcomes reflect a continuum up to a threshold beyond which
a patient is likely to experience an adverse outcome, defined as long-term cognitive impairment. The aggregate sum of these factors can bring
the patients risk for long-term impairment closer toward this threshold (the upward trajectory indicated by the red arrow); however, minimization
of modifiable clinical factors can bring the aggregate sum further away from the threshold, promoting a less adverse cognitive outcome (the
downward trajectory indicated by the green arrow)
Sasannejad et al. Critical Care (2019) 23:352 Page 5 of 12
compounded cognitive deficits on maze-learning tasks
greater than exaggerated sickness behavior alone [43].
Mechanical ventilation and inflammatory and sedative-
associated delirium
Mechanical ventilation is independently associated with
persistent cognitive impairment, diminished quality of
life, and depression [44]. One third of mechanically
ventilated patients perform abnormally on neurocogni-
tive testing at 6 months, comprising deficits in visuo-
construction, visual memory, psychomotor speed, and
verbal fluency [44]. Accelerated Alzheimers disease-type
pathophysiology can follow short-term high-tidal-
volume mechanical ventilation in mice, including im-
paired β-amyloid clearance, increased inflammation me-
diated by TNF-αand IL-6, and altered blood-brain
barrier permeability [45]. Prolonged courses of mechan-
ical ventilation in ARDS also expose patients to sedating
medications and anesthesia. Among delirium subtypes,
sedative-associated delirium is the most common and,
with prolonged duration, associated with the greatest de-
gree of long-term cognitive impairment at 12 months
following discharge [30]. Among sedative types, benzodi-
azepines impart the greatest risk for delirium, while dex-
medetomidine has been associated with lower risk for
delirium [46]; however, data and practice choices are
limited, as most intensive care unit patients are treated
with multiple sedatives [30]. The effect of paralytic ex-
posure on long-term cognitive outcomes is unknown
[3]. Continuous exposure to sedative medications over
several days results in impaired sedative clearance, in
turn exacerbating delirium [30]. In addition to inducing
acute-on-chronic cholinergic transmission dysfunction
in elderly patients, transient axonal damage may repre-
sent another mechanism by which sedatives can contrib-
ute to long-term cognitive decline [47].
Table 2 Selected animal studies investigating post-ARDS cognitive impairment
Author(s) Year Animal
De la Torre
et al.
1992 Rat Chronic cerebrovascular insufficiency following ligation of the common carotid and left subclavian arteries in aged
rats induces behavioral and cognitive impairments consistent with dementia
Pappas et al. 1996 Rat Rats exposed to chronic reduction of cerebral blood flow following carotid artery ligation develop memory
dysfunction and cell loss in the CA1 region of the hippocampus
et al.
1997 Rabbit Positive end-expiratory pressure reduces intracranial compliance in rabbits
Wilson et al. 2003 Mouse High-tidal-volume mechanical ventilation upregulates cytokines in mouse lungs
et al.
2005 Mouse Systemic inflammation simulated by lipopolysaccharide in mechanically ventilated mice induces cytokine-mediated
lung injury in mechanically ventilated wild-type mice
Fries et al. 2005 Pig Mechanically ventilated pigs exposed to hypoxemia with lung injury develop histopathologic changes in the CA1
region of the hippocampus not when exposed to the same degree of hypoxemia alone, suggesting lung injury as
a mechanism of damage independent from hypoxemia
et al.
2005 Rat Systemic inflammation induces apoptosis in the rat brain, particularly in the hippocampus
Wilson et al. 2005 Mouse Pulmonary inflammation following high-tidal-volume mechanical ventilation in mice without underlying lung injury
is mediated by TNF-α
et al.
2009 Pig Low- versus high-tidal-volume mechanical ventilation improves cerebral tissue oxygenation in pigs
et al.
2009 Mouse Mechanical ventilation even at lower tidal volumes causes lung injury in wild-type mice without history of lung
et al.
2011 Pig Mechanically ventilated pigs exposed to hypoxemia with lung injury demonstrate trends toward elevated cytokines
IL-6 and TNF-αin the CA1 region of the hippocampus versus mechanically ventilated pigs exposed to hypoxemia
Heuer et al. 2011 Pig In mechanically ventilated pigs, ARDS results in elevations in TNF-α, IL-6, and IL-1β, which further increase in pigs
with acute intracranial hypertension. The combination of ARDS and acute intracranial hypertension results in hippo-
campal damage. Acute intracranial hypertension induces lung injury and extravascular lung water
et al.
2011 Mouse In a mouse model of septic encephalopathy, an IL-1βcytokine-mediated process disrupts the synaptic processing
of long-term potentiation in the hippocampus
Davis et al. 2015 Mouse Baseline neurodegeneration in mice increases the risk, duration, and severity of delirium
et al.
2016 Rat TNF-αand IL-6 are detected in the contused hemisphere of rats soon after closed head injury, but not in healthy
rats. TNF-αis detected as early as 1 h after injury and peaks at 4h, whereas IL-6 is detected at 35 h and peaks at 8
h after injury
Lahiri et al. 2019 Mouse High-tidal-volume mechanical ventilation simulates Alzheimers disease pathophysiology in transgenic Alzheimers
disease and wild-type mice
Sasannejad et al. Critical Care (2019) 23:352 Page 6 of 12
Putative biological mechanisms
Inflammation and hypoxemia
Animal studies of ARDS reflect a wide range of ap-
proaches, including murine and porcine models, chem-
ical lung injury, ventilator-induced lung injury following
mechanical ventilation, and combinations of lung injury
with systemic inflammatory states, such as sepsis [48].
Selected animal studies relevant to the understanding of
the mechanisms of post-ARDS cognitive impairment are
summarized in Table 2. While ARDS models typically
invoke a high-tidal-volume strategy, it is important to
note that mechanical ventilation itself, even at low tidal
volumes, can still cause lung injury [49].
Various mechanisms of ARDS-mediated neurological
damage have been theorized, including hypoxemia and
cytokine-mediated damage [50]. A porcine model of
ARDS identified cytokine-mediated brain damage from
lung injury, rather than hypoxemia, as the major patho-
physiological contributor to hippocampal damage, spe-
cifically in CA1 and CA2 [50]. A subsequent study on
pigs randomized to mechanical ventilation-induced
ARDS versus hypoxia-only groups found greater cogni-
tive impairment and trends toward increased hippocam-
pal inflammation and systemic IL-6 and TNF-α
expression among ARDS subjects, further corroborating
the distinct pathophysiological roles of mechanical venti-
lation and concomitant cytokine release [51]. Among
mechanical ventilation groups, low-tidal-volume ventila-
tion is associated with improved brain tissue oxygen-
ation and reduced cytokine release compared to high-
tidal-volume groups [52].
Animal models also demonstrate that ARDS associated
with acute brain injury differs in physiology, time course,
and treatment from traditional ARDS: it occurs later and
features sympathetic nervous system activation, which,
in turn, can trigger neurogenic pulmonary edema sec-
ondary to increased alpha-adrenergic activity [53,54].
