Commentary: Detailed assessment of hidden risks of postoperative delirium

Abstract

Central MessageSilent cerebral ischemia (SCI) is related to postoperative delirium. SCI is found coincidentally in preoperative evaluations but also could supervene after the aortic arch surgery.See Article page 87.Postoperative delirium is a serious complication and has a great impact on surgical outcomes.1Järvelä K. Porkkala H. Karlsson S. Martikainen T. Selander T. Bendel S. Postoperative delirium in cardiac surgery patients.J Cardiothorac Vasc Anesth. 2018; 32: 1597-1602Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,2Andrási T.B. Talipov I. Dinges G. Arndt C. Rastan A.J. Risk factors for postoperative delirium after cardiac surgical procedures with cardioplegic arrest.Eur J Cardiothorac Surg. January 17, 2022; ([Epub ahead of print])Crossref PubMed Scopus (1) Google Scholar Although it is a transient complication only in the acute phase, it is actually a serious complication in that it has a large negative effect over the long term after surgery.3Crocker E. Beggs T. Hassan A. Denault A. Lamarche Y. Bagshaw S. et al.Long-term effects of postoperative delirium in patients undergoing cardiac operation: a systematic review.Ann Thorac Surg. 2016; 102: 1391-1399https://doi.org/10.1016/j.athoracsur.2016.04.071Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Silent cerebral ischemia (SCI) is a type of stroke in which the symptoms that occur in a normal stroke are invisible. SCI is known to be an independent predictor of stroke onset in elderly patients.4Bokura H. Kobayashi S. Yamaguchi S. Iijima K. Nagai A. Toyoda G. et al.Silent brain infarction and subcortical white matter lesions increase the risk of stroke and mortality: a prospective cohort study.J Stroke Cerebrovasc Dis. 2006; 15: 57-63Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Elderly people who develop SCI are more likely to develop a new SCI.5Gupta A. Giambrone A.E. Gialdini G. Finn C. Delgado D. Gutierrez J. et al.Silent brain infarction and risk of future stroke: a systematic review and meta-analysis.Stroke. 2016; 47: 719-725Crossref PubMed Scopus (123) Google Scholar In this issue of the Journal, Shibagaki and colleagues6Shibagaki K. Shirasaka T. Sawada J. Saijo Y. Kunioka S. Kikuchi Y. et al.Silent cerebral ischemia detected by magnetic resonance imaging can predict postoperative delirium after total arch replacement for aneurysm.J Thorac Cardiovasc Surg Open. 2022; 10: 87-96Scopus (2) Google Scholar reported the relationship between the preoperative SCI and postoperative delirium after aortic arch replacement. The cerebral white matter lesions shown on magnetic resonance images (MRIs) mainly show the SCI, and periventricular hyperintensity indicates severe white matter lesions on MRI. They examined the preoperative MRIs in detail and found the periventricular hyperintensity is strongly related to the postoperative delirium.The importance of this report is in the analysis not of simple cardiac surgery but of cases that require brain protection. Brain protection has made great strides, which is a major reason why the safety of arch replacement has improved dramatically over the last 2 decades. However, perioperative cerebral damage cannot be completely prevented, the anterograde cerebral protection method itself is not always complete, and the possibility of causing perioperative SCI during the operation cannot be denied. Seven of the 59 enrolled cases were excluded in this study as having developed postoperative cerebral infarction, yet there was no description that MRI was examined in all cases after surgery. Therefore, it cannot be denied that perioperative SCI may have occurred, and this SCI might have caused delirium. In fact, Charbonneau and colleagues7Charbonneau P. Kölbel T. Rohlffs F. Eilenberg W. Planche O. Bechstein M. et al.STEP collaboratorsSilent brain infarction after endovascular arch procedures: preliminary results from the STEP Registry.Eur J Vasc Endovasc Surg. 2021; 61: 239-245Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar reported that subclinical strokes, which means the SCI, were frequently found after the arch repair with thoracic endovascular aortic repair.While the title indicates total arch replacement, the study really includes hemiarch replacement. In the non-postoperative delirium group, whose average age was 6 years younger, more than 10% did not have a reconstruction of the arch branches. Although a unified method has been adopted for the brain-protection method, cases requiring reconstruction of the arch branches are likely to cause cerebral infarction. From that viewpoint, it can be said that there is an issue in comparison including the small number of total enrolled cases.I would like to pay tribute to their fine research. It is very interesting and important fact that preoperative silent cerebral ischemia has a great impact on postoperative delirium. However, it is also a fact that there are many factors regarding the SCI during the perioperative period in the cases of aortic arch surgery. The relationship between the possibility of newly emerging SCI under cerebral protection during arch replacement and postoperative delirium is expected to be investigated based on this research. Silent cerebral ischemia (SCI) is related to postoperative delirium. SCI is found coincidentally in preoperative evaluations but also could supervene after the aortic arch surgery. Silent cerebral ischemia (SCI) is related to postoperative delirium. SCI is found coincidentally in preoperative evaluations but also could supervene after the aortic arch surgery. See Article page 87. See Article page 87. Postoperative delirium is a serious complication and has a great impact on surgical outcomes.1Järvelä K. Porkkala H. Karlsson S. Martikainen T. Selander T. Bendel S. Postoperative delirium in cardiac surgery patients.J Cardiothorac Vasc Anesth. 