RESUMO
BACKGROUND: Carotid endarterectomy (CEA) is associated with perioperative stroke and mortality in a minority of cases. The aim of this systematic review and meta-analysis was to investigate the effect of pre-operative statins on perioperative outcomes in patients undergoing CEA for internal carotid artery (ICA) stenosis. METHODS: A systematic review of PubMed, Medline, and the Cochrane Database of Systematic Reviews was performed. Studies were included which reported perioperative stroke and/or survival outcomes following CEA for ICA stenosis and compared patients who were and were not taking pre-operative statins. Relevant data were extracted and pooled using meta-analysis. RESULTS: Seven studies met the inclusion criteria, comprising 21,387 patients. A total of 68.9% (14,976) were administered statins and 31.1% (6657) were statin-free. Pre-operative statin use was higher in patients with a history of cardiac disease (12.2 vs. 23.6% in the statin-free group), diabetes (31.6 vs. 25.1% in the statin-free group), and hypertension (83.5 vs. 72.2% in the statin-free group), while a greater proportion of statin-free patients had symptomatic disease (44.9 vs. 55.5% in the statin-free group). Statins were associated with reduced perioperative stroke in all patients (OR 0.57; 95% CI 0.34-0.95; p = 0.03) and in symptomatic patients (OR 0.57; 95% CI 0.35-0.93; p = 0.03). A trend towards lower perioperative mortality (OR 0.54; 95% CI 0.29, 1.03; p = 0.06) and significantly improved overall survival was observed in the statin group (HR 0.69; 95% CI 0.59-0.81; p < 0.001) at a mean follow-up of 62 months (range 27-76 months). CONCLUSIONS: Administration of statins before CEA is associated with lower rates of perioperative stroke and improved overall survival. Compliance with optimal medical treatment associated with the use of pre-operative statins may limit the clinical significance of these findings. Future investigation to characterize the potential benefit of statin therapy in patients undergoing CEA for ICA stenosis is warranted.
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Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Feminino , Humanos , MasculinoRESUMO
BACKGROUND: Factors including ASA physical status, blood loss, and case length have been described as correlating with the decision to delay tracheal extubation after specific surgical procedures. In this retrospective study, we investigated whether handoffs by anesthesia attendings were associated with delayed extubation after general anesthesia for a broad range of surgical procedures. METHODS: We reviewed the records of 37,824 patients who underwent general anesthesia with an endotracheal tube for surgery (excluding tracheostomy surgery, cardiac surgeries, and liver and lung transplant surgeries) from 2008 to 2013 at Columbia University Medical Center. Our primary outcome was whether the patient was extubated at the end of the surgical case. We hypothesized that attending handoff was a factor that would independently affect the decision of the anesthesiologist to extubate at the end of the surgical case. In addition, we investigated whether the association between handoff and extubation was affected by the timing of the procedure (ending in the daytime versus evening hours) by including an interaction term in the analysis. We adjusted for other variables affecting the decision to delay extubation. RESULTS: Patients (5.4%, n = 2033) were not extubated in the operating room after the completion of their surgery. Cases with an attending handoff appeared to have a greater risk of delayed extubation with an adjusted risk ratio (aRR) of 1.14 (95% confidence interval [CI], 1.03-1.25). Further analysis demonstrated that the attending handoff had a significant effect in daytime cases (aRR, 1.62; 95% CI, 1.29-2.04) but not in evening cases (aRR, 1.07; 95% CI, 0.97-1.19). CONCLUSIONS: Attending handoff was an independent significant factor that increased the risk for the delay of extubation at the end of a surgical case.
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Extubação , Tomada de Decisão Clínica , Transferência da Responsabilidade pelo Paciente/organização & administração , Anestesia Geral , Feminino , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/organização & administração , Cuidados Pós-Operatórios , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
Literature on the anesthetic management of endovascular treatment of acute ischemic stroke (AIS) is limited. Anesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Thus, the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) created a task force to provide expert consensus recommendations on anesthetic management of endovascular treatment of AIS. The task force conducted a systematic literature review (up to August 2012). Because of the limited number of research articles relating to this subject, the task force solicited opinions from experts in this area. The task force created a draft consensus statement based on the available data. Classes of recommendations and levels of evidence were assigned to articles specifically addressing anesthetic management during endovascular treatment of stroke using the standard American Heart Association evidence rating scheme. The draft consensus statement was reviewed by the Task Force, SNACC Executive Committee and representatives of Society of NeuroInterventional Surgery (SNIS) and Neurocritical Care Society (NCS) reaching consensus on the final document. For this consensus statement the anesthetic management of endovascular treatment of AIS was subdivided into 12 topics. Each topic includes a summary of available data followed by recommendations. This consensus statement is intended for use by individuals involved in the care of patients with acute ischemic stroke, such as anesthesiologists, interventional neuroradiologists, neurologists, neurointensivists and neurosurgeons.
