Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery / Deterioro cognitivo a largo plazo tras cirugía cardiaca en pacientes de edad avanzada

Introduction: Older patients are more likely to have cognitive dysfunction, and a great pro-portion of patients undergone surgical procedures are older adults. Postoperative cognitivedysfunction (POCD) has been shown as a consistent complication after major surgical proceduressuch as heart surgery.Aim: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coro-nary artery bypass grafting and aortic valve replacement, and to establish related risk factors.Methods: We prospectively and sequentially included 44 patients with coronary disease andaortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized anda neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months aftersurgery.Results: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4%and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspectssuch as age (p < 0.01), history of smoking (p < 0.01), arterial hypertension (p = 0.022), diabetesmellitus (p = 0.024), heart failure (p = 0.036) and preoperative cognitive dysfunction (p < 0.01),and surgery-associated aspects such as EuroSCORE (p < 0.01) and operation time (p < 0.01) wereidentified as related risk factors. Conclusions: Older patients who underwent heart surgery had long-term POCD. Both patient-and surgery-related risk factors were established as related risk factors. These findings suggestthat the prevalence of cognitive dysfunction after cardiac surgery in older patients could berelated to a possible progression to dementia. In addition, many of the risk factors identifiedmay be modifiable but in practice, these patients are not attended to for their possible cognitiveimpairment.(AU)

Introducción: Los pacientes de edad avanzada tienen más riesgo de sufrir deterioro cognitivo, yson cada vez más frecuentemente sometidos a una cirugía. El deterioro cognitivo posquirúrgico(DCP) tras cirugía cardiaca se ha mostrado como una complicación importante.Objetivos: Determinar la presencia del DCP a largo plazo en pacientes ≥ 65 a˜nos intervenidosde derivación coronaria y reemplazo de válvula aórtica, y establecer los factores de riesgorelacionados.Métodos: Se realizó un estudio en el que se incluyeron de forma prospectiva y secuen-cial 44 pacientes con enfermedad coronaria y estenosis aórtica programados para cirugía. Elseguimiento fue estandarizado y se realizaron evaluaciones neuropsicológicas preoperatoria-mente a los 1, 6 y 12 meses postoperatorios.Resultados: Se observó la presencia de un DCP significativo (33,5, 63,4 y 38,9% a 1, 6 y 12 meses,respectivamente) respecto al nivel basal (20,5%). Se identificaron como factores de riesgo varia-bles asociadas al paciente como la edad (p < 0,01), el tabaquismo (p < 0,01), la hipertensiónarterial (p = 0,022), la diabetes mellitus (p = 0,024), la insuficiencia cardiaca (p = 0,036) y el dete-rioro cognitivo preoperatorio (p < 0,01), y variables quirúrgicas como el EuroSCORE (p < 0,01) yel tiempo de intervención (p < 0,01).Conclusiones: Los pacientes de edad avanzada sometidos a cirugía cardiaca presentaron DCP alargo plazo. Variables asociadas al paciente y quirúrgicas se mostraron como factores de riesgo,muchas de ellas modificables. Estos hallazgos sugieren que la presencia de DCP en pacientes demás edad podría suponer mayor riesgo de evolución a demencia. En la práctica clínica habitualno es evaluado el rendimiento cognitivo.(AU)

Basal ganglia ischaemic infarction after thrombectomy: cognitive impairment at acute stage.

BACKGROUND AND PURPOSE: After successful mechanical thrombectomy for middle cerebral artery occlusion, basal ganglia infarction is commonly detectable. Whilst the functional outcome of these patients is often good, less knowledge is available about the cognitive outcome. The aim of our study was to assess the presence of cognitive impairment within 1 week after thrombectomy. METHODS: In all, 43 subjects underwent a general cognitive assessment using the Montreal Cognitive Assessment and an extensive battery of tests. Patients were classified as cognitively impaired (CImp) or not (noCImp) according to a Montreal Cognitive Assessment score below 18. RESULTS: Cognitively impaired and noCImp subjects did not differ either in their National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at admittance, or in their Fazekas score and Alberta Stroke Program Early Computed Tomography Score. At discharge, CImp subjects showed higher scores than noCImp subjects on NIHSS (p = 0.002) and mRS (p < 0.001). The percentage of pathological performances on each neuropsychological test in the whole sample and in CImp and noCImp patients shows a similar cognitive profile between the groups. CONCLUSIONS: Some patients who underwent thrombectomy experienced a detectable cognitive impairment that probably led to worse NIHSS and mRS. The neuropsychological profile of such cognitive impairment at the acute stage consists of wide deficits in numerous cognitive domains, suggesting that basal ganglia damage may lead to complex functional impairments.