2018; 32: 1597-1602Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,2Andrási T.B. Talipov I. Dinges G. Arndt C. Rastan A.J. Risk factors for postoperative delirium after cardiac surgical procedures with cardioplegic arrest.Eur J Cardiothorac Surg. January 17, 2022; ([Epub ahead of print])Crossref PubMed Scopus (1) Google Scholar Although it is a transient complication only in the acute phase, it is actually a serious complication in that it has a large negative effect over the long term after surgery.3Crocker E. Beggs T. Hassan A. Denault A. Lamarche Y. Bagshaw S. et al.Long-term effects of postoperative delirium in patients undergoing cardiac operation: a systematic review.Ann Thorac Surg. 2016; 102: 1391-1399https://doi.org/10.1016/j.athoracsur.2016.04.071Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Silent cerebral ischemia (SCI) is a type of stroke in which the symptoms that occur in a normal stroke are invisible. SCI is known to be an independent predictor of stroke onset in elderly patients.4Bokura H. Kobayashi S. Yamaguchi S. Iijima K. Nagai A. Toyoda G. et al.Silent brain infarction and subcortical white matter lesions increase the risk of stroke and mortality: a prospective cohort study.J Stroke Cerebrovasc Dis. 2006; 15: 57-63Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Elderly people who develop SCI are more likely to develop a new SCI.5Gupta A. Giambrone A.E. Gialdini G. Finn C. Delgado D. Gutierrez J. et al.Silent brain infarction and risk of future stroke: a systematic review and meta-analysis.Stroke. 2016; 47: 719-725Crossref PubMed Scopus (123) Google Scholar In this issue of the Journal, Shibagaki and colleagues6Shibagaki K. Shirasaka T. Sawada J. Saijo Y. Kunioka S. Kikuchi Y. et al.Silent cerebral ischemia detected by magnetic resonance imaging can predict postoperative delirium after total arch replacement for aneurysm.J Thorac Cardiovasc Surg Open. 2022; 10: 87-96Scopus (2) Google Scholar reported the relationship between the preoperative SCI and postoperative delirium after aortic arch replacement. The cerebral white matter lesions shown on magnetic resonance images (MRIs) mainly show the SCI, and periventricular hyperintensity indicates severe white matter lesions on MRI. They examined the preoperative MRIs in detail and found the periventricular hyperintensity is strongly related to the postoperative delirium. The importance of this report is in the analysis not of simple cardiac surgery but of cases that require brain protection. Brain protection has made great strides, which is a major reason why the safety of arch replacement has improved dramatically over the last 2 decades. However, perioperative cerebral damage cannot be completely prevented, the anterograde cerebral protection method itself is not always complete, and the possibility of causing perioperative SCI during the operation cannot be denied. Seven of the 59 enrolled cases were excluded in this study as having developed postoperative cerebral infarction, yet there was no description that MRI was examined in all cases after surgery. Therefore, it cannot be denied that perioperative SCI may have occurred, and this SCI might have caused delirium. In fact, Charbonneau and colleagues7Charbonneau P. Kölbel T. Rohlffs F. Eilenberg W. Planche O. Bechstein M. et al.STEP collaboratorsSilent brain infarction after endovascular arch procedures: preliminary results from the STEP Registry.Eur J Vasc Endovasc Surg. 2021; 61: 239-245Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar reported that subclinical strokes, which means the SCI, were frequently found after the arch repair with thoracic endovascular aortic repair. While the title indicates total arch replacement, the study really includes hemiarch replacement. In the non-postoperative delirium group, whose average age was 6 years younger, more than 10% did not have a reconstruction of the arch branches. Although a unified method has been adopted for the brain-protection method, cases requiring reconstruction of the arch branches are likely to cause cerebral infarction. From that viewpoint, it can be said that there is an issue in comparison including the small number of total enrolled cases. I would like to pay tribute to their fine research. It is very interesting and important fact that preoperative silent cerebral ischemia has a great impact on postoperative delirium. However, it is also a fact that there are many factors regarding the SCI during the perioperative period in the cases of aortic arch surgery. The relationship between the possibility of newly emerging SCI under cerebral protection during arch replacement and postoperative delirium is expected to be investigated based on this research. Silent cerebral ischemia detected by magnetic resonance imaging can predict postoperative delirium after total arch replacement for aneurysmJTCVS OpenVol. 10PreviewTo identify whether preoperative magnetic resonance imaging findings of the brain can predict postoperative delirium in patients who undergo arch replacement for aneurysms. Full-Text PDF Open Access