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BACKGROUND: Systemic inflammation has been implicated in the development of cognitive dysfunction following carotid endarterectomy (CEA). Neutrophil-lymphocyte ratio (NLR) is a reliable measure of systemic inflammation. We hypothesize that patients with elevated preoperative NLR have increased risk of cognitive dysfunction 1 day after CEA. METHODS: Five hundred fifty-one patients scheduled for CEA were enrolled at Columbia University in New York, NY from 1995 to 2012. NLR was retrospectively reviewed; only 432 patients had preoperative NLR values available within 2 weeks of CEA. NLR was analyzed as a continuous variable and categorically with a cutoff of ≥5 and <5 and equal tertiles, as done in previous studies. RESULTS: Patients with cognitive dysfunction had significantly higher NLR than those without cognitive dysfunction (4.5 ± 4.0 vs 3.2 ± 2.6; P < .001). The incidence of cognitive dysfunction was significantly higher in patients with NLR ≥5 than NLR <5 (34.7% vs 12.8%; P < .001). Significantly fewer patients in the low tertile had cognitive dysfunction than in the high tertile (6.9% vs 25.9%; P <.001) and middle tertile (6.9% vs 17.4%; P = .006). In the final multivariate model, diabetes mellitus (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.08-3.75; P = .03) and NLR ≥5 (OR, 3.38; 95% CI, 1.81-6.27; P < .001) were significantly associated with higher odds of cognitive dysfunction, while statin use was significantly associated with lower odds (OR, 0.48; 95% CI, 0.27-0.84; P = .01). CONCLUSIONS: Preoperative NLR is associated with cognitive dysfunction 1 day after CEA. NLR ≥5 and diabetes mellitus are significantly associated with increased odds of cognitive dysfunction whereas statin use is significantly associated with decreased odds.
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Doenças das Artérias Carótidas/cirurgia , Transtornos Cognitivos/epidemiologia , Cognição , Endarterectomia das Carótidas/efeitos adversos , Linfócitos/imunologia , Neutrófilos/imunologia , Idoso , Doenças das Artérias Carótidas/sangue , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/epidemiologia , Doenças das Artérias Carótidas/imunologia , Distribuição de Qui-Quadrado , Transtornos Cognitivos/sangue , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/imunologia , Transtornos Cognitivos/psicologia , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Incidência , Modelos Logísticos , Contagem de Linfócitos , Masculino , Análise Multivariada , Cidade de Nova Iorque/epidemiologia , Razão de Chances , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Transient bradycardia during the stimulation phase of electroconvulsive therapy (ECT) is a well-known clinical observation. The optimal dose of atropine needed to prevent bradycardia has not been determined. This study was designed to investigate the effect of low doses of atropine on heart rate during ECT. METHODS: Patients who received at least 2 different doses of atropine over their series of right unilateral ECT were included in the analysis. The anesthetic consisted of 0, 0.2, 0.3, or 0.4 mg of atropine, methohexital, and succinylcholine. Heart rate was measured by the RR interval, the time between sequential R waves on the electrocardiogram. Analysis was performed using logistic multivariate regression and repeated-measures multivariate analysis of variance. RESULTS: One hundred eighteen ECT sessions were identified from 19 patients. Patients were grouped into 4 groups by atropine dose (0, 0.2, 0.3, or 0.4 mg) with 9, 33, 13, and 63 ECT sessions identified for each dose, respectively. Patients who received atropine had significantly less bradycardia after electrical stimulus and a faster heart rate through the seizure than patients who did not receive atropine. There was no significant difference in heart rate between patients receiving 0.2, 0.3, and 0.4 mg of atropine at any time point. There was no significant difference in heart rate at time points after the seizure conclusion in any group of patients. CONCLUSION: Low-dose atropine results in significantly less bradycardia after electrical stimulus. There was no significant difference in heart rate across low doses of atropine.
