Postoperative Mini-mental State Examination Research Articles

Relationship of Brain Edema after Deep Brain Stimulation Surgery With Motor and Cognitive Function

Background: Some patients with Parkinson’s disease (PD) develop peri-lead brain edema after deep brain stimulation (DBS) surgery. The influence of edema on neurological function is not well characterized. We investigated the relationship of brain edema after DBS surgery with motor and cognitive function. Methods: Thirteen patients with PD (6 males and 7 females; mean age: 61.2 years) who underwent bilateral subthalamic nucleus (STN) DBS surgery were included. All patients underwent magnetic resonance imaging (MRI) examination on day 6 post-DBS surgery. The volume of edema was measured either in the frontal white matter or STN on fluid attenuated inversion recovery (FLAIR) images. We examined the relationship between these volumes and changes in cognitive and motor function. Results: Patients were divided into those with frontal subcortical edema (FE) ≥3,000 mm 3 (FE+ group; n = 7) and <3,000 mm 3 (FE–group; n = 6). In the FE+ group, the postoperative Mini-Mental State Examination score worsened by 2.4 points after one week compared with that immediately before surgery, while that in the FE- group worsened only by 0.2 points (p = 0.038). On comparing patients with peri-STN edema (SE) ≥1,000 mm 3 (SE+ group; n = 3) and those with SE <1,000 mm 3 (SE- group; n = 10) the SE+ group showed a tendency for delayed tuning of DBS to occur after more than 20 days postoperatively. Conclusions: Development of FE after DBS surgery was related to transient cognitive decline. On the other hand, SE seemed associated with altered motor function. Funding Information: This work was supported by JSPS KAKENHI (grant number JP19K17031), Research Funding of Longevity Sciences (19-24), Research on Policy Planning and Evaluation for Rare and Intractable Disease, Ministry of Health, Labour and Welfare (H30-006). Declaration of Interests: The authors have no conflicts of interest to declare. Ethics Approval Statement: All participants provided written informed consent for participation in the study. The study was conducted according to the Declaration of Helsinki and approved by the Ethical Review Board of the Mie University Hospital (3148) and the Suzuka Kaisei Hospital (2016-05).

Bispectral-Based Ultrasound Image Restoration Algorithm for Neurological Disorders Analysis in Patients Anesthetized with Sevoflurane

The aim of this work was to investigate preventive effect of dexmedetomidine combined with sevoflurane on neurological disorders in liver cancer patients during postoperative recovery under the ultrasound image restoration (UIR) algorithm. A blind deconvolution medical UIR algorithm was established in this study. The patients anesthetized with sevoflurane for liver cancer surgery were rolled into an experimental group (group A) (dexmedetomidine treatment before surgery) and a control group (group B) (normal saline treatment before surgery). They were monitored routinely before, during, and after surgery, and immune and liver functions of patients were observed before and after surgery. Besides, their cognitive function and adverse reactions were assessed after surgery. Results showed that patients from group A had smaller fluctuation in average arterial blood pressure and heart rate, but their bispectral index (BIS) increased obviously after surgery in contrast to those of group B ( P &lt; 0.05 ). Moreover, changes of immune and liver functions in patients from group A decreased sharply compared with group B ( P &lt; 0.05 ). The postoperative minimental state examination (MoCA) score of patients from group A was 27.51 ± 2.02, while the score of group B was 25.79 ± 2.35. The postoperative (MoCA) score of group A was markedly higher than the score of group B, and the difference was statistically obvious ( P &lt; 0.05 ). Besides, the incidence of postoperative cognitive dysfunction (POCD) in patients from group A and B was 12.91% and 32.26% in turn. The incidence of POCD in patients from group A was sharply lower than the incidence of group B ( P &lt; 0.05 ). In addition, the total incidence of adverse reactions in patients from group A was 6.45%, which was significantly lower than the 22.58% of group B, and the difference was statistically substantial ( P &lt; 0.05 ). In summary, dexmedetomidine combined with sevoflurane could effectively reduce POCD and promote systemic circulation recovery, which had clinical application value.