ARDS is frequently triggered by sepsis, a proinflamma-
tory condition characterized by elevated peripheral cyto-
kines and cerebral hypoperfusion, culminating in
multifactorial encephalopathy and end-organ damage
[55]. Peripheral cytokine elevation alters blood-brain
barrier metabolism by activating endothelial cells, while
simultaneously impairing systemic and cerebral blood
flow, altering glucose metabolism in the brain, and ex-
posing patients to deleterious environmental factors in
the course of treatment [55]. Cerebral autoregulation
disruption in early septic shock further compounds sys-
temic hypotension, as endotoxin-triggered inducible ni-
tric oxide synthase production excessively vasodilates
blood vessels, precluding appropriate modulation of vas-
cular resistance [56]. Patients with concurrent sepsis and
ARDS incur further risk for impaired cerebral autoregu-
lation, as sepsis renders the cerebral autoregulatory
mechanism more sensitive to P
: in one study, 50%
of septic patients with low P
lost autoregulation,
rising to 100% with normal or high P
Blood-brain barrier damage and amyloid-βclearance
The blood-brain barrier is a key neurobiological struc-
ture underlying cognitive function. Under normal
physiological conditions, the blood-brain barrier trans-
ports amyloid-βprotein from within neurons to the
extracellular space, where it can be cleared by the glym-
phatic system [5759]. Accumulated amyloid-βworsens
blood-brain barrier dysfunction by increasing permeabil-
ity, impairing transporter function, and modulating
endothelial cell expression patterns, in turn perpetuating
impairment in the clearance of amyloid-βand inflamma-
tory cytokines [60]. Amyloid-βtoxicity induces apoptosis
in blood-brain barrier endothelial cells and downregu-
lates tight junction proteins Zo-1, occludin, and claudin
[61]. Hippocampal blood-brain barrier breakdown has
been identified early in the disease course in transgenic
Alzheimers disease mouse models, with breakdown pre-
ceding the detection of amyloid-βdeposits, cerebral
amyloid angiopathy, or behavioral changes [58]. Animal
studies demonstrate a relationship between amyloid-β
deposits and hippocampal damage, as intrahippocampal
injection of amyloid-βin rats specifically induced apop-
tosis in the CA1 region of the hippocampus [62].
Amyloid-βimpairs the memory-consolidation process of
long-term potentiation in the rat hippocampus in a
time- and concentration-dependent fashion [63], mech-
anistically comprising impairments in intracellular cal-
cium homeostasis and NMDA receptor function [27].
Pathophysiological similarities between Alzheimers
disease and the acute sequelae of high-tidal-volume
mechanical ventilation in mice suggest a link between
the mechanisms underlying cognitive damage in ARDS,
Alzheimers disease, and delirium through a combination
of inflammation and amyloid-βaccumulation [45].
Mechanical ventilation increases cerebral TNF-αinde-
pendently of serum TNF-α, suggesting that cerebral
amyloid-βdeposition in this setting may reflect a direct
response to mechanical ventilation or pulmonary injury
rather than sequelae of systemic inflammation [45].
Neuroimaging comparisons of ARDS survivors within
a year of hospital discharge, versus healthy matched con-
trol patients, demonstrate accelerated cerebral and hip-
pocampal atrophy [64]. This is consistent with autopsy
findings from deceased intensive care unit patients who
had experienced delirium, in which hippocampal hyp-
oxic ischemic lesions were not only the most commonly
identified abnormality, but were also found only in pa-
tients who had experienced ARDS [65]. Magnetic
resonance imaging studies have identified hippocampal
blood-brain barrier dysfunction preceding structural or
Sasannejad et al. Critical Care (2019) 23:352 Page 7 of 12
functional phenotypes [66]. Post-mortem studies reflect
consistency with these results, with evidence of micro-
vascular damage and leukocyte infiltration at the sites of
blood-brain barrier damage [66].
Acute and chronic blood-brain barrier insults:
linking risk factors and mechanisms
Acute weakening, diminished reserve, cytokine
circulation, and apoptosis
ARDS and concomitant systemic inflammation reflect a
multifactorial array of simultaneous insults, comprising
cytokine release, metabolic dysregulation, impaired cere-
bral perfusion, medication side-effects, and environmen-
tal stimuli including physical restraints and noise [55].
Peripheral cytokine release generates positive feedback,
inciting further cytokine production through vagal tone
increase, blood-brain barrier endothelial activation, and
humoral system activation [55]. These processes collect-
ively culminate in microglial activation, releasing add-
itional cytokines, nitric oxide, and reactive oxidative
species within the central nervous system [55]. Micro-
glial activation occurs not only in systemic inflammation,
but also in aging, as older rodents injected with periph-
eral E. coli lipopolysaccharide produced cytokines, pri-
marily IL-1β, selectively in the hippocampus [67,68]. A
study investigating anatomic patterns of apoptosis in a
mouse model of systemic inflammation identified the
hippocampus as the most vulnerable region to Bax-
mediated apoptotic cascade activation following nitric
oxide synthase production downstream of microglial ac-
tivation [69].
Anatomical studies of humans and rodents confirm
the selective vulnerability of the CA1 hippocampal layer
to ischemic injury in a mechanism thought to reflect
glutamate excitotoxicity [70]. Mouse models of septic
encephalopathy confirm the role of IL-1βin damaging
learning and memory centers of the hippocampus, as
hippocampal neurons expressing IL-1βdemonstrated
electrophysiological evidence of inhibition of long-term
potentiation [71], thereby acting in a similar mechanism
as amyloid-β-mediated impairment of learning and
memory [72]. Existing blood-brain barrier damage sec-
ondary to amyloid-βaccumulation is associated with di-
minished cerebral blood flow and impaired blood flow
regulation in the elderly, secondary to impaired neuro-
vascular coupling [73]. This, in turn, can render patients
with Alzheimers disease susceptible to worsening cogni-
tive dysfunction in the setting of systemic hypoperfusion
and hypoxemia, which are common in ARDS [73].
The mechanistic relationships of brain and lung injur-
ies reflect synergy rather than direct causality, as brain
injury itself triggers cytokine production, including
TNF-αand IL-6 [74]. Indeed, lungs harvested from rab-
bits that had undergone brain herniation were less
resilient in tolerating high-pressure mechanical ventila-
tion compared to sham craniostomy animals, suggesting
potentiation of ARDS by systemic inflammation, in turn
due to brain injury [75]. Baseline blood-brain barrier
weakening, from chronic amyloid-βaccumulation, ren-
ders patients with mild cognitive impairment and Alz-
heimers disease susceptible to increased hippocampal
exposure to cytokines. Systemic inflammation, from
ARDS and sepsis, in turn, perpetuates cytokine-mediated
hippocampal damage by imparting acute-on-chronic
blood-brain-barrier damage while simultaneously in-
creasing systemic cytokine circulation.
Organ crosstalk in the setting of injurious mechanical
ventilation is not limited to brain-lung interactions. Ani-
mal studies demonstrate lung-kidney and lung-gut inter-
actions yielding insight into the pathogenesis of multi-
organ dysfunction syndrome, as rabbits exposed to high-
tidal-volume mechanical ventilation developed epithelial
cell apoptosis in the kidney and small intestine [76]. In
addition to cytokine-mediated damage and apoptosis,
additional mechanisms of acute kidney injury associated
with high-tidal-volume mechanical ventilation include
renal blood flow redistribution, hypoperfusion from sys-
temic hemodynamic changes, and metabolic disruption
from blood gas changes [77]. Human studies corroborate
this relationship, with a threefold increase in the risk of
acute kidney injury among critically ill patients exposed
to invasive mechanical ventilation (OR 3.58, 95% CI
1.856.92) [78].