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Antiarrítmicos/farmacologia , Atropina/farmacologia , Eletroconvulsoterapia , Frequência Cardíaca/efeitos dos fármacos , Adulto , Idoso , Anestesia , Antiarrítmicos/administração & dosagem , Atropina/administração & dosagem , Bradicardia/etiologia , Bradicardia/prevenção & controle , Relação Dose-Resposta a Droga , Eletrocardiografia/efeitos dos fármacos , Eletroconvulsoterapia/efeitos adversos , Eletroencefalografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND AND PURPOSE: Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction). METHODS: A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury. RESULTS: Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27-0.96]; P=0.04). CONCLUSIONS: Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883.
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Estenose das Carótidas/complicações , Estenose das Carótidas/tratamento farmacológico , Endarterectomia das Carótidas/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Idoso , Encéfalo/patologia , Cognição , Transtornos Cognitivos/complicações , Transtornos Cognitivos/diagnóstico , Humanos , Pessoa de Meia-Idade , Análise Multivariada , Doenças do Sistema Nervoso/complicações , Doenças do Sistema Nervoso/prevenção & controle , Razão de Chances , Fatores de Risco , Resultado do TratamentoRESUMO
The management of acute ischemic stroke is rapidly developing.Although acute ischemic stroke is a major cause of adult disability and death, the number of patients requiring emergency endovascular intervention remains unknown, but is a fraction of the overall stroke population. Public health initiatives endeavor to raise public awareness about acute stroke to improve triage for emergency treatment, and the medical community is working to develop stroke services at community and academic medical centers throughout the United States. There is an Accreditation Council for Graduate Medical Educationapproved pathway for training in endovascular surgical neuroradiology, the specialty designed to train physicians specifically to treat cerebrovascular diseases. Primary and comprehensive stroke center designations have been defined, yet questions remain about the best delivery model. Telemedicine is available to help community medical centers cope with the complexity of stroke triage and treatment. Should comprehensive care be provided at every community center, or should patients with complex medical needs be triaged to major stroke centers with high-level surgical,intensive care, and endovascular capabilities? Although the answers to these and other questions about stroke care delivery remain unanswered owing to the paucity of empirical data, we are convinced that stroke care regionalization is crucial for delivery of high-quality comprehensive ischemic stroke treatment. A stroke team available 24 hours per day, 7 days per week requires specialty skills in stroke neurology, endovascular surgical neuroradiology, neurosurgery, neurointensive care, anesthesiology, nursing, and technical support for optimal success. Several physician groups with divergent training backgrounds (i.e., interventional neuroradiology, neurosurgery,neurology, peripheral interventional radiology, and cardiology) lay claim to the treatment of stroke patients,particularly the endovascular or interventional methods. Few would challenge neurologists over the responsibility for emergency evaluation and triage of stroke victims for intra intravenous fibrinolysis, even though emergency physicians are most commonly the first to evaluate these patients. There are many unanswered questions about the role of imaging in defining best treatment. Perfusion imaging with CT or MRI appears to have relevance even though its role remains undefined and is the subject of ongoing research. Meanwhile, investigators are exploring new, and perhaps more specific,imaging methods with cerebral metabolic rate of oxygen and cellular acid-base imbalance. There are currently 6 ongoing trials of stroke intervention, many with proprietary technologies and private funding, competing for the same patient population as multicenter trials funded by the NIH. At the same time, much of the interventional stroke treatment currently occurs outside of trials in the community and academic settings without the collection of much-needed data. Market forces will certainly shape future stroke therapy, but it is unclear whether the current combination of private and public funding for these endeavors is the best method of development.