Pulsatil ve Nonpulsatil Kardiyopulmoner Baypas ile Koroner Baypas Cerrahisi Uygulanan Hastalarda Nörokognitif Değişikliklerin Elektroensefalografi ve Minimental Test Kullanılarak Değerlendirilmesi

Introduction: The aim of this study was to compare the neurocognitive effects of pulsatile and non-pulsatile perfusion using electroencephalography and the Mini-Mental State Examination (MMSE) in patients undergoing coronary bypass surgery. Patients and Methods: We created two groups, each containing 11 consecutive randomized patients, who were candidates for coronary bypass surgery. Pulsatile cardiopulmonary bypass (CPB) was conducted in Group I, and non-pulsatile CPB was conducted in Group II. An electroencephalogram (EEG) was performed preoperatively, intraoperatively, 15 minutes after placement of the cross-clamp, and seven days postoperatively. The MMSE was performed preoperatively and on postoperative day seven. Results: In both groups, pathological EEG waves were detected intraoperatively. However, no statistically significant difference was found between the groups (p> 0.05). Urine output was significantly higher at postoperative day1 in Group I. Overall urine drainage was higher in Group I, but the difference was not statistically significant. Diabetes mellitus, hypercholesterolemia, hypertension, cross-clamp, and perfusion time did not have a significant impact on the formation of pathological EEG waves. The difference between pre- and postoperative MMSE scores was not statistically significant (p> 0.05). Conclusion: No remarkable superiority was shown between CPB pulsatile and non-pulsatile perfusion in our study. Improving physiology of perfusion techniques during CPB and performing further studies on patients at high risk for organ perfusion would suggest more comprehensive perfusion flow strategies.

Postoperative Cognitive Dysfunction following General Anaesthesia in Patients Undergoing Elective Non-cardiac Surgery.

To determine frequency of early postoperative cognitive dysfunction (POCD) in patients aged 40 to 60 years, following general anaesthesia in patients undergoing elective, non-cardiac surgery. Descriptive study. Department of Anaesthesiology, The Aga Khan University Hospital (AKUH), Karachi, from December 2015 to May 2016. After obtaining approval from EthicalReview Committee of AKUH andinformed consent, ASA I and II patients, aged between 40 to 60 years of either gender, undergoing general anaesthesia for elective non-cardiac surgical procedures, were recruited. Patients were assessed preoperatively by using mini-mental state examination (MMSE); and patients having a score equal to or greater than 23 (maximum 30) were included in the study. All patients were reassessed at 24 hours postoperatively by MMSE. Both the MMSE evaluations were performed by primary investigator on predesigned data collection form. A total of 150 patients were enrolled in the study. Preoperative MMSE score ranged from 24 to 30 while postoperative MMSE score (at 24 hours) was between 25 and 30. Thus, no patient developed POCD following general anaesthesia for elective, non-cardiac surgery in this study. Early POCD was not found in the presently studied population of middle aged patients having elective non-cardiac surgery under general anaesthesia. Key Words: Postoperative cognitive dysfunction (POCD), General anaesthesia, Non-cardiac surgery, Mini- mental state examination.

A systematic review: comparative analysis of the effects of propofol and sevoflurane on postoperative cognitive function in elderly patients with lung cancer

BackgroundThe potential risk for cognitive impairment following surgery and anesthesia is a common concern, especially in the elderly and more fragile patients. The risk for various neurocognitive effects is thus an area of importance. The independent impact of surgery and anesthesia is still not known. Likewise, the independent effect of different drugs used during anesthesia is a matter of debate, as is the number and amounts of drugs used and the “depth of anesthesia.” So, understanding the drug-related phenomenon and mechanisms for postoperative cognitive impairment is essential. This meta-analysis aims to compare the effects of propofol and sevoflurane anesthesia on postoperative cognitive function in elderly patients with lung cancer.MethodsThis study is a systematic review and meta-analysis for controlled clinical studies. Public-available online databases were searched to identify eligible randomized placebo-controlled trials or prospective cohort studies concerning the effects of propofol and sevoflurane on postoperative cognitive function. The primary endpoints are postoperative mini-mental state examination (MMSE) scores at various time points; the secondary endpoint is the serum S100beta concentration 24 h after surgery. Standard mean differences (SMDs) along with 95% confidence intervals (CIs) were extracted and analyzed using random or fixed-effects models. Analyses regarding heterogeneity, risk of bias assessment, and sensitivity were performed.ResultsWe searched 1626 eligible publications and 14 studies of 1404 patients were included in the final analysis. The majority of included studies had been undertaken in Asian populations. Results suggested that propofol has a greater adverse effect on cognitive function in the elderly patients with lung cancer than sevoflurane. There were significant differences in issues of MMSE 6 h (11 studies; SMD -1.391, 95% CI -2.024, − 0.757; p < 0.001), MMSE 24 h (14 studies; SMD -1.106, 95% CI -1.588, − 0.624; p < 0.001), MMSE 3d (11 studies; SMD -1.065, 95% CI -1.564, − 0.566; p < 0.001), MMSE 7d (10 studies; SMD -0.422, 95% CI -0.549, − 0.295; p < 0.001), and serum S100beta concentration at 1 day after surgery (13 studies; SMD 0.746, 95% CI 0.475, 1.017; p < 0.001).ConclusionPropofol has a more significant adverse effect on postoperative cognitive function in elderly patients with lung cancer than sevoflurane.