Positive pressure ventilation and amyloid-βaccumulation
Despite benefits of positive end-expiratory pressure
(PEEP) in improving oxygenation and alveolar recruit-
ment, its application also introduces physiological risk:
increased intrathoracic pressure from PEEP can impair
both cerebral venous outflow and systemic venous re-
turn, resulting in simultaneously increased intracranial
pressure and reduced cerebral perfusion pressure, re-
spectively [16]. Animal studies have found increased
intracranial pressure and decreased mean arterial pres-
sure with increases in PEEP, in addition to reduced
intracranial compliance [79]. In another study on a
mouse model of stroke, increased PEEP reduced cerebral
perfusion pressure by reducing mean arterial pressure,
but had minimal effect on intracranial pressure when
mean arterial pressure remained stable, reinforcing the
importance of hemodynamic stability [79]. Human stud-
ies confirm the effects of PEEP in hemodynamically un-
stable patients, as PEEP up to 20 cm H
O was shown in
one study to significantly decrease mean arterial pres-
sure and cerebral blood flow [80]. Consequences of
PEEP on cerebral microcirculation therefore may com-
pound effects from other potential mechanisms of cogni-
tive impairment in critically ill patients with both ARDS
Sasannejad et al. Critical Care (2019) 23:352 Page 8 of 12
and brain injury, exacerbating both the cerebral hypo-
perfusion of sepsis and the impairment in amyloid-β
clearance following impaired cerebral outflow in vulner-
able patients. In another study in acutely brain-injured
patients, PEEP leading to alveolar hyperinflation in-
creased dead space and P
, in turn resulting in arter-
ial vasodilation and concomitantly increased intracranial
pressure, with further worsening in the setting of dimin-
ished intracranial compliance [81]. The effects of PEEP
on cerebrovascular hemodynamics, neurological injury,
and cognitive outcomes remain largely unknown and
represent an active area of research.
Ventilation of neurologically injured patients entails a
balance between preventing intracranial pressure ele-
vation secondary to hypercarbia while minimizing ex-
posure to an injurious factor. The association between
high-tidal-volume ventilation and ARDS in patients
with intracerebral hemorrhage highlights the import-
ance of incorporating tidal volume minimization in
ventilation setting strategies [24]. Animal studies com-
paring low- versus high-tidal-volume ventilation in
porcine ARDS models find improved oxygenation and
lower lactate levels in brain tissue when using low-
tidal-volume ventilation, which is supported by clin-
ical outcomes in human patients [52,82]. Patients
ventilated at lower tidal volumes (8mL/kg) follow-
ing cardiac arrest had a significantly higher chance of
being classified as cerebral performance category 1 at
follow-up [82]. Avoidance of benzodiazepines and se-
lection of dexmedetomidine as a sedative agent may
reduce the risk of delirium in patients with ARDS re-
gardless of neurological injury status [46].
Given the systemic inflammatory effects of ARDS, in
addition to murine studies implicating TNF-αin mediat-
ing neutrophil recruitment in the early phases of high-
tidal-volume-associated stretch lung injury, immunomo-
dulating therapies such as monoclonal antibodies against
TNF-αmay represent a future area of pharmacotherapy
[83]. As the receptor for advanced glycation end prod-
ucts (RAGE) has been found to mediate amyloid-βinflux
and microglial activation at the blood-brain barrier, this
may also represent a future pharmacological target in
humans, with data from mouse models of Alzheimers
disease showing effective control of amyloid-βaccumu-
lation and amyloid-β-mediated cellular stress using
RAGE inhibitors [84].
Fluid management
Fluid management reflects another vital juncture of con-
sideration, particularly among neurologically injured pa-
tients with concurrent sepsis. The Fluid and Catheter
Treatment Trial found that despite similar 60-day mor-
tality, patients with ARDS treated with conservative
rather than liberal fluid management (central venous
pressure < 4 versus 1014, respectively) experience
shorter intensive care unit stays and fewer days requiring
a ventilator [85]. However, follow-up of this trial found
an association between conservative fluid management
and worse cognitive function [1]. The choice of whether
to target treatment toward cerebral perfusion pressure
or intracranial pressure goals in the management of
brain injury invites further consideration of fluid man-
agement strategy in this patient population. A study
comparing treatment strategies in patients with severe
traumatic brain injury found a significantly elevated risk
of developing ARDS among patients receiving cerebral
perfusion pressure-targeted treatment compared to
those receiving intracranial pressure-targeted treatment,
with an odds ratio of 5.1 [19]. Patients with brain injur-
ies appear uniquely susceptible to deleterious effects of
vasopressors: when vasopressors were used in order to
meet cerebral perfusion pressure goals, the risk of devel-
oping ARDS further rose, with odds ratios of 5.7 with
epinephrine (95% CI 1.037534.3323) and 10.8 with
dopamine (95% CI 1.4488.3) [19]. The widespread use
of high PEEP in ARDS raises questions of whether inter-
actions between PEEP and intracranial pressure or cere-
bral perfusion pressure require changes in practice when
treating neurologically injured patients who do go on to
develop ARDS. Studies investigating the relationship be-
tween PEEP and cerebral microcirculation identify
hemodynamic stability as an important factor mitigating
against adverse effects of PEEP [79,80]. Specifically, des-
pite adverse microcirculatory effects of PEEP, Muench
et al. found that it was only in the scenario of existing
hemodynamic instability that PEEP adversely decreased
cerebral perfusion pressure [80], and Georgiadis et al.
similarly found that PEEP did not affect intracranial
pressure as long as mean arterial pressure remained
stable [79]. Therefore, while fluid minimization may be
beneficial in a general population of critically ill patients
[85], aggressive application of a conservative fluid man-
agement approach in neurologically injured patientses-
pecially if vasopressors become required to maintain
hemodynamic stabilitymay contribute to not only the
risk of ARDS, but also that of cerebral hypoperfusion
after initiating treatment with high-PEEP ventilation. Fu-
ture studies are needed to determine an optimal, per-
haps individualized PEEP threshold, that maximizes
pulmonary and neurological function.
Other interventions
The interdisciplinary, collaborative environment of the
intensive care unit allows for coordinated patient care
optimization approaches to mitigate contributors to
Sasannejad et al. Critical Care (2019) 23:352 Page 9 of 12
patient discomfort and long-term adverse effects. These
interventions not only are relevant for neurologically in-
jured cohorts of patients with ARDS, but may also im-
prove outcomes in the general population of intensive
care unit patients. A recent example of such an ap-
proach is the ABCDEF bundle, comprising the following
elements: assess, prevent, and manage pain; both spon-
taneous awakening trials and spontaneous breathing tri-
als; choice of analgesia and sedation; delirium: assess,
prevent, and manage; early mobility and exercise; and
family engagement and empowerment [86]. Implementa-
tion of the ABCDEF bundle for 15,000 patients as part
of the ICU Liberation Collaborative found that patients
treated with this bundle experienced significant differ-
ences in outcomes compared to those who did not, in-
cluding higher likelihoods of discharge home and
survival within the first 7 days of hospitalization, and
lower likelihoods of coma, delirium, physical restraint
use, ventilator-dependence, and readmission [86]. Im-
provements in each of these outcomes showed a signifi-
cant dose-response corresponding with compliance with
the bundle, in which 10% increases in bundle compli-
ance produced 15% improvement in survival and days
without coma and delirium [86]. Minimizing corticoster-
oid use and length of stay may also reduce the risk of
adverse long-term cognitive and physical outcomes
among ARDS survivors [6].