Surgical Approach and Dislocation Risk After Hemiarthroplasty in Geriatric Patients With Femoral Neck Fracture With and Without Cognitive Impairments-Does Cognitive Impairment Influence Dislocation Risk?

OBJECTIVES: To determine whether there is an association between surgical approach and dislocation risk in patients with cognitive impairment compared with those without cognitive impairment treated with hemiarthroplasty for femoral neck fracture. DESIGN: Retrospective study. SETTING: Large, multicenter health system. PATIENTS/PARTICIPANTS: One thousand four hundred eighty-one patients who underwent hemiarthroplasty for femoral neck fractures. 828 hips met inclusion criteria, 290 (35.0%) were cognitively impaired, and 538 (65.0%) were cognitively intact. INTERVENTION: Hemiarthroplasty. MAIN OUTCOME MEASURE: Prosthetic hip dislocation. RESULTS: The overall dislocation rate was 2.1% (17 of 828), 3.4% (10 of 290) in the cognitively impaired group, and 1.3% (7 of 538) in the cognitively intact group with a median time to dislocation of 20.5 days (range 2-326 days), 24.5 days (range 3-326 days), and 19.0 days (range 2-36 days), respectively. In the entire cohort, there were no dislocations (0 of 58) with the direct anterior approach (DA); 1.1% (6 of 553) and 5.1% (11 of 217) dislocated with the modified Hardinge (MH) and posterior approaches (PA), respectively. In the cognitively impaired group, there were no dislocations with the DA (0 of 19); 1.5% (3 of 202) and 10.1% (7 of 69) dislocated with the MH and PA, respectively. In the cognitively intact group, there were no dislocations (0 of 39) with the DA; 0.85% (3 of 351) and 2.7% (4 of 148) dislocated with the MH and PA, respectively. There were statistically significant associations between surgical approach and dislocation in the entire cohort and the cognitively impaired group when comparing the MH and PA groups. This was not observed in the cognitively intact group. Patients who dislocated had 3.2 times (95% CI 1.2, 8.7) ( P = 0.0226) the hazard of death compared with patients who did not dislocate. Dislocation effectively increased the risk of death by 221% (HR 3.2 95% CI 1.2, 8.7) ( P = 0.0226). CONCLUSIONS: In this patient population, the PA has a higher dislocation rate than other approaches and has an especially high rate of dislocation when the patients were cognitively impaired. The authors of this study suggest careful consideration of surgical approach when treating these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of carotid revascularization on cognitive function and brain functional connectivity in carotid stenosis patients with cognitive impairment: a pilot study.

OBJECTIVE: Carotid stenosis can lead to both cognitive impairment (CI) and ischemic stroke. Although carotid revascularization surgery, which includes carotid endarterectomy (CEA) and carotid artery stenting (CAS), can prevent future strokes, its effect on cognitive function is controversial. In this study, the authors examined resting-state functional connectivity (FC) in carotid stenosis patients with CI undergoing revascularization surgery, with a particular focus on the default mode network (DMN). METHODS: Twenty-seven patients with carotid stenosis who were scheduled to undergo CEA or CAS between April 2016 and December 2020 were prospectively enrolled. A cognitive assessment, including the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Japanese version of the Montreal Cognitive Assessment (MoCA), as well as resting-state functional MRI, was performed 1 week preoperatively and 3 months postoperatively. For FC analysis, a seed was placed in the region associated with the DMN. The patients were divided into two groups according to the preoperative MoCA score: a normal cognition (NC) group (MoCA score ≥ 26) and a CI group (MoCA score < 26). The difference in cognitive function and FC between the NC and CI groups was investigated first, and then the change in cognitive function and FC after carotid revascularization was investigated in the CI group. RESULTS: There were 11 and 16 patients in the NC and CI groups, respectively. The FC of the medial prefrontal cortex with the precuneus and that of the left lateral parietal cortex (LLP) with the right cerebellum were significantly lower in the CI group than in the NC group. In the CI group, significant improvements were found in MMSE (25.3 vs 26.8, p = 0.02), FAB (14.4 vs 15.6, p = 0.01), and MoCA scores (20.1 vs 23.9, p = 0.0001) after revascularization surgery. Significantly increased FC of the LLP with the right intracalcarine cortex, right lingual gyrus, and precuneus was observed after carotid revascularization. In addition, there was a significant positive correlation between the increased FC of the LLP with the precuneus and improvement in the MoCA score after carotid revascularization. CONCLUSIONS: These findings suggest that carotid revascularization, including CEA and CAS, might improve cognitive function based on brain FC in the DMN in carotid stenosis patients with CI.