Lumboperitoneal shunt for the treatment of idiopathic normal pressure hydrocephalus

Objective To investigate the clinical outcomes of patients with idiopathic normal pressure hydrocephalus (iNPH) treated with lumboperitoneal shunt (LPS). Methods In this 4-year study (December 2013 to December 2017), we retrospectively analyzed 31 adult patients (age>18 y) with iNPH who underwent preoperative evaluation using HLPS (Huaxi LPS preoperative evaluation scale) at Department of Neurosurgery, West China Hospital, Sichuan University. The improvement of symptoms and imaging following LPS, including Keifer's hydrocephalus score (KHS), Evans index, score of mini-mental state examination (MMSE), complications, shunt revision rate, and quality of life including modified Rankin scale (mRS) and function independent measurement (FIM), were synchronously investigated. Results Compared to preoperative conditions, patients had lower KHS (10.06±5.69 vs. 6.06±4.41, P=0.003) and Evans index (0.35±0.05 vs. 0.27±0.05, P=0.001) at 5 days post LPS. The results of MMSE showed that 9 (29.0%) patients were normal while 15 (48.4%) had mild dementia, 5 (16.1%) had moderate dementia and 2 (6.5%) had severe dementia. At 5 days post LPS, 12 (38.7%) patients were normal while 17 (54.8%) had mild dementia and 2 (6.5%) had severe dementia. Statistical analysis suggested that preoperative and postoperative MMSE scores were significantly different (Z=-3.466, P=0.001). The overall incidence of complications was 35.5%. Six (19.4%) patients had over-drainage, 5(16.1%) reported infection, 3 (9.7%) reported inadequate drainage, and 1 (3.2%) developed abdominal symptoms. The median follow-up duration was 9 (1- 48) months. The follow-up indicated that the overall rate of shunt failure was 19.4% and the median of mRS and FIM were 1 (0-5) and 93.5 (23-126), respectively. Conclusion Patients who underwent evaluation before LPS using HLPS could have favorable clinical outcomes with low failure rate. Key words: Hydrocephalus, normal pressure; Treatment outcome; Idiopathic; Lumboperitoneal shunt

Effects of intravenous anesthesia with sufentanil combined with propofol on hemodynamics and oxygen metabolism in patients with esophageal cancer under high altitude