Reducing the practical burden of cognitive recovery fol-
lowing critical illness depends crucially on understand-
ing the links between brain injury and lung injury. New
deficits in learning and memory, and new development
of psychiatric illness, inherently limit the maximum ex-
tent of recovery by restricting the extent to which pa-
tients can meaningfully participate in rehabilitation. The
influence of pre-existing cognitive impairment on sus-
ceptibility and recovery highlights the importance of ac-
curate detection and definition of cognitive impairment.
Evidence for distinct patterns of inflammatory damage,
the predilection of cytokines for the hippocampus, and
activation of systemic inflammatory pathways in high-
tidal-volume mechanical ventilation collectively support
minimizing tidal volume as much as possible to avoid
ARDS, in turn helping prevent further endothelial and
microglial activation of the inflammatory cascade. The
ability to control and monitor parameters such as PEEP
and fluid balance in the intensive care unit setting pro-
vides an opportunity to optimize treatment on an indi-
vidual basis to minimize the risk of long-term cognitive
As new data continue to reveal increasing layers of
complexity with which these parameters influence the
brain-lung axis and one another, further studies will
hope to elucidate management strategies that entail not
just minimization or maximization of individual vari-
ables, but a balanced and nuanced approach to achieve
both physical and cognitive recovery from ARDS. Mind-
ful implementation of multidisciplinary approaches to
providing more humanistic patient care may improve
long-term cognitive outcomes.
ARDS: Acute respiratory distress syndrome; CAM-ICU: Confusion Assessment
Method for Intensive Care Unit Patients; PEEP: Positive end-expiratory pres-
sure; RAGE: Receptor for advanced glycation end products; ABCDEF: Assess,
prevent, and manage pain; both spontaneous awakening trials and
spontaneous breathing trials; choice of analgesia and sedation; delirium:
assess, prevent, and manage; early mobility and exercise; and family
engagement and empowerment
Not applicable
CS, EWE, and SL drafted the manuscript. All authors read and approved the
final manuscript.
NIH/NIA R03AG064106, American Academy of Neurology Institute (SL).
Availability of data and materials
Not applicable
Ethics approval and consent to participate
Not applicable
Consent for publication
Not applicable
Competing interests
EWE: Pfizer and Orion honoraria for CME events. NIH and VA Funding. CS
and SL declare that they have no competing interests.
Author details
Division of Neurocritical Care and Emergency Neurology, Department of
Neurology, Yale School of Medicine, New Haven, CT, USA.
Critical Illness,
Brain Dysfunction, Survivorship (CIBS) Center, Department of Pulmonary and
Critical Care Medicine, Veterans Affairs Tennessee Valley Geriatric Research
Education and Clinical Center (GRECC), Vanderbilt University School of
Medicine, Nashville, TN, USA.
Division of Neurocritical Care, Department of
Neurology, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP
Building, Suite A6600, A8103, Los Angeles, CA 90048, USA.
Division of
Neurocritical Care, Department of Neurosurgery, Cedars-Sinai Medical Center,
127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA
90048, USA.
Division of Neurocritical Care, Department of Biomedical
Sciences, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP
Building, Suite A6600, A8103, Los Angeles, CA 90048, USA.
Received: 18 July 2019 Accepted: 27 September 2019
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Sasannejad et al. Critical Care (2019) 23:352 Page 12 of 12
... Autopsy studies have shown acute hypoxic injury in the cerebrum and cerebellum with accompanying neuron loss in patients who died from complications from severe acute COVID-19 infection [41,55]. Also, acute hypoxia due to cardiac arrest and acute respiratory distress syndrome is associated with cognitive deficits which last long after recovery [56,57]. Cognitive impairment could theoretically arise from acute hypoxia experienced as a secondary effect of COVID-19induced pneumonia. ...
... The blood brain barrier (BBB), an important protective and supportive structure of the brain, is sensitive to an ongoing immune response [54]. In particular, BBB disruption has been linked with a number of long-term neuropathologies such as dementia and multiple sclerosis, and it has been speculated that SARS-CoV-2 infection could exacerbate these pathologies [57,80]. However, the mechanisms linking LGI with neurodysfunction and neurodegeneration remain unclear. ...
... Future studies could further investigate the effect of the virus on BBB integrity and characterize how a pro-inflammatory state disrupts this barrier on the cellular level [80]. Certain cytokines such as interleukin 1 beta have been observed to damage the hippocampus and impede learning and recall in mouse models with septic encephalopathy, suggesting a still unclear role of the "cytokine storm" in brain damage and the development of lasting neurological symptoms [57,124]. Studies could also aim to untangle the relationship between metabolic disruptions and chronic B cell lymphopenia and to determine which factor is more important in NC-PASC development [85]. ...
Full-text available
With a growing number of patients entering the recovery phase following infection with SARS-CoV-2, understanding the long-term neurological consequences of the disease is important to their care. The neurological complications of post-acute sequelae of SARS-CoV-2 infection (NC-PASC) represent a myriad of symptoms including headaches, brain fog, numbness/tingling, and other neurological symptoms that many people report long after their acute infection has resolved. Emerging reports are being published concerning COVID-19 and its chronic effects, yet limited knowledge of disease mechanisms has challenged therapeutic efforts. To address these issues, we review broadly the literature spanning 2020–2022 concerning the proposed mechanisms underlying NC-PASC, outline the long-term neurological sequelae associated with COVID-19, and discuss potential clinical interventions.
... Ранее ряд авторов сообщали, что длительное снижение КФ и нейродегенерация с ассоциированной атрофией гиппокампа осложняют системное воспаление, связанное с тяжелым сепсисом [8][9][10]. Острый респираторный дистресссиндром часто проявляется клинически у пациентов с COVID-19, что также связано со снижением КФ и нейродегенерацией [11,12]. Вирус SARS-CoV-2 действует на все ткани и органы, за исключением нейроцитов. ...
... Вирус SARS-CoV-2 действует на все ткани и органы, за исключением нейроцитов. В случаях присоединения COVID-19 к неврологической патологии у пациентов отмечалось изменение клинической картины и закономерное ухудшение течения основного неврологического заболевания [1,[3][4][5][6][7]12]. Основными жалобами пациентов как в остром, так и в постковидном периоде являются: тахикардия, миалгия, сильная головная боль диффузного характера, несистемное головокружение, тошнота, снижение или полное отсутствие аппетита, спутанность сознания, апатия, трудности в подборе слов. ...
... Длительное пребывание пациентов в отделении реанимации, искусственная вентиляция легких, медикаментозная седация при остром респираторном дистресс-синдроме (ОРДС) являются факторами риска развития КН [20]. Так, во французском исследовании при выписке пациентов с COVID-19 из отделения реанимации в 15 из 45 случаев (33%) диагностировались КН в виде снижения концентрации внимания, зрительно-пространственных нарушений [21]. ...
... Предполагают, что в развитии или ухудшении КН у пациентов, перенесших COVID-19, принимают участие множество факторов. К таким факторам относят прямое воздействие вирусной инфекции на нервную систему, системную воспалительную реакцию организма человека на вирус, цереброваскулярную ишемию вследствие эндотелиальной дисфункции или выраженной коагулопатии, ОРДС при тяжелом течении COVID-19, использование искусственной вентиляции легких, медикаментозную седацию при ОРДС, дисфункцию внутренних органов [20,27]. ...