[Impairment of cognitive functions in patients with chronic thromboembolic pulmonary hypertension before and after surgical treatment]. / Kognitivnye narusheniya u patsientov s khronicheskoi tromboembolicheskoi legochnoi gipertenziei do i posle khirurgicheskogo lecheniya.

OBJECTIVE: To study cognitive functions in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and in the long-term after pulmonary thromboendarterectomy and to study factors that negatively affect cognitive status. MATERIAL AND METHODS: One hundred and twenty-four patients with CTEPH were examined before and 6 months after surgery with an assessment of cognitive impairment using the Mini-Mental State Examination (MMSE). Multivariate regression analysis was used to identify factors affecting the MMSE indicators before and in the long-term postoperative periods. RESULTS: Initially, patients with CTEPH had a total MMSE score 23.8±1.1. Six months after surgery, the score was 26.1±1.9 (p<0.001). A history of stroke, disability, stress (loss of spouse), and a high Charleson comorbidity index were independent factors affecting MMSE score before surgery. After surgery, the total MMSE score was influenced by a history of stroke, stress (loss of spouse), residual pulmonary hypertension and atrial fibrillation in the early postoperative period. CONCLUSION: Cognitive impairment in the form of mild dementia was observed in patients with CTEPH before surgery. Six months after the operation, an improvement in cognitive status was revealed, which corresponded to moderate cognitive impairment. At the same time, no complete recovery of cognitive functions was recorded. Patients with CTEPH still experienced the greatest difficulties in the following areas: concentration and counting, memory. A history of stroke, disability, stress (loss of spouse), and a high comorbidity index are associated with a decrease in MMSE scores before surgery. Six months after surgery, MMSE score was affected by a history of stroke, stress (loss of spouse), residual pulmonary hypertension and atrial fibrillation in the early postoperative period.

Cognitive decline and quality of life after resective epilepsy surgery.

OBJECTIVES: The objectives of this study were to examine the association between cognitive decline and quality of life (QoL) change in a large sample of individuals with drug-resistant epilepsy who underwent resective surgery and to examine whether the association between cognitive decline and QoL is differentially affected by seizure classification outcome (Engel Class 1 vs. 2-4) or side of surgery (left vs. right hemisphere). MATERIALS AND METHODS: The sample comprised 224 adults (ages ≥ 18) with drug-resistant focal epilepsy treated with resective surgery who underwent comprehensive pre-operative and post-operative evaluations including neuropsychological testing and the Quality of Life in Epilepsy Inventory - 31 between 1991 and 2020. Linear mixed-effects models were fit to examine subject-specific trajectories and assess the effects of time (pre- to post-operative), cognitive decline (number of measures that meaningfully declined), and the interaction between time and cognitive decline on pre- to post-operative change in QoL. RESULTS: Increases in QoL following resection were observed (B = -10.72 [SE = 1.22], p < .001; mean difference between time point 1 and time point 2 QoL rating = 8.11). There was also a main effect of cognitive decline on QoL (B = -.85 [SE = .27], p = .002). Follow-up analyses showed that the number of cognitive measures that declined was significantly associated with post-surgical QoL, (r = -.20 p = .003), but not pre-surgical QoL, (r = -.04 p = .594), and with pre-to post-surgery raw change in QoL score, (r = -.18 p = .009). A cognitive decline by time point interaction was observed, such that those who had greater cognitive decline had less improvement in overall QoL following resection (B = .72 [SE = .27], p = .009). Similar results were observed within the Engel Class 1 outcome subgroup. However, within the Engel Class 2-4 outcome subgroup, QoL improved following resection, but there was no main effect of cognitive decline or interaction between cognitive decline and time point on QoL change. There was no main effect of resection hemisphere on overall QoL, nor were there interactions with hemisphere by time, hemisphere by cognitive decline, or hemisphere by time by cognitive decline. CONCLUSIONS: Quality of life improves following epilepsy surgery. Participants who had cognitive decline across a greater number of measures experienced less improvement in QoL post-operatively overall, but there was no clear pattern of domain-specific cognitive decline associated with change in QoL. Our results indicate that cognitive decline in a diffuse set of cognitive domains negatively influences post-operative QoL, particularly for those who experience good seizure outcomes (i.e., seizure freedom), regardless of the site or side of resection.