Objective To investigate the effect of intravenous anesthesia with sufentanil combined with propofol on hemodynamics and oxygen metabolism in patients with esophageal cancer under high altitude. Methods 60 patients with esophageal cancer radical surgery was selected from March 2015 to March 2017 in our hospital and were divided into two groups according to the random number table, 30 patients in each group. Patients in the control group were given with fentanyl and propofol intravenous anesthesia, and patients in the observation group were given sufentanil combined with propofol anesthesia. The occurrence of restlessness during the recovery of anesthesia in the two groups were observed, the spontaneous breathing recovery time, extubation time and postoperative Mini-mental State Examination (MMSE) score were recorded, and the indexes of hemodynamics and oxygen metabolism were measured at the time of before induction of anesthesia (T0), tracheal intubation (T1), skin incision (T2), thoracotomy (T3), free esophagus (T4), esophageal catheter removal time (T5). Results The spontaneous respiration recovery time and extubation time of the observation group were significantly shorter than those of the control group (P<0.05). The degree of restlessness in the observation group was weaker than that in the control group (P<0.05). Mean arterial pressure (MAP) in the control group at T2-T4 were significantly higher than those in T0 (P<0.05), but MAP and heart rate (HR) in the observation group at T1-T5 were significantly lower than those of T0 (P<0.05). Compared with T0 group, oxygen saturation (SpO2), oxygen saturation of mixed venose blood (SvO2) and oxygen delivery (DO2) at T1-T5 were significantly decreased (P<0.05), oxygen consumption (VO2) at T2-T4 was significantly increased (P<0.05), especially in the control group (P<0.05). The MMSE scores of the two groups were significantly lower than those before the operation (P<0.05), and the scores in observation group was significantly higher than the control group (P<0.05). Conclusions The intravenous anesthesia with sufentanil combined with propofol is more helpful in maintaining hemodynamic stability and oxygen metabolism balance than intravenous anesthesia with fentanyl combined with propofol and has little effect on postoperative anesthesia recovery and cognitive function. Key words: Sufentanil/AD; Propofol/AD; Anesthesia, intravenous/MT/AE; Esophageal neoplasms/SU; Hemodynamics

Effects of closed-loop intravenous anesthesia guided by Bispectral Index in adult patients on emergence delirium: a randomized controlled study.

Emergence delirium (ED) is an acute change in cognition after general anesthesia (GA) occurring in operative room, recovery room or in postanesthesia care. The automated propofol-remifentanil titration by Bispectral Index (BIS) (AutoTIVA) avoids period of deep (BIS<40) anesthesia and could potentially decrease the ED. The aim of this study was to evaluate ED in surgical patients under AutoTIVA, manual titration of propofol-remifentanil (ManualTIVA) or volatile BIS-guided GA. Moreover, we aimed to evaluate age-related postoperative Mini-Mental State Examination (MMSE) changes. One hundred and thirty-two adult patients scheduled for elective urologic surgery were randomized in: AutoTIVA, desflurane (DES), sevoflurane (SEVO), ManualTIVA anesthesia. The MMSE was performed before GA and 15 minutes after tracheal extubation. The percentage of BIS 40-60 was significantly higher in the AutoTIVA compared to DES, SEVO and ManualTIVA (87% vs. 78 %, 58%, 39%, respectively; P≤0.001). The percentage of BIS<40 was significantly lower in AutoTIVA than in the other groups (P<0.001). No difference in hemodynamics was found among groups. Postoperative MMSE scores were similar to baseline in the AutoTIVA (26 [24-28] vs. 26 [23-28]) while they markedly decreased in all other groups (P<0.001). Postoperative MMSE decreased at any age. None experienced awareness was recorded. Our results suggest that patients treated with AutoTIVA performed better in the cognitive test compared to the other groups receiving manual target-controlled GA due to a higher adequate level of anesthesia measured by BIS. Cognitive tests should be performed to test ED in all patients undergoing GA.

Comparison of the anesthesia effects of sevoflurane and propofol in extensive hysterectomy patients and the influence on cognitive function

Objective To compare the anesthesia effects of sevoflurane and propofol in extensive hysterectomy patients and the influence on cognitive function. Methods 94 patients of extensive hysterectomy were selected, according to the drawing method they were divided into control group and observation group, 47 cases in each group, the patients were given propofol or sevoflurane anesthesia respectively.The postoperative mini-mental state examination(MMSE) score and the incidence of cognitive dysfunction, inflammation factors, stress reaction, hemodynamic, anesthetic effect and complications were observed in the two groups. Results After operation, the MMSE score of the observation group was higher than that of the control group[(25.44±3.18)points vs.(23.96±2.93)points](t=2.346, P=0.021), the incidence rate of cognitive dysfunction in the observation group was lower than that of the control group [2.12%(1/47) vs.12.76%(6/47)], there was satistically significant difference between the two groups(χ2=3.858, P=0.049 5). The inflammatory factors, stress reaction and hemodynamic index of the observation group were better than those of the control group(all P 0.05). Conclusion The effect of sevoflurane on cognitive function in patients with extensive hysterectomy is less than propofol, and the anesthesia effect is more precisely. Key words: Hysterectomy; Sevoflurane; Propofol; Anesthesia; Cognitive function

Effect of dexmedetomidine on postoperative cognitive dysfunction in elderly patients after general anaesthesia: A meta-analysis.