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Estenose das Carótidas/terapia , Endarterectomia das Carótidas/tendências , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/tendências , Animais , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Endarterectomia das Carótidas/métodos , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/tendências , Humanos , Acidente Vascular Cerebral/etiologia , Terapia Trombolítica/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Up to 28% of patients undergoing carotid endarterectomy (CEA) are estimated to experience neurocognitive dysfunction following surgery. The complement cascade plays a central role in ischaemia-reperfusion injury. The authors investigated the effect of common polymorphisms in the complement component 3 (C3F) and complement factor H (CFH Y402H) genes on incidence of neurocognitive dysfunction post-CEA. METHODS: This study examined a nested cohort of prospectively recruited patients receiving elective CEA, who were genotyped for the C3F or Y402H polymorphisms. Each patient underwent a standard battery of eight neuropsychometric tests before, and 1 day and 30 days after, surgery. RESULTS: 57 of 142 (40%) CEA patients had at least one copy of the C3F allele (C3F+), and 17 of 137 (12%) patients had two copies of the CFH Y402H allele (Y402H++). At postoperative day 1, patients were three times (OR 3.05, p=0.045) or six times (OR 6.41, p=0.006) more likely to experience moderate-to-severe neurocognitive dysfunction if they carried the C3F+ or Y402H++ genotype, respectively. Patients with both risk genotypes had an almost eightfold risk of dysfunction (OR 7.67, p=0.046). Right-hand-dominant C3F+ subjects undergoing right-side CEA performed significantly worse on tests of visuospatial function than C3F- subjects. At day 30, C3F+ and Y402H++ genotypes trended towards significance as predictors of dysfunction (p=0.07 and p=0.22, respectively). CONCLUSION: The C3F and Y402H polymorphisms are strong independent predictors of moderate-to-severe neurocognitive dysfunction at 1 day following CEA. Furthermore, patients undergoing right-sided CEA are predisposed to deficits associated with cortex ipsilateral to the operative carotid artery.
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Transtornos Cognitivos/etiologia , Complemento C3/genética , Endarterectomia das Carótidas/efeitos adversos , Idoso , Alelos , Transtornos Cognitivos/genética , Fator H do Complemento/genética , Feminino , Lateralidade Funcional/genética , Genótipo , Humanos , Masculino , Testes Neuropsicológicos , Polimorfismo Genético , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/genética , Fatores de RiscoRESUMO
BACKGROUND: Certain classes of antihypertensive drugs have been associated with intraoperative hypotension, and frequently, patients are receiving multiple classes of antihypertensive medications. We sought to determine whether one class of antihypertensive medication either alone, or in combination with other classes of antihypertensive medications, increased the probability of intraoperative hypotension, determined by the amount of vasopressor required during carotid endarterectomy (CEA) performed under general anesthesia with specific arterial blood pressure management. METHODS: This is a post hoc analysis of 252 patients scheduled for elective CEA under general anesthesia, all of whom participated in a prospective evaluation of cognitive dysfunction. Patients were characterized by class and number of preoperative antihypertensive medications taken. A predetermined anesthetic regimen was administered to all patients, with a phenylephrine infusion titrated to maintain mean arterial blood pressure at baseline before clamping the carotid artery, and approximately 20% above baseline during clamping. Computerized anesthesia records were used to record hemodynamics and to quantify medication administered intraoperatively. RESULTS: Patients taking diuretics as part of their antihypertensive regimen required significantly more (1.6 times) total intraoperative phenylephrine than those not taking diuretics, independently of the number of other antihypertensive medications. This difference in the phenylephrine requirement occurs only during the preclamp period, i.e., from induction to application of carotid artery clamping for the maintenance of preoperative blood pressure. However, in contrast to this result, there is no difference in pressor requirement comparing classes of antihypertensive medications to increase the mean arterial blood pressure 20% above baseline during the period when the carotid artery is clamped. CONCLUSION: Diuretics are associated with increased vasopressor requirements in patients having a CEA under general anesthesia in the preclamp period, which is likely true for any patient having a general anesthetic.