Effects of carotid artery stenting on cognitive impairment in patients with severe symptomatic carotid artery stenosis.

The effect of carotid artery stenting and medication on improvement of cognitive function in patients with severe symptomatic carotid artery stenosis is unknown. To investigate the effect of stenting compared with medication alone for severe carotid atherosclerotic stenosis on cognitive impairment. Patients with carotid stenosis and cognitive impairment were prospectively randomly divided into 2 groups of stenting or medication alone. Cognitive function was evaluated with the Montreal cognitive assessment (MoCA), Mini-Mental State Examination, and Barthel Index of Activities of Daily Living (BI). Continuous data in normal distribution were tested with the t-test but with the Mann-Whitney U test if not in normal distribution. Categorical data were presented as frequency and percentages and tested with the Fisher exact test. A P value < .05 was regarded as statistical significant. Carotid artery stenting was successfully performed in all patients (100%) in the stenting group. Compared with before treatment, the Mini-Mental State Examination, MoCA and BI scores at 6 months in the medication alone group and at 1, 3, and 6 months in the stenting group were significantly (P < .005) improved. The stenting group had significantly (P < .05) better scores than the medication alone group at the same time. At 6-month follow-up, the visuospatial/executive functions (3.69 ±â€…1.42 vs 2.42 ±â€…1.23), attention (5.24 ±â€…1.52 vs 3.63 ±â€…1.47), and language (2.64 ±â€…0.71 vs 1.96 ±â€…0.69) were significantly (P < .05) improved in the stenting group compared with the medication alone group. Carotid artery stenting may significantly improve cognitive impairment and neurological function compared with medication alone in patients with severe carotid atherosclerotic stenosis concurrent with cognitive impairment.

Motor skills, cognitive impairment, and quality of life in normal pressure hydrocephalus: early effects of shunt placement.

BACKGROUND: Traditionally, clinical findings of normal pressure hydrocephalus are mainly characterized by the Hakim triad. The aim of this study is to evaluate the performance of patients suffering from idiopathic normal pressure hydrocephalus (iNPH) in a more holistic manner regarding motor skills, cognitive impairment, and quality of life. METHODS: In total, 30 individuals diagnosed with iNPH as well as a reference group with another 30 individuals were included. The iNPH patients and the reference group were age, educational, and morbidity matched. A standardized test battery for psychomotor skills, gait, neuropsychological abilities as well as questionnaires for quality of life was applied. The iNPH group was tested prior to surgery, at 6 weeks, and 3 months postoperatively. The reference group was tested once. RESULTS: Patients showed a significant improved performance in various items of the test battery during the first 3 months postoperatively. This included neuropsychological evaluation, motor skills including gait and upper motor function as well as the quality of life of the patients. Compared to reference individuals, neuropsychological aspects and quality of life of iNPH patients improved in some parts nearly to normal values. CONCLUSION: Our findings underline that shunt surgery does not only improve the symptoms in iNPH patients but also ameliorates the quality of life to a great extent close to those of age and comorbidity matched reference individuals. This data enables an optimized counseling of iNPH patients regarding the expectable outcome after shunt surgery especially regarding cognitive performance, motor skills as well as life quality.

The influencing factors and changes of cognitive function within 40 Rasmussen encephalitis patients that received a hemispherectomy.

OBJECTIVE: To evaluate the influencing factors and cognitive functional changes in Rasmussen encephalitis (RE) patients who received a hemispherectomy. METHODS: Forty RE patients underwent a hemispherectomy with at least a 2 years follow- up were included in this study . Postoperative seizure outcomes were evaluated according to the Engle classification scale. Univariate analysis and a multivariate logistic regression model in a backward fashion were used to identify the potential predictors of cognitive function. RESULTS: All 40 patients had an Engle classification outcome at a 2 years follow-up. Univariate and multivariate analyses revealed that seizure duration (OR 10.06, 95% CI 1.54-3.85, p = 0.038), age at surgery (OR 3.06, 95% CI 1.21-3.56, p = 0.043), and MRI score (OR 0.09, 95% CI 0.01-0.67 p = 0.024) are associated with postoperative cognitive outcomes respectively. Moreover,  VIQ and PIQ were negatively correlated linearly with duration of seizures and MRI score. Patients with a good VIQ and PIQ before the operation were more likely to have a better VIQ and PIQ postoperatively (p < 0.001 and p < 0.001, respectively). And, operation side is an important factor affecting cognitive function; therefore, a left hemispherectomy has a greater impact on the patient's IQ and language. CONCLUSIONS: RE patients' cognitive dysfunctions are improved after a hemispherectomy. Right-side operation can achieve better postoperative cognitive outcomes especially in VIQ and language. A shorter duration of seizures, early age at surgery, and less severe brain atrophy suggest better cognitive outcomes after a hemispherectomy.