... Post-ARDS cognitive impairment is not only associated with COVID-19 disease. Other diseases can also cause cognitive impairment after ARDS [49]. Neurocognitive impairment after ARDS is associated with hypoxia, induced hyperinflammation, and hemodynamic instability. ...
... Meta-analyses and studies have reported that neurocognitive dysfunction after ARDS has a high incidence. The incidence of neurocognitive dysfunction is 70−100% at the time of hospital discharge, 46−80% one year after discharge and 20% five years after discharge [49]. In addition, mechanical ventilation without ARDS is associated with long-term cognitive dysfunction and poor quality of life. ...
Full-text available
COVID-19 disease was defined as a disease of primary respiratory system. However, symptoms associated with central nervous system were detected in approximately 2/3 of the hospitalized patients. The rate of ischemic cerebrovascular diseases is higher in central nervous system. In addition, hemorrhagic cerebrovascular diseases, encephalitis and/or encephalopathy are the other diseases. Complex pathogenesis was demonstrated in the central nervous system diseases associated with SARS-CoV-2. It was reported that SARS-CoV-2 virus could directly invade the central nervous system, especially via the olfactory nerves or the haematological pathway. As a result, endothelial cells, pericytes and/or neurons can be infected (direct pathway). Another mechanism is central nervous system deficit resulting from peripheral immune reactivation (indirect pathway). All these etiopathogenetic results support that COVID-19 disease is associated with cognitive dysfunction. Cerebral hypoperfusion associated with vascular endothelial structures is the main factor in the etiopathogenesis. It was reported that COVID-19 disease induced amyloid-β (Aβ) and α-synuclein phosphorylation. Besides, it was detected that this process was associated with tau and TDP-43 pathology. “Cognitive COVID-19” is a term that describes acute and long-term cognitive changes in people infected with SARS-CoV-2. Encephalopathy, delirium and cognitive disorders are most frequently detected. In this chapter, the clinical and etiopathogenetic processes of cognitive dysfunction after COVID-19 disease were evaluated. In addition, the disease, disease process and treatment were evaluated in general.
... Blood pressure elevations in acute stroke may be mediated by a variety of mechanisms, including preexisting hypertension, but also stress associated with the acute illness and hospitalization, increased sympathetic drive with catecholamine and cortisol release, activation of the rennin-angiotensin aldosterone system, and the Cushing reflex in cases of markedly increased intracranial pressure due to intracerebral hematoma or edema (17) . ...
... Concerning cognitive performance, we found that 44% of patients from Group-1 and 5% of patients from Group-2 presented with global cognitive impairment (mild to severe deficits) as measured by the MMSE global score, consistent with previous studies [27,49,51]. Moreover, the FAB scores showed that 88% of patients from Group-1 and 26% of patients from Group-2 presented with global executive impairment (mild to severe deficits), indicating a higher degree of dysexecutive function in Group-1 patients (who received non-invasive mechanical ventilation) compared to Group-2 patients (who benefited from oxygen therapy with masks), in line with previous findings that reported executive function deficits in patients who had contracted COVID-19 [12,52,53] as well as in other acute respiratory syndromes [54]. As suggested by [26], patients who received non-invasive ventilation treatment would have experienced higher levels of acute and chronic stress compared to those who were intubated and sedated, thus resituated a higher degree of executive function deficits. ...
Full-text available
(1) Background: We investigated the differences in the neuropsychological profile as well as the pneumological and motor functions in two groups of patients admitted to rehabilitation who received different respiratory support during their COVID-19 infection. (2) Methods: Group-1 (n = 18; 15 male, median age 67.5) consisted of patients who received non-invasive mechanical ventilation; Group-2 (n = 19; 16 male, median age 63) consisted of patients who received invasive mechanical ventilation. All patients underwent a neuropsychological assessment including Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and the Repeatable Battery for the Assessment of Neuropsychological Status (R-BANS) to evaluate the patients’ cognition. Depression and anxiety were also measured at admission and discharge to rehabilitation. (3) Results: At admission, patients impaired at MMSE were 44% in Group-1 and 5% in Group-2, while patients impaired at FAB were 88% in Group-1 and 26% in Group-2. Wilcoxon’s effect size revealed meaningful differences between groups for FAB, R-BANS global score, immediate and delayed memory, and attention-coding task, with Group-2 performing better than Group-1 across all measures. At discharge, 52% of the 25 patients re-assessed still had mild to moderate cognitive deficits, while 19% had depression and 35% had anxiety. (4) Conclusions: Patients who received oxygen therapy experienced higher levels of acute and chronic stress compared to those who benefitted from invasive mechanical ventilation. Despite patients showing a meaningful improvement at discharge, cognitive impairment persisted in a great number of patients; therefore, long-term neuropsychological follow-up and treatment for COVID-19 patients are recommended.
... However, further insights from clinical and postmortem studies seem to pinpoint that the abnormal and prolonged hyperinflammatory state following infection might be a more important feature to determine the onset of these symptoms post-infection [74,121]. Previous evidence collected from studies on respiratory non-SARS-CoV-2 viral infections showed that systemic and excessive cytokine inflammatory responses, characterized by prolonged IL-6 and TNF-α expression, can lead to damages in brain areas such as the hippocampus [19,122,123]. This trend was also detected in COVID-19 patients with cognitive impairment in which a prominent inflammatory response is flagged by a generalized increase in the concentration of the biomarkers of inflammation such as CPR and various cytokines [65,98,124,125]. ...
Full-text available
The present study aims to provide a critical overview of the literature on the relationships between post-acute COVID-19 infection and cognitive impairment, highlighting the limitations and confounding factors. A systematic search of articles published from 1 January 2020 to 1 July 2022 was performed in PubMed/Medline. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies using validated instruments for the assessment of cognitive impairment were included. Out of 5515 screened records, 72 studies met the inclusion criteria. The available evidence revealed the presence of impairment in executive functions, speed of processing, attention and memory in subjects recovered from COVID-19. However, several limitations of the literature reviewed should be highlighted: most studies were performed on small samples, not stratified by severity of disease and age, used as a cross-sectional or a short-term longitudinal design and provided a limited assessment of the different cognitive domains. Few studies investigated the neurobiological correlates of cognitive deficits in individuals recovered from COVID-19. Further studies with an adequate methodological design are needed for an in-depth characterization of cognitive impairment in individuals recovered from COVID-19.
... There are various indications for sedation in the intensive care unit (ICU), including patient adaptation to mechanical ventilation, pain/agitation/anxiety management and implementation of invasive procedures. However, if sedation is prolonged or excessive, it can lead to relevant complications, including delirium [1][2][3][4]. Individual response to sedation itself may vary greatly, increasing the risk of oversedation. Although there is a consensus regarding the indication for the use of light instead of deep sedation, quantification of these differences is not always feasible [5]. ...