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Anestesia/métodos , Anti-Hipertensivos/farmacologia , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/métodos , Hipertensão/tratamento farmacológico , Idoso , Anestesia Geral , Anestésicos/administração & dosagem , Anti-Hipertensivos/classificação , Pressão Sanguínea , Comorbidade , Interações Medicamentosas , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Hemodinâmica , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Fenilefrina/farmacologia , ProbabilidadeRESUMO
BACKGROUND AND PURPOSE: Cognitive dysfunction occurs in 9% to 23% of patients during the first month after carotid endarterectomy (CEA). A 4-basepair (AAAT) tandem repeat polymorphism (either 3 or 4 repeats) has been described in the promoter region of inducible nitric oxide synthase (iNOS), a gene with complex roles in ischemic injury and preconditioning against ischemic injury. We investigated whether the 4-repeat variant (iNOS(+)) affects the incidence of cognitive dysfunction after CEA. METHODS: One-hundred eighty-five CEA and 60 spine surgery (control) subjects were included in this nested cohort analysis. Subjects underwent a battery of 7 neuropsychometric tests before and 1 day and 1 month after surgery. Multivariate logistic regression analyses were performed to determine if the iNOS promoter variant was independently associated with the incidence of cognitive dysfunction at 1 day and 1 month. Further, all right-hand-dominant CEA subjects were grouped by operative side and performance on each test was compared between iNOS(+) and iNOS(-) groups. RESULTS: Forty-four of 185 CEA subjects had at least 1 iNOS promoter allele containing 4 copies of the tandem repeat (iNOS(+)). iNOS(+) status was significantly protective against moderate/severe cognitive dysfunction 1 month after CEA. Right-hand-dominant iNOS(+) CEA subjects undergoing left-side CEA performed significantly better than iNOS(-) subjects on a verbal learning test and those undergoing right-side CEA performed significantly better on a test of visuospatial function. CONCLUSIONS: We demonstrate an iNOS promoter polymorphism variant provides protection against moderate/severe cognitive dysfunction 1 month after CEA. Further, this protection appears to involve cognitive domains localized ipsilateral to the operative carotid artery.
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Transtornos Cognitivos/etiologia , Transtornos Cognitivos/genética , Endarterectomia das Carótidas/efeitos adversos , Óxido Nítrico Sintase Tipo II/genética , Complicações Pós-Operatórias/psicologia , Regiões Promotoras Genéticas/genética , Idoso , Alelos , Apolipoproteínas E/genética , Transtornos Cognitivos/psicologia , Feminino , Genótipo , Humanos , Modelos Logísticos , Masculino , Testes Neuropsicológicos , Óxido Nítrico/biossíntese , Óxido Nítrico/fisiologia , Polimorfismo Genético/genéticaRESUMO
BACKGROUND: Cognitive dysfunction is fairly common after noncardiac surgery and may be related to intraoperative blood pressure management. The authors present an analysis of risk factors for cognitive deterioration after spine surgery in older patients, with particular emphasis on intraoperative blood pressure in normotensive and hypertensive patients. METHODS: This is a post hoc cohort analysis of 45 patients enrolled before undergoing lumbar laminectomy or microdiscectomy. The patients underwent a battery of 5 neuropsychometric tests preoperatively, and 1 day and 1 month postoperatively. Computerized anesthesia records were used to obtain intraoperative mean arterial pressure (MAP) data. Simple linear regressions between intraoperative MAP and postoperative cognitive performance were performed, and multivariate linear regression models of postoperative cognitive performance were constructed to analyze potential risk factors for cognitive decline after surgery. RESULTS: Twenty-one normotensive patients (mean age, 62.4 yr) and 24 hypertensive patients (mean age, 67.9 yr) were included in this analysis. There was a significant positive relationship between minimum intraoperative MAP values and 1-day cognitive performance by simple linear regression in hypertensive (P = 0.003), but not normotensive, patients. In multivariate linear regression analysis of cognitive performance, there was a significant interaction between hypertension and minimum intraoperative MAP at 1 day and 1 month. CONCLUSIONS: In hypertensive patients, there was a significant relationship between minimum intraoperative MAP and decline in cognitive function 1 day and 1 month after surgery. A prospective controlled trial of intraoperative blood pressure control, especially during induction of anesthesia when MAP values typically drop, is needed to confirm these findings.