Neurocognitive and Psychopathological Predictors of Weight Loss After Bariatric Surgery: A 4-Year Follow-Up Study.

Twenty to thirty percent of patients experience weight regain at mid and long-term follow-up. Impaired cognitive functions are prevalent in people suffering from obesity and in those with binge eating disorder, thereby, affecting the weight-loss outcomes. The aim of our study was to investigate neurocognitive and psychopathological predictors of surgical efficacy in terms of percentage of excess weight loss (%EWL) at follow-up intervals of one year and 4-year. Psychosocial evaluation was completed in a sample of 78 bariatric surgery candidates and included psychometric instruments and a cognitive battery of neuropsychological tests. A schedule of 1-year and 4-year follow-ups was implemented. Wisconsin Sorting Card Test total correct responses, scores on the Raven's Progressive Matrices Test, and age predicted %EWL at, both, early and long-term periods after surgery while the severity of pre-operative binge eating (BED) symptoms were associated with lower %EWL only four years after the operation. Due to the role of pre-operative BED in weight loss maintenance, the affected patients are at risk of suboptimal response requiring ongoing clinical monitoring, and psychological and pharmacological interventions when needed. As a result of our findings and in keeping with the latest guidelines we encourage neuropsychological assessment of bariatric surgery candidates. This data substantiated the rationale of providing rehabilitative interventions tailored to cognitive domains and time specific to the goal of supporting patients in their post-surgical course.

Liver Transplant Is Associated with Sustained Improvement in Tandem Gait and Risk of Falls.

BACKGROUND: Cirrhosis is associated with poor health-related quality of life (HRQOL), cognitive dysfunction (CD), and lack of coordination leading to falls. Tandem gait (TG; heel-toe) can be used to assess coordination. The impact and relationship between CD, TG and falls pre-/post-liver transplant (LT) is unclear. We aimed to determine the impact of LT on CD, abnormal TG, and HRQOL in cirrhosis. METHODS: We analyzed patients who underwent complete neurological examination, cognitive testing by psychometric hepatic encephalopathy score (PHES), and HRQOL assessment using sickness impact profile (SIP). All patients were followed for 1 post-LT visit at 6 or 12 months post-LT for clinical course and falls. Change in CD, TD, and falls pre-/post-LT were compared. RESULTS: Off 131 recruited, 61 patients completed all visits. Majority were men (84%), with HCV etiology (34%). Pre-LT: Abnormal TG trended towards increased falls (OR 3.3, P = 0.08). Forty-nine % had abnormal TG, 61% had CD, 32.7% had CD + abnormal TG, 62% had prior OHE, and 14.7% had falls. Abnormal and normal TG patients had similar ages, BMI, sex, education level, and MELD scores. Abnormal TG group had higher prior overt HE (P = 0.03) and worse physical SIP score (P = 0.008). Post-LT: There was sustained improvement in CD, HRQOL, falls, and TG post-LT more at 12 than 6 months in all patients. Patients who had abnormal TG pre-LT continued to have a worse PHES (P = 0.0064) and physical SIP score (P = 0.008) compared to normal pre-LT TG patients. CONCLUSION: After LT, there is a sustained improvement in coordination measured via tandem gait, accompanied by a lower rate of falls.

The association between surgical characteristics and cognitive decline following deep brain stimulation of the subthalamic nucleus in Parkinson's disease.