ObjectiveWe undertook a meta-analysis to investigate the effect of dexmedetomidine on postoperative cognitive dysfunction (POCD).MethodsWe searched PubMed, EMBASE, the Cochrane Library, CNKI and Google Scholar to find randomized controlled trials (RCTs) of the influence of dexmedetomidine on POCD in elderly adults who had undergone general anaesthesia. Two researchers independently screened the literature, extracted data, and evaluated methodologic quality against inclusion and exclusion criteria. We used RevMan 5.2 to undertake our meta-analysis.ResultsThirteen RCTs were included. Compared with controls, dexmedetomidine: 1) significantly reduced the incidence of POCD (relative risk = 0.59, 95% confidence interval [CI] 0.45–2.95) and improved Mini-Mental State Examination (MMSE) score (mean difference, MD = 1.74, 95% CI 0.43–3.05) on the first postoperative day; and 2) reduced the incidence of POCD after the first postoperative day (MD = 2.73, 95% CI 1.33–4.12).ConclusionDexmedetomidine reduces the incidence of POCD and improves postoperative MMSE score.

Abstract PR363

Background & Objectives: Postoperative brain damage is a serious problems in cardiac surgery patients. Dexmedetomidine and isoflurane have been reported to have neuroprotective properties in animal. But no report currently compares dexmedetomidine combined with isoflurane and isoflurane anesthesia on brain injury after cardiac surgery. Materials & Methods: 97 patients scheduled for valve replacement surgery with cardiopulmonary bypasses were randomly divided into 2 groups: dexmedetomidine and isoflurane (D-I, n=50) and isoflurane alone (I, n=47). Anesthesia was maintained with either dexmedetomidine and isoflurane or isoflurane alone combined with sufentanil. Dexemedetomidine was infused at 0.6 μg/kg for 15 min as a bolus, followed with 0.2 μg/kg/h until the end of surgery. The inhaled concentration of isoflurane was adjusted to keep the bispectral index (BIS) 40-50 throughout the procedure in both groups. Jugular blood samples were drawn for analysis of matrix metalloproteinase-9(MMP-9) and glial fibrillary acidic protein levels(GFAP) peri-operatively: before induction; 5 min after cardiopulmonary bypass(CPB) onset;after CPB; the first day after operation and the second day after operation. Plasma lactate levels in arterial and jugular venous blood were also quantified at the same five time points. Antisaccadic eye movement(ASEM) test and Mini-Mental State Examination(MMSE) were tested on the day before operation and the seventh day postoperatively. Results: Serum MMP-9 and GFAP concentration increased after CPB and decreased to basal levels on the second morning after surgery in both groups. MMP-9 concentration in group D-I were lower on times of CPB off and the first day after operation. However lower GFAP concentration in group D-I were found on times of 5 min after CPB onset and CPB off. No significant differences were found between the two groups when the difference of arterial and jugular bulb venous blood lactate levels were compared except 5 minutes after CPB on. The MMSE score of total patients was declined significantly from the baseline values of 26.9±1.4 to 25.4±1.5 on the seventh day after operation(p< 0.001). The ASEM scores also decreased significantly from the baseline values of 16.4±3.8 to 13.7±6.8 postoperatively (p< 0.001). No difference were found in postoperative MMSE (p=0.787)and ASEM impairment (p=0.439) between the treatment groups. Conclusion: Dexmedetomidine combined with isoflurane can decrease the biochemical markers of brain injury but does not improve cognitive function after cardiac surgery compared with isoflurane alone.