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Cognição/fisiologia , Hipertensão/psicologia , Complicações Pós-Operatórias/psicologia , Coluna Vertebral/cirurgia , Idoso , Anestesia , Pressão Sanguínea/fisiologia , Estudos de Coortes , Discotomia , Feminino , Humanos , Hipertensão/fisiopatologia , Laminectomia , Modelos Lineares , Masculino , Sistemas Computadorizados de Registros Médicos , Pessoa de Meia-Idade , Monitorização Intraoperatória , Testes Neuropsicológicos , Medição da Dor , Fatores de Risco , Vasoconstritores/efeitos adversos , Vasoconstritores/uso terapêuticoRESUMO
OBJECT: Recent data from both experimental and clinical studies have supported the use of intravenous magnesium as a potential therapy in the setting of cerebral ischemia. This study assessed whether intraoperative magnesium therapy improves neuropsychometric testing (NPT) following carotid endarterectomy (CEA). METHODS: One hundred eight patients undergoing CEA were randomly assigned to receive placebo infusion or 1 of 3 magnesium-dosing protocols. Neuropsychometric testing was performed 1 day after surgery and compared with baseline performance. Assessment was also performed on a set of 35 patients concurrently undergoing lumbar laminectomy to serve as a control group for NPT. A forward stepwise logistic regression analysis was performed to evaluate the impact of magnesium therapy on NPT. A subgroup analysis was then performed, analyzing the impact of each intraoperative dose on NPT. RESULTS: Patients treated with intravenous magnesium infusion demonstrated less postoperative neurocognitive impairment than those treated with placebo (OR 0.27, 95% CI 0.10-0.74, p = 0.01). When stratified according to dosing bolus and intraoperative magnesium level, those who were treated with low-dose magnesium had less cognitive decline than those treated with placebo (OR 0.09, 95% CI 0.02-0.50, p < 0.01). Those in the high-dose magnesium group demonstrated no difference from the placebo-treated group. CONCLUSIONS: Low-dose intraoperative magnesium therapy protects against neurocognitive decline following CEA.
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Endarterectomia das Carótidas , Idoso , Isquemia Encefálica/terapia , Transtornos Cognitivos/prevenção & controle , Feminino , Humanos , Infusões Intravenosas , Laminectomia , Magnésio/efeitos adversos , Magnésio/sangue , Masculino , Testes Neuropsicológicos , Complicações Pós-Operatórias , Estudos ProspectivosRESUMO
Somatosensory-evoked potential (SSEP) monitoring is commonly used to detect changes in nerve conduction and prevent impending nerve injury. We present a case series of two patients who had SSEP monitoring for their surgical craniotomy procedure, and who, upon positioning supine with their head tilted 30 degrees-45 degrees, developed unilateral upper extremity SSEP changes. These SSEP changes were reversed when the patients were repositioned. These cases indicate the clinical usefulness of monitoring SSEPs while positioning the patient and adjusting position accordingly to prevent injury.
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Craniotomia/métodos , Potenciais Somatossensoriais Evocados/fisiologia , Doenças do Sistema Nervoso/diagnóstico , Idoso , Anestesiologia/métodos , Eletrodos , Eletrofisiologia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Monitorização Fisiológica/métodos , Doenças do Sistema Nervoso/patologia , Valor Preditivo dos TestesRESUMO
BACKGROUND: Carotid endarterectomy (CEA) is an effective treatment for the prevention of stroke in patients with carotid artery stenosis. We aimed to clarify the incidence and risk factors for early cognitive dysfunction (eCD) and early cognitive improvement (eCI), defined as change in cognitive performance ≤24 hours after surgery, using a battery of neuropsychometric tests. METHODS: In total, 585 patients undergoing CEA were tested with neuropsychometric tests before and after surgery; 155 patients undergoing "simple" spine surgery were the reference group. Patient performance for each test was evaluated by z scores. Cognitive change was defined as eCD (or eCI) if: 1) patients had a z score ≤-2 (or ≥2) in ≥2 cognitive domains or 2) patients had mean z scores across all domains ≤-1.5 (or ≥1.5). Associations between the categorical cognitive outcomes and variables of interest were modeled using the proportional odds model. RESULTS: Of the 585 subjects, 24% had eCD, 6% had eCI, and 70% had "no change." Patients who had eCD were more likely to be statin naïve (odds ratio [OR] 1.23 [1.03-1.48], P = 0.02) or women (OR 1.27 [1.06-1.53], P = 0.02). Those with eCI were less likely to have less formal education (OR 0.95 [0.90-1.00], P = 0.04) and less likely to have diabetes mellitus (OR 0.8 [0.65-0.99], P = 0.04). CONCLUSIONS: Patients having CEA may develop eCD or eCI postoperatively. Medications likely to be associated with less eCD are statins and aspirin, which correlate most strongly in asymptomatic patients. In addition to confirming previous findings, we found that women were more likely than men to develop eCD. More sex-specific studies and analysis are needed to better explore these findings.