OBJECTIVE: Despite optimal improvement in motor functioning, both short- and long-term studies have reported small but consistent changes in cognitive functioning following STN-DBS in Parkinson's disease (PD). The aim of the present study was to explore whether surgical characteristics were associated with cognitive decline one year following STN-DBS. METHODS: We retrospectively analyzed 49 PD patients who underwent bilateral STN-DBS. Cognitive change scores were related to the number of microelectrode recording (MER) trajectories, the STN length as measured by MER, and cortical entry points. Regression analyses were corrected for age at surgery, disease duration, education and preoperative levodopa responsiveness. Patients were then divided into a cognitive and non-cognitive decline group for each neuropsychological test and compared regarding demographic and surgical characteristics. RESULTS: One year postoperatively, significant declines were found in verbal fluency, Stroop Color-Word test and Trail Making Test B (TMT-B). Only changes in TMT-B were associated with the coronal entry point in the right hemisphere. The number of MER trajectories and STN length were not associated with cognitive change scores. When comparing the cognitive decline and non-cognitive decline groups, no significant differences were found in surgical characteristics. CONCLUSIONS: The electrode passage through the right prefrontal lobe may contribute to subtle changes in executive function. However, only few patients showed clinically relevant cognitive decline. The use of multiple MER trajectories and a longer STN length were not associated with cognitive decline one year following surgery. From a cognitive point of view, DBS may be considered a relatively safe procedure.

Cognitive improvement after cochlear implantation in deaf children with associated disabilities.

AIM: To monitor functional auditory and non-verbal cognitive skills in children with cochlear implants who had associated disabilities over a 24-month period and define how cochlear implantation may impact on non-verbal cognition by restoring functional auditory skills. METHOD: Sixty-four children with cochlear implants (36 females, 28 males; mean age 4y 3mo, SD 3y 5mo, 9mo-14y 5mo) were recruited and divided into three groups: children with typical development group (TDG); children with associated disabilities not linked to non-verbal cognitive disorders group (ADG1); and children with associated disabilities linked to non-verbal cognitive disorders group (ADG2). Tests of functional auditory, communicative, and non-verbal cognitive skills were performed before cochlear implantation and at 12 and 24 months after cochlear implantation. RESULTS: Functional auditory and communicative skills improved similarly in the three groups at 12 and 24 months after implantation. An increase in non-verbal cognitive scores was present in children in the ADG2 from baseline to 12 and 24 months (p<0.01), whereas scores remained stable in children in the TDG and ADG1. The increased functional auditory skills scores after cochlear implantation corresponded to an increase in non-verbal cognitive scores (p=0.032) in children in the ADG2. INTERPRETATION: Children with associated disabilities, especially if linked to non-verbal cognitive disorders, benefitted from cochlear implantation. They improved their comprehension of acoustic information inferred from the environment, improving not only functional auditory skills but also non-verbal cognition.

Surgery-induced cognitive dysfunction is alleviated through triggering receptor expressed on myeloid cells 2.

Neuroinflammation plays a key role in perioperative neurocognitive disorders (PND). Increased evidences indicate that triggering receptor expressed on myeloid cells 2 (TREM2) can mitigate inflammatory response in the brain, and the aim of this study is to investigate whether TREM2 is involved in surgery-induced cognitive dysfunction in adult mice. We used adult C57BL/6 mice subjected to intramedullary fixation surgery, and found that surgery did not impair the motor ability of mice, but worsened the learning and memory function, and reduced the expression of TREM2. Meanwhile, up-regulated TREM2 expression in the brain of mice, induced by selective TREM2 agonist HSP60, significantly improved the learning and memory, alleviated the neuroinflammation, and decreased the neuronal cell apoptosis in mice. Meanwhile, TREM2-siRNA abolished the increased expression of TREM2 induced by HSP60, and reversed all the HSP60-induced beneficial effects. Therefore, our study indicated that up-regulation of TREM2 alleviated neuroinflammation and improved learning and memory function after surgery in mice.

Neurocognitive recovery and global cerebral perfusion improvement after cranioplasty in chronic sinking skin flap syndrome of 18 years: Case report using arterial spin labelling magnetic resonance perfusion imaging.

Sinking skin flap syndrome (SSFS) is a complication among long-term survivors of stroke or traumatic brain injury treated by decompressive craniectomy. The syndrome encompasses a wide spectrum of neurological symptoms including cognitive decline, seizures, speech and sensorimotor deficits. Early cranioplasty appears to improve cerebral perfusion, but the efficacy of cranioplasty in neurocognitive outcome in long-standing SSFS patient is unclear. We report a 64-year-old patient who suffered from traumatic brain injury and underwent decompressive craniectomy 18 years ago. She had chronic SSFS with pre-cranioplasty assessments demonstrating severe neurocognitive impairments which were static over time. After cranioplasty with custom-made polyetheretherketone flap to restore the 264 cm2 skull defect, magnetic resonance perfusion scan with pseudo-continuous arterial spin labelling technique showed a two-fold augmentation of cerebral blood flow in both frontal lobes, as well as areas distal to the sunken skin flap compared to baseline. This is accompanied by improvement of neurocognitive function as assessed by Montreal Cognitive Assessment, Neurobehavioral Cognitive State Examination, and Rivermead Behavioural Memory Test three and six months after cranioplasty. The patient's quality of life and that of her primary carer also showed improvement. This report describes a case of neurocognitive and global cerebral perfusion improvement after cranioplasty in the setting of prolonged SFSS of 18 years, and adds to the growing body of literature supporting the therapeutic role of cranioplasty beyond purely protective or cosmetic indications. The advantages and clinical utility of pCASL MR perfusion in assessing serial CBF before and after cranioplasty is illustrated.