Effect of Edaravone on Postoperative Cognitive Function and Cerebral Oxygen Metabolism in Elderly Patients with Spinal Surgery

Summary Background To investigate the effect of edaravone on the postoperative cognitive function and cerebral oxygen metabolism in elderly patients with spinal surgery. Methods One hundred and twenty patients undergoing elective thoracolumbar surgery, aged 65–75 years, were randomly divided into two groups: edaravone group (Group E, n =60) and control group (Group C, n =60). At 30 minutes before anesthesia, the patients in Group E received 0.5 mg/kg edaravone, while the patients in Group C received the same volume of normal saline. Mini-mental state examination (MMSE) was performed at 1 day before the operation, and 1 day and 4 days after the operation. Results A total of 26 patients in both groups had postoperative cognitive dysfunction. Compared with the preoperative MMSE scores, postoperative MMSE scores decreased significantly in both groups ( p p Conclusion Edaravone can reduce the incidence of early postoperative cognitive dysfunction in elderly patients. The underlying mechanism may be related to improvement of cerebral oxygen metabolism.

Effect of dexmedetomidine on early postoperative cognitive dysfunction and peri-operative inflammation in elderly patients undergoing laparoscopic cholecystectomy.

The use of intravenous dexmedetomidine during surgery has been shown to suppress inflammatory cytokines peri-operatively. It has also been demonstrated that dexmedetomidine may benefit cognitive function in elderly patients following surgery; however, it is not clear whether dexmedetomidine reduces postoperative cognitive dysfunction (POCD) via the suppression of inflammatory cytokines. The aim of the present study was to investigate the effects of dexmedetomidine on early POCD and inflammatory cytokines in elderly patients undergoing laparoscopic cholecystectomy (LC). The study comprised 120 elderly patients undergoing selective LC, who were randomly allocated to receive either dexmedetomidine intravenously (DEX group, n=60) or the same volume of normal saline (control group, n=60). Cognitive function was assessed by Mini-Mental State Examination (MMSE) scores 1 day prior to surgery, 6 h following surgery and postoperatively on days 1 and 2. Interleukin (IL)-1β, IL-6 and C-reactive protein (CRP) levels were also measured at these time-points. On the basis of whether the patients had POCD on the first day after surgery, patients were divided into a POCD group and a non-POCD group. Blood cytokine levels were compared between the patients with and without POCD. A total of 100 patients completed both pre- and postoperative MMSE tests. At 1 day following surgery, POCD occurred in 10/50 (20%) patients in the DEX group and in 21/50 (42%) patients in the control group (P=0.017). At 6 h following surgery, IL-1β, IL-6 and CRP levels showed significant increases (P<0.01) compared with the baseline levels in the two groups. Furthermore, in the control group, CRP levels showed a significant increase on day 1 (P<0.001) and day 2 (P=0.017) postoperatively. In the DEX group compared with the control group, IL-1β, IL-6 and CRP levels were markedly decreased at 6 h and 1 day after surgery (P<0.01). Concentrations of IL-1β, IL-6 and CRP were significantly higher in patients who developed POCD on day 1 following surgery than in the patients who did not develop POCD (P<0.05). The findings of the current study support the hypothesis that dexmedetomidine administration during anesthesia decreases the incidence of early POCD, most likely by the mechanism of reduction of the inflammatory response level.

Recovery of postoperative cognitive function in elderly patients after a long duration of desflurane anesthesia: a pilot study

Postoperative cognitive dysfunction (POCD) increases morbidity and mortality. The mechanisms underlying POCD remain elusive; however, systemic responses induced by anesthesia and surgery might trigger neuroinflammation and POCD. Desflurane is a preferable volatile anesthetic agent for elderly patients because it facilitates shorter recovery from general anesthesia. The aim of this study was to determine whether quality of emergence and cognitive function in elderly patients undergoing a long duration desflurane anesthesia are better than those in the case of sevoflurane anesthesia. Forty-two patients who were older than 65 years of age and scheduled for surgery of more than 4 h in duration were enrolled in this study. Patients were randomly assigned to a desflurane anesthesia group (D group) and sevoflurane anesthesia group (S group). General anesthesia was maintained with 3.5 % desflurane (D group) and 1.0 % sevoflurane (S group). The Mini-Mental State Examination (MMSE) was used for assessing cognitive function 24 h before and after surgery. Postoperative MMSE score in the D group was significantly improved compared to that in the preoperative period. In conclusion, elderly patients undergoing desflurane anesthesia have significantly better quality of emergence and may have better cognitive function than those in elderly patients undergoing sevoflurane anesthesia.