Full-text available
Excessive sedation is associated with poor outcome in critically ill acute respiratory distress syndrome (ARDS) patients. Whether this prognostic effect varies among ARDS patients with and without COVID-19 has yet to be determined. We compared the prognostic value of excessive sedation—in terms of delirium, length of stay in intensive care unit (ICU-LOS) and ICU mortality—between COVID-19 and non-COVID-19 critically ill ARDS patients. This was a second analysis of prospectively collected data in four European academic centers pertaining to 101 adult critically ill ARDS patients with and without COVID-19 disease. Depth of sedation (DOS) and delirium were monitored through processed electroencephalogram (EEG) and the Confusion Assessment Method for ICU (CAM-ICU). Our main exposure was excessive sedation and how it relates to the presence of delirium, ICU-LOS and ICU mortality. The criterion for excessive sedation was met in 73 (72.3%) patients; of these, 15 (82.2%) and 58 (69.1%) were in non-COVID-19 and COVID-19 ARDS groups, respectively. The criteria of delirium were met in 44 patients (60.3%). Moreover, excessive sedation was present in 38 (86.4%) patients with delirium (p < 0.001). ICU death was ascertained in 41 out of 101 (41.0%) patients; of these, 37 (90.2%) had excessive sedation (p < 0.001). The distribution of ICU-LOS among excessive-sedated and non-sedated patients was 22 (16–27) vs. 14 (10.5–19.5) days (p < 0.001), respectively. In a multivariable framework, excessive sedation was independently associated with the development of delirium (p = 0.001), increased ICU mortality (p = 0.009) and longer ICU-LOS (p = 0.000), but only in COVID-19 ARDS patients. Independent of age and gender, excessive sedation might represent a risk factor for delirium in COVID-19 ARDS patients. Similarly, excessive sedation shows to be an independent predictor of ICU-LOS and ICU mortality. The use of continuous EEG-based depth of sedation (DOS) monitoring and delirium assessment in critically ill COVID-19 patients is warranted.
... Cerebral dysfunction ranging from acute delirium to longterm neurocognitive impairment may occur among up to 80% of critically ill patients after intensive care unit (ICU) discharge (Pandharipande et al. 2013;Sasannejad et al. 2019). During the COVID-19 pandemic, this problem has been particularly emphasized in severe coronavirus-infected patients who were admitted to ICUs and received life-saving support (Helms et al. 2020;Pun et al. 2021). ...
Full-text available
Mechanically ventilated patients suffering critical illness are at high risk of developing neurocognitive impairments. Angiotensin type 2 receptor (AGTR2) has been demonstrated to be anti-inflammatory and neuroprotective. The present study thus aimed to investigate whether AGTR2 can alleviate cerebral dysfunction in mice subjected to cochallenge with lipopolysaccharide (LPS) and mechanical ventilation (MV), and to reveal the underlying mechanism. We utilized a mice model that received a single injection of LPS (1 mg/kg, intraperitoneally) followed 2 h later by MV (10 ml/kg, lasting for 2 h). Pretreatment with the AGTR2 pharmacological agonist C21 (0.03, 0.3, and 3 mg/kg, intraperitoneally, once daily, lasting for 10 days). Locomotor activity and behavioral deficits were evaluated 24 h post-MV by open-field and fear-condition tests. Brain hippocampus and prefrontal cortex tissues were collected for immunofluorescence staining and western blotting to evaluate the resulting impacts on microglia, including morphological traits, functional markers, synaptic engulfment, superoxide production, and signaling molecules. Compared with vehicle-control, pre-administrated C21 reduced the branch endpoints and length of microglia processes in a dose-dependent manner in mice subjected to LPS/MV. The neuroprotective effect of AGTR2 was behaviorally confirmed by the improvement of memory decline in LPS/MV-treated mice following C21 pretreatment. In addition to morphological alterations, C21 reduced microglial functional markers and reduced microglial-dendrite contact and microglial engulfment of synaptic protein markers. In terms of the underlying molecular mechanism, AGTR2 stimulation by C21 leads to activation of protein phosphatase 2A, which subsequently mitigates microglial PKCδ and NF-κB activation, and inhibites NOX2-derived ROS production. The AGTR2 agonist C21 alleviates behavioral deficits in those mice subjected to LPS/MV, via mechanisms that involve reactive microglia and abnormal synaptic plasticity in NOX2-derived ROS and the PKCδ-NFκB pathway. Graphical Abstract
Lungenerkrankungen nehmen sowohl in der Todesursachenstatistik als auch in der Perspektive einer globalen Krankheitsbelastung Spitzenränge ein. Das Thema der affektiven Komorbidität wird für Asthma bronchiale, chronische obstruktive Lungenkrankheit, zystische Lungenfibrose, interstitielle Lungenerkrankung, pulmonale Hypertonie, obstruktive Schlafapnoe, Lungenkarzinom, akutes Lungenversagen dargestellt. Epidemiologisch sind erhöhte Prävalenzraten koexistenter affektiver und Stress-bezogener Störungen mit je signifikanten negativen Einflüssen auf die komplexe Dynamik des jeweiligen Krankheitsgeschehens im Verlauf nachgewiesen. Vorbestehende Depressionen, Ängste und posttraumatische Stressoren nehmen in der Entwicklung einzelner Lungenerkrankungen, insbesondere von Asthma bronchiale und COPD eine bedeutsame, wenngleich differentielle Rolle ein. Ein eventueller Risikostatus ist wiederum bei anderen Lungenkrankheiten schwieriger zu beurteilen. In einer ätiopathogenetischen Perspektive sind genetische, neuroendokrine, (auto-) immunologisch-inflammatorische und vor allem auch Einflüsse der autonom-nervösen Regulation der Atmung je speziell in der Zusammenschau zu analysieren. Es liegen ermutigende, aber nicht immer konsistente Resultate aus Studien zur Psychotherapie und Pharmakotherapie koexistenter affektiver und Stress-bezogener Störungen vor.
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Background Mechanical ventilation is strongly associated with cognitive decline after critical illness. This finding is particularly evident among older individuals who have pre-existing cognitive impairment, most commonly characterized by varying degrees of cerebral amyloid-β accumulation, neuroinflammation, and blood-brain barrier dysfunction. We sought to test the hypothesis that short-term mechanical ventilation contributes to the neuropathology of cognitive impairment by (i) increasing cerebral amyloid-β accumulation in mice with pre-existing Alzheimer’s disease pathology, (ii) increasing neurologic and systemic inflammation in wild-type mice and mice with pre-existing Alzheimer’s disease pathology, and (iii) increasing hippocampal blood-brain barrier permeability in wild-type mice and mice with pre-existing Alzheimer’s disease pathology. Methods We subjected double transgenic Alzheimer’s disease (APP/PSEN1) and wild-type mice to mechanical ventilation for 4 h and compared to non-mechanically ventilated Alzheimer’s disease model and wild-type mice. Cerebral soluble/insoluble amyloid-β1–40/amyloid-β1–42 and neurological and systemic markers of inflammation were quantified. Hippocampal blood-brain barrier permeability was quantified using a novel methodology that enabled assessment of small and large molecule permeability across the blood-brain barrier. Results Mechanical ventilation resulted in (i) a significant increase in cerebral soluble amyloid-β1–40 (p = 0.007) and (ii) significant increases in neuroinflammatory cytokines in both wild-type and Alzheimer’s disease mice which, in most cases, were not reflected in the plasma. There were (i) direct correlations between polymorphonuclear cells in the bronchoalveolar fluid and cerebral soluble amyloid-β1–40 (p = 0.0033), and several Alzheimer’s disease-relevant neuroinflammatory biomarkers including cerebral TNF-α and IL-6; (iii) significant decreases in blood-brain barrier permeability in mechanically ventilated Alzheimer’s disease mice and a trend towards increased blood-brain barrier permeability in mechanically ventilated wild-type mice. Conclusions These results provide the first evidence that short-term mechanical ventilation independently promotes the neuropathology of Alzheimer’s disease in subjects with and without pre-existing cerebral Alzheimer’s disease pathology. Future studies are needed to further clarify the specific mechanisms by which this occurs and to develop neuroprotective mechanical ventilation strategies that mitigate the risk of cognitive decline after critical illness. Electronic supplementary material The online version of this article (10.1186/s13054-019-2356-2) contains supplementary material, which is available to authorized users.