Cognitive Impairment in Children with Arachnoid Cyst of Sylvian Fissure: Does it Justify the Neurosurgical Treatment?

This report discusses the relationship between arachnoid cysts (ACs) and cognitive deficits, and we ask if cognitive impairments could justify neurosurgical treatment. In clinical practice, only AC patients with symptoms of intracranial hypertension or focal neurological deficits are referred to surgery. Occasionally, one might assume that nonspecific problems such as impairment of learning, speech, or cognitive functions are caused by an AC and can be improved by surgery. We describe three patients, in which surgery was indicated on the basis of clinical symptoms such as headaches and the size of the cysts. A neuropsychological examination before AC surgery revealed reduced cognitive potential, and the same examination repeated after surgery showed improvement. We have not found any other reason for this change, except for the decompression of the AC.

Transplantation of GABAergic Interneuron Progenitor Attenuates Cognitive Deficits of Alzheimer's Disease Model Mice.

Excitatory (E) and inhibitory (I) balance of neural network activity is essential for normal brain function and of particular importance to memory. Disturbance of E/I balance contributes to various neurological disorders. The appearance of neural hyperexcitability in Alzheimer's disease (AD) is even suggested as one of predictors of accelerated cognitive decline. In this study, we found that GAD67+, Parvalbumin+, Calretinin+, and Neuropeptide Y+ interneurons were progressively lost in the brain of APP/PS1 mice. Transplanted embryonic medial ganglionic eminence derived interneuron progenitors (IPs) survived, migrated, and differentiated into GABAergic interneuron subtypes successfully at 2 months after transplantation. Transplantation of IPs hippocampally rescued impaired synaptic plasticity and cognitive deficits of APP/PS1 transgenic mice, concomitant with a suppression of neural hyperexcitability, whereas transplantation of IPs failed to attenuate amyloid-ß accumulation, neuroinflammation, and synaptic loss of APP/PS1 transgenic mice. These observations indicate that transplantation of IPs improves learning and memory of APP/PS1 transgenic mice via suppressing neural hyperexcitability. This study highlights a causal contribution of GABAergic dysfunction to AD pathogenesis and the potentiality of IP transplantation in AD therapy.

Cognitive Function, Access to Kidney Transplantation, and Waitlist Mortality Among Kidney Transplant Candidates With or Without Diabetes.

RATIONALE & OBJECTIVE: Intact cognition is generally a prerequisite for navigating through and completing evaluation for kidney transplantation. Despite kidney transplantation being contraindicated for those with severe dementia, screening for more mild forms of cognitive impairment before referral is rare. Candidates may have unrecognized cognitive impairment, which may prolong evaluation, elevate mortality risk, and hinder access to kidney transplantation. We estimated the burden of cognitive impairment and its association with access to kidney transplantation and waitlist mortality. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 3,630 participants (January 2009 to June 2018) with cognitive function measured (by the Modified Mini-Mental State Examination [3MS]) at kidney transplantation evaluation at 1 of 2 transplantation centers. PREDICTORS: Cognitive impairment (3MS score<80). OUTCOMES: Listing, waitlist mortality, and kidney transplantation. ANALYTICAL APPROACH: We estimated the adjusted chance of listing (Cox regression), risk for waitlist mortality (competing-risks regression), and kidney transplantation rate (Poisson regression) by cognitive impairment. Given potential differences in cause of cognitive impairment among those with and without diabetes, we tested whether these associations differed by diabetes status using a Wald test. RESULTS: At evaluation, 6.4% of participants had cognitive impairment, which was independently associated with 25% lower chance of listing (adjusted HR, 0.75; 95% CI, 0.61-0.91); this association did not differ by diabetes status (Pinteraction=0.07). There was a nominal difference by diabetes status for the association between cognitive impairment and kidney transplantation rate (Pinteraction=0.05), while the association between cognitive impairment and waitlist mortality differed by diabetes status kidney transplantation rates (Pinteraction=0.02). Among candidates without diabetes, those with cognitive impairment were at 2.47 (95% CI, 1.31-4.66) times greater risk for waitlist mortality; cognitive impairment was not associated with this outcome among candidates with diabetes. LIMITATIONS: Single measure of cognitive impairment. CONCLUSIONS: Cognitive impairment is associated with a lower chance of being placed on the waitlist, and among patients without diabetes, with increased mortality on the waitlist. Future studies should investigate whether implementation of screening for cognitive impairment improves these outcomes.