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Estenose das Carótidas/cirurgia , Transtornos Cognitivos/cirurgia , Endarterectomia das Carótidas/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/diagnóstico , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Cuidados Pós-Operatórios , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Up to 25% of patients experience subtle declines in post-operative neurocognitive function following, otherwise uncomplicated, carotid endarterectomy (CEA). We sought to determine if post-CEA neurocognitive deficits are associated with cerebral blood flow (CBF) abnormalities on post-operative MR perfusion brain scans. METHODS: We enrolled 22 CEA patients to undergo a battery of neuropsychometric tests pre-operatively and on post-operative day 1 (POD 1). Neurocognitive dysfunction was defined as a two standard deviation decline in performance in comparison to a similarly aged control group of lumbar laminectomy patients. All patients received MR perfusion brain scans on POD 1 that were analysed for asymmetries in CBF distribution. One patient experienced a transient ischemic attack within 24 hours before the procedure and was excluded from our analysis. RESULTS: Twenty-nine percent of CEA patients demonstrated neurocognitive dysfunction on POD 1. One hundred percent of those patients with cognitive deficits demonstrated CBF asymmetry, in contrast to only 27% of those patients without cognitive impairment. Post-CEA cognitive dysfunction was significantly associated with CBF abnormalities (RR=3.75, 95% CI: 1.62-8.67, p=0.004). CONCLUSION: Post-CEA neurocognitive dysfunction is significantly associated with post-operative CBF asymmetry. These results support the hypothesis that post-CEA cognitive impairment is caused by cerebral hemodynamic changes. Further work exploring the relationship between CBF and post-CEA cognitive dysfunction is needed.
Assuntos
Circulação Cerebrovascular/fisiologia , Transtornos Cognitivos/etiologia , Imagem de Difusão por Ressonância Magnética , Endarterectomia das Carótidas/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/metabolismo , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Fatores de RiscoRESUMO
BACKGROUND: In previous studies, we found that approximately 25% of patients having carotid endarterectomy with general anesthesia (CEA general) develop cognitive dysfunction compared with a surgical control Group 1 day and 1 mo after surgery. In this study, we tested the hypothesis that patients having CEA with regional anesthesia (CEA regional) will develop significant cognitive dysfunction 1 day after surgery compared with a control group of patients receiving sedation 1 day after surgery. We did not study persistence of dysfunction. METHODS: To test this hypothesis, we enrolled 60 patients in a prospective study. CEA regional was performed with superficial and deep cervical plexus blocks in 41 patients. The control group consisted of 19 patients having coronary angiography or coronary artery stenting performed with sedation. A control group is necessary to account for the "practice effect" associated with repeated cognitive testing. The patients from the CEA regional group were enrolled at New York Medical Center and the control group at Columbia-Presbyterian Medical Center. The cognitive performance of all patients was evaluated using a previously validated battery of neuropsychometric tests. Differences in performance, 1 day after compared with before surgery, were evaluated by both event-rate and group-rate analyses. RESULTS: On postoperative day 1, 24.4% of patients undergoing CEA regional had significant cognitive dysfunction, where "significant" was defined as a total deficit score > or =2 SD worse than the mean performance in the control group. CONCLUSIONS: Patients undergoing CEA regional had an incidence of cognitive dysfunction which was not different than patients having CEA general as previously published and compared with a contemporaneously enrolled group.
Assuntos
Anestesia por Condução/efeitos adversos , Transtornos Cognitivos/etiologia , Endarterectomia das Carótidas , Idoso , Anestesia Geral/efeitos adversos , Estenose das Carótidas , Transtornos Cognitivos/diagnóstico , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Dor Pós-Operatória/diagnósticoRESUMO
BACKGROUND AND PURPOSE: Although the incidence of major stroke attributable to carotid endarterectomy (CEA) is low (1% to 2%), approximately 25% of patients experience subtle postoperative neurocognitive dysfunction. This study examines whether preoperative leukocyte profiles predict cognitive outcome in asymptomatic CEA patients. METHODS: Sixty-nine asymptomatic CEA patients underwent neuropsychometric testing preoperatively and on postoperative day 1 (POD1). Preoperative white blood cell counts and differentials were obtained. Logistic regression was performed for risk factors for neurocognitive decline. Variables achieving univariate P<0.10 were included in multivariate analysis. RESULTS: Eighteen (26%) patients experienced neurocognitive decline on POD1; multivariate analysis demonstrated that preoperative monocyte count (P=0.011) and age (P=0.02) independently predicted outcome. CONCLUSIONS: Preoperative monocyte count and age are independently associated with acute neurocognitive decline after CEA for asymptomatic stenosis.