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The blood–brain barrier (BBB) keeps neurotoxic plasma-derived components, cells, and pathogens out of the brain. An early BBB breakdown and/or dysfunction have been shown in Alzheimer’s disease (AD) before dementia, neurodegeneration and/or brain atrophy occur. However, the role of BBB breakdown in neurodegenerative disorders is still not fully understood. Here, we examine BBB breakdown in animal models frequently used to study the pathophysiology of AD, including transgenic mice expressing human amyloid-β precursor protein, presenilin 1, and tau mutations, and apolipoprotein E, the strongest genetic risk factor for AD. We discuss the role of BBB breakdown and dysfunction in neurodegenerative process, pitfalls in BBB measurements, and how targeting the BBB can influence the course of neurological disorder. Finally, we comment on future approaches and models to better define, at the cellular and molecular level, the underlying mechanisms between BBB breakdown and neurodegeneration as a basis for developing new therapies for BBB repair to control neurodegeneration.
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Alzheimer’s disease (AD) is the most common neurodegenerative disease, characterized by excessive beta amyloid (Aβ) deposition in brain, leading to blood–brain barrier (BBB) disruption. The mechanisms of BBB disruption in AD are still unclear, despite considerable research. The adipokine adiponectin is known to regulate various metabolic functions and reduce inflammation. Though adiponectin receptors have been reported in the brain, its role in the central nervous system has not been fully characterized. In the present study, we investigate whether adiponectin contributes to the tight junction integrity and cell death of brain endothelial cells under Aβ-induced toxicity conditions. We measured the expression of adiponectin receptors (AdipoR1 and AdipoR2) and the alteration of tight junction proteins in in vivo 5xFAD mouse brain. Moreover, we examined the production of reactive oxygen species (ROS) and the loss of tight junction proteins such as Claudin 5, ZO-1, and inflammatory signaling in in vitro brain endothelial cells (bEnd.3 cells) under Aβ toxicity. Our results showed that Acrp30 (a globular form of adiponectin) reduces the expression of proinflammatory cytokines and the expression of RAGE as Aβ transporters into brain. Moreover, we found that Acrp 30 attenuated the apoptosis and the tight junction disruption through AdipoR1-mediated NF-κB pathway in Aβ-exposed bEnd.3 cells. Thus, we suggest that adiponectin is an attractive therapeutic target for treating BBB breakdown in AD brain.
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Rationale: Neurocognitive outcome after out-of-hospital cardiac arrest (OHCA) often is poor even when initial resuscitation succeeds. Lower tidal volumes (VT) attenuate extrapulmonary organ injury in other disease states and are neuro-protective in preclinical models of critical illness. Objective: To evaluate the association between VT and neurocognitive outcome following OHCA. Methods: Propensity-adjusted analysis of two-center retrospective cohort of OHCA patients who received mechanical ventilation for at least the first 48 hours of hospitalization. VT was calculated as the time-weighted average over the first 48 hours, in mL/kg predicted body weight (PBW). The primary endpoint was favorable neurocognitive outcome (cerebral performance category 1-2) at discharge. Measurements and main results: Of 256 included patients, 38% received time-weighted average VT > 8 mL/kg PBW during the first 48 hours. Lower VT was independently associated with favorable neurocognitive outcome in propensity-adjusted analysis (OR 1.61, 95% CI 1.13-2.28 per 1 mL/kg PBW decrease in VT; p=.008). This finding was robust to several sensitivity analyses. Lower VT also was associated with more ventilator-free days (ß = 1.78, 95% CI 0.39-3.16 per 1 mL/kg PBW decrease; p=.012) and shock-free days (ß = 1.31, 95% CI 0.10-2.51; p=.034). VT was not associated with hypercapnia (p=1.00). While the propensity score incorporated several biologically relevant covariates, only height, weight, and admitting hospital were independent predictors of VT ≤ 8 mL/kg PBW. Conclusions: Lower VT following OHCA is independently associated with favorable neurocognitive outcome, more ventilator-free days, and more shock-free days. These findings suggest a role for low-VT ventilation after cardiac arrest.
Objective: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. Design: Prospective, multicenter, cohort study from a national quality improvement collaborative. Setting: 68 academic, community, and federal ICUs collected data during a 20-month period. Patients: 15,226 adults with at least one ICU day. Interventions: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders. Measurements and results: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001). Conclusions: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
Importance Delirium is associated with accelerated cognitive decline. The pathologic substrates of this association are not yet known, that is, whether they are the same as those associated with dementia, are independent, or are interrelated. Objective To examine whether the accelerated cognitive decline observed after delirium is independent of the pathologic processes of classic dementia. Design, Setting, and Participants Harmonized data from 987 individual brain donors from 3 observational cohort studies with population-based sampling (Vantaa 85+, Cambridge City Over-75s Cohort, Cognitive Function and Ageing Study) performed from January 1, 1985, through December 31, 2011, with a median follow-up of 5.2 years until death, were used in this study. Neuropathologic assessments were performed with investigators masked to clinical data. Data analysis was performed from January 1, 2012, through December 31, 2013. Clinical characteristics of brain donors were not different from the rest of the cohort. Outcome ascertainment was complete given that the participants were brain donors. Exposures Delirium (never vs ever) and pathologic burden of neurofibrillary tangles, amyloid plaques, vascular lesions, and Lewy bodies. Effects modeled using random-effects linear regression and interactions between delirium and pathologic burden were assessed. Outcomes Change in Mini-Mental State Examination (MMSE) scores during the 6 years before death. Results There were 987 participants (290 from Vantaa 85+, 241 from the Cambridge City Over-75s Cohort, and 456 from the Cognitive Function and Ageing Study) with neuropathologic data; mean (SD) age at death was 90 (6.4) years, including 682 women (69%). The mean MMSE score 6 years before death was 24.7 points. The 279 individuals with delirium (75% women) had worse initial scores (−2.8 points; 95% CI, −4.5 to −1.0; P < .001). Cognitive decline attributable to delirium was −0.37 MMSE points per year (95% CI, −0.60 to −0.13; P < .001). Decline attributable to the pathologic processes of dementia was −0.39 MMSE points per year (95% CI, −0.57 to −0.22; P < .001). However, the combination of delirium and the pathologic processes of dementia resulted in the greatest decline, in which the interaction contributed an additional −0.16 MMSE points per year (95% CI, −0.29 to −0.03; P = .01). The multiplicative nature of these variables resulted in individuals with delirium and the pathologic processes of dementia declining 0.72 MMSE points per year faster than age-, sex-, and educational level–matched controls. Conclusions and Relevance Delirium in the presence of the pathologic processes of dementia is associated with accelerated cognitive decline beyond that expected for delirium or the pathologic process itself. These findings suggest that additional unmeasured pathologic processes specifically relate to delirium. Age-related cognitive decline has many contributors, and these findings at the population level support a role for delirium acting independently and multiplicatively to the pathologic processes of classic dementia.