Clinical, semiological, electroencephalographic, and neuropsychological features of "pure" neocortical temporal lobe epilepsy.

We examined the clinical, semiological, scalp EEG, and neuropsychological features of patients with "pure" neocortical temporal lobe epilepsy (NTLE) who were successfully treated by neocortical temporal resection sparing the mesial temporal structures. This retrospective study included 17 patients with lesional NTLE who satisfied the following criteria: presence of a discrete structural lesion in the lateral temporal lobe on preoperative MRI; lateral temporal resection sparing the mesial temporal structures; follow-up for at least two years after surgery; and favourable postoperative seizure outcome (Engel Class I). The study included 10 females and seven males, and the age at surgery ranged from 15 to 48 years (mean: 30.7 years). Auras, video-recorded seizure semiology, interictal and ictal EEG, and pre- and post-operative neuropsychological data were reviewed. Twenty patients with mesial temporal lobe epilepsy (MTLE) with hippocampal sclerosis, who had a favourable postoperative seizure outcome (Engel Class I), were selected as a control group. Age at seizure onset was significantly greater in patients with NTLE than in controls. A history of febrile convulsion was significantly less frequent in NTLE patients. Epigastric ascending sensation (6% versus 40%; p=0.017), oral automatisms (29% versus 80%; p=0.003), gestural automatisms (47% versus 80%; p=0.047), and dystonic posturing (0% versus 40%; p=0.003) were significantly less frequent in NTLE than controls. Ictal unitemporal rhythmic theta activity was also significantly less frequent in NTLE than controls (35.3% versus 75%; p=0.015). Preoperative IQ score (range: 68 to 114; mean: 88.9) and preoperative memory quotient score (range: 56-122; mean: 98.1) were significantly higher in NTLE (p=0.003 and p=0.048, respectively). There were notable differences in clinical, semiological, EEG, and neuropsychological features between "pure" NTLE and MTLE. These findings may be useful to identify the epileptogenic zone.

Surgical management of pediatric patients with encephalopathy due to electrical status epilepticus during sleep (ESES).

ESES is a developmental epileptic disorder directly responsible for progressive encephalopathy and neurocognitive regression. The natural history, indications for surgical intervention, and predictors for favorable seizure and neuropsychological outcome remain unclear. We performed a retrospective review of children who underwent resective or disconnective surgery for ESES between January 2009 and July 2016 at a large tertiary pediatric center. Information on the patients' demographics, seizure semiology, radiographic and electrographic findings, and surgical management was collected. The primary outcome was seizure freedom at last follow-up visit, and secondary outcomes were neuropsychological improvement and electrographic ESES resolution. We identified 11 children who underwent surgery for ESES. The mean ages were 3.2 years for seizure onset, 7.1 years for formal ESES diagnosis, and 9.4 years for surgery. Seizure etiologies included cortical malformations (four patients), encephalomalacia and gliosis from prior hemorrhage or tumor resections (three patients), developmental porencephaly (one patient), and Rasmussen's encephalitis (one patient); the etiology was unknown in two children. Preoperatively, nine children had motor deficits, seven had speech and language delay, and three had visual field defects. All children had seizures and neuropsychological regression prior to surgical consideration. Focal cortical resections were performed in seven children, and hemispherectomies in four. Post-operatively, nine children experienced decreased seizure frequency, eight had neuropsychological improvement, and nine had resolution of electrographic ESES. Patients with poor surgical outcomes had more significant pre-operative comorbidities, in addition to bilateral ESES activity. In this case series, surgery for a carefully selected group of children with ESES is safe and feasible, yielding rates of seizure freedom and neuropsychological improvement that compare favorably with previous reports for antiepileptic drugs, benzodiazepines, and steroids. As we gain greater understanding into the management of ESES, surgery is an increasingly useful tool for patients with mild or moderate neurodevelopmental delay, focal epileptogenic foci, and hemi-ESES electrographic findings.