Background: Delirium during critical illness results from numerous insults, which might be interconnected and yet individually contribute to long-term cognitive impairment. We sought to describe the prevalence and duration of clinical phenotypes of delirium (ie, phenotypes defined by clinical risk factors) and to understand associations between these clinical phenotypes and severity of subsequent long-term cognitive impairment. Methods: In this multicentre, prospective cohort study, we included adult (≥18 years) medical or surgical ICU patients with respiratory failure, shock, or both as part of two parallel studies: the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study, and the Delirium and Dementia in Veterans Surviving ICU Care (MIND-ICU) study. We assessed patients at least once a day for delirium using the Confusion Assessment Method-ICU and identified a priori-defined, non-mutually exclusive phenotypes of delirium per the presence of hypoxia, sepsis, sedative exposure, or metabolic (eg, renal or hepatic) dysfunction. We considered delirium in the absence of hypoxia, sepsis, sedation, and metabolic dysfunction to be unclassified. 3 and 12 months after discharge, we assessed cognition with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We used multiple linear regression to separately analyse associations between the duration of each phenotype of delirium and RBANS global cognition scores at 3-month and 12-month follow-up, adjusting for potential confounders. Findings: Between March 14, 2007, and May 27, 2010, 1048 participants were enrolled, eight of whom could not be analysed. Of 1040 participants, 708 survived to 3 months of follow-up and 628 to 12 months. Delirium was common, affecting 740 (71%) of 1040 participants at some point during the study and occurring on 4187 (31%) of all 13 434 participant-days. A single delirium phenotype was present on only 1355 (32%) of all 4187 participant-delirium days, whereas two or more phenotypes were present during 2832 (68%) delirium days. Sedative-associated delirium was most common (present during 2634 [63%] delirium days), and a longer duration of sedative-associated delirium predicted a worse RBANS global cognition score 12 months later, after adjusting for covariates (difference in score comparing 3 days vs 0 days: -4·03, 95% CI -7·80 to -0·26). Similarly, longer durations of hypoxic delirium (-3·76, 95% CI -7·16 to -0·37), septic delirium (-3·67, -7·13 to -0·22), and unclassified delirium (-4·70, -7·16 to -2·25) also predicted worse cognitive function at 12 months, whereas duration of metabolic delirium did not (1·14, -0·12 to 3·01). Interpretation: Our findings suggest that clinicians should consider sedative-associated, hypoxic, and septic delirium, which often co-occur, as distinct indicators of acute brain injury and seek to identify all potential risk factors that may impact on long-term cognitive impairment, especially those that are iatrogenic and potentially modifiable such as sedation. Funding: National Institutes of Health and the Department of Veterans Affairs.
Importance Anesthesia and surgery are believed to act on the central nervous system by a fully reversible mechanism innocuous to nerve cells. Evidence that neurological sequelae may follow would challenge this belief and would thereby suggest a need to reassess theories of the mechanism of anesthetic action or the response of the central nervous system to surgery. Objective To measure 2 biomarkers of neurological injury (neurofilament light and tau) in plasma in a series of timed collections before and after anesthesia and surgery. Design, Setting, and Participants These 2 related observational studies (CAPACITY and ARCADIAN) recruited patients 60 years and older who were undergoing general anesthesia for surgeries performed within a tertiary hospital. Blood samples were taken immediately before surgical anesthesia was administered and then sequentially after surgery at 30-minute, 6-hour, 24-hour, and 48-hour intervals. Sampling took place from January 2014 to August 2015. Data analysis took place from October 2016 to February 2017. Main Outcomes and Measures Plasma neurofilament light and tau. Results A total of 30 patients were enrolled (13 from the CAPACITY study and 17 from the ARCADIAN study). The mean (SD) age was 69.1 (7.0) years, and 18 members (59%) of the participant group were female; 22 (73%) were undergoing joint arthroplasty. Mean neurofilament light increased at each measurement from a combined baseline mean (SD) of 22.3 (20.4) pg/mL to a maximal combined mean (SD) level of 35.1 (28.7) pg/mL, a maximum increase of 67% (95% CI, 45%-89%; P < .001), at 48 hours postoperatively. The level of tau increased significantly from baseline at every measurement, from a combined baseline mean (SD) of 3.1 (1.3) pg/mL to a maximal combined mean (SD) of 10.8 (9.5) pg/mL, a peak increase of 257% (95% CI, 154%-361%; P < .001), at 6 hours postoperatively. After 6 hours, the mean level began to return to baseline but remained elevated after 48 hours. Conclusions and Relevance Neurofilament light is a specific marker of axonal injury and has been shown to indicate neuronal damage in a number of diseases. Tau proteins are an integral component of axonal integrity, and increased tau indicates neuronal damage. The increases in both neurofilament light and tau over 48 hours after surgery suggest that general anesthesia and surgery may be associated with neuronal damage in the short term. Further investigations will be required to study any association with clinical outcomes. These preliminary findings demand that we question the prevailing assumption that anesthesia and surgery are innocuous, transient, and without injurious changes to the central nervous system.
Alzheimer disease (AD) is the most common type of dementia, and is currently incurable; existing treatments for AD produce only a modest amelioration of symptoms. Research into this disease has conventionally focused on the CNS. However, several peripheral and systemic abnormalities are now understood to be linked to AD, and our understanding of how these alterations contribute to AD is becoming more clearly defined. This Review focuses on amyloid-β (Aβ), a major hallmark of AD. We review emerging findings of associations between systemic abnormalities and Aβ metabolism, and describe how these associations might interact with or reflect on the central pathways of Aβ production and clearance. On the basis of these findings, we propose that these abnormal systemic changes might not only develop secondary to brain dysfunction but might also affect AD progression, suggesting that the interactions between the brain and the periphery have a crucial role in the development and progression of AD. Such a systemic view of the molecular pathogenesis of AD could provide a novel perspective for understanding this disease and present new opportunities for its early diagnosis and treatment.
Amyloid plaques and neurofibrillary tangles (NFTs) in the brain are the neuropathological hallmarks of Alzheimer's disease (AD). Amyloid plaques are composed of β-amyloid peptides (Aβ), while NFTs contain hyperphosphorylated tau proteins. Patients with familial AD who have mutations in the amyloid precursor protein (APP) gene have either increased production of Aβ or generate more aggregation-prone forms of Aβ. The findings of familial AD mutations in the APP gene suggest that Aβ plays a central role in the pathophysiology of AD. Aβ42, composed of 42 amino acid residues, aggregates readily and is considered to form amyloid plaque. However, the processes of plaque formation are still not well known. It is generally thought that Aβ is secreted into the extracellular space and aggregates to form amyloid plaques. Aβ as extracellular aggregates and amyloid plaques are thought to be toxic to the surrounding neurons. The intraneuronal accumulation of Aβ has more recently been demonstrated and is reported to be involved in synaptic dysfunction, cognitive impairment, and the formation of amyloid plaques in AD. We herein provide an overview of the process of the intraneuronal accumulation of Aβ and plaque formation, and discuss its implications for the pathology, early diagnosis, and therapy of AD.