The change of circulating insulin like growth factor binding protein 7 levels may correlate with postoperative cognitive dysfunction

Insulin-like growth factor binding protein (IGFBP) 7 may be a critical regulator of memory consolidation. This study was performed to assess the relationship between circulating IGFBP7 levels and postoperative cognition dysfunction (POCD) in patients scheduled for elective head and neck carcinoma surgery under general anesthesia. Among one hundred and two patients included in this study, forty-four patients completed collection of all four blood samples and thirty-five patients were diagnosed with POCD. The results of Mini-Mental State Examination (MMSE) test and enzyme-linked immunosorbent assay showed that postoperative MMSE score and circulating insulin-like growth factor (IGF)-1 level were lower and circulating IGFBP7 level was higher than preoperative level. Circulating IGF-1 level was significantly lower and D-value of preoperative and postoperative day 1 circulating IGFBP7 levels (ΔIGFBP71) was significantly higher in the POCD group. Age preoperative MMSE, IGF-1 level and ΔIGFBP71 significantly correlated with POCD, but preoperative IGFBP7 level not. Logistic regression analysis revealed that older patients, lower preoperative MMSE score, IGF-1 level and higher IGFBP7 level significantly increased the risk of POCD, but ΔIGFBP71 not. Hence, circulating IGF-1 and IGFBP7 levels and their changes during operation under general anesthesia may correlate with POCD, but further investigation in larger samples is needed.

Preoperative Acetazolamide SPECT is Useful for Predicting Outcome of Shunt Operation in Idiopathic Normal Pressure Hydrocephalus Patients

Good outcome of shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) patients are highly dependent on accurate preoperative assessments. Acetazolamide ethylcysteinate-dimer-single photon emission computer tomography (SPECT) was applied to iNPH patients for more exact preoperative evaluation. Sixty-five patients were categorized into 3 groups: group I (normals, n = 30), group II (with ventriculomegaly due to age-relating changes, n = 10), and group III (who underwent shunt surgery based on the diagnosis of iNPH, n = 25). Acetazolamide SPECT was performed in all patients, and mini-mental state examination (MMSE) was performed before and 1 month after the surgery in group III. Acetazolamide SPECT study demonstrated normal increase of cerebral blood flow (CBF, more than 40%) in groups I and II. Group III was classified into 2 subgroups on the examination; a mean increasing percentage (%increase) of CBF was less than 20% in group IIIa and more than 40% in group IIIb. One month after the surgery, acetazolamide SPECT showed normal %increase of CBF in IIIa, and the increase in postoperative MMSE score was significantly greater in group IIIa than IIIb (P < 0.05). In iNPH patients, less than 20% increase in preoperative acetazolamide SPECT predicted improvement of MMSE score with 100% sensitivity and 60% specificity. Poor %increase of CBF by acetazolamide implies a low capacity for vasodilation in the brain due to compression and stretching by ventriculomegaly. Acetazolamide SPECT study is not an absolute examination but one of the valuable supplementary objective examinations to determine the surgical indication in iNPH-suspected patients.

Effects of sevoflurane before cardiopulmonary bypass on cerebral oxygen balance and early postoperative cognitive dysfunction

Postoperative cognitive dysfunction (POCD) is associated with cardiopulmonary bypass (CPB). We investigated the effect of different doses of inhaled sevoflurane administered prior to CPB on cerebral oxygen supply and demand, and the incidence of associated early POCD. One hundred and twenty patients were randomly allocated into four treatment groups (n = 30, each) and administered a high- [1.5 minimum alveolar concentration (MAC)], moderate- (1.0 MAC), low- (0.5 MAC), or no- sevoflurane dose prior to CPB. Standard blood gas parameters, serum S-100 protein, and neuron-specific enolase (NSE) were measured at different time points. The mini-mental state examination (MMSE) was administered 1 day before and 24 and 72 h after surgery. The jugular bulb venous oxygen saturation (SjvO2) in the moderate- and high-dose groups at a nasopharyngeal temperature of 25-28 °C was significantly higher compared with the control group, while the arteriovenous oxygen content difference (AVDO2) and cerebral extraction of oxygen (CEO2) were significantly reduced. The serum S-100 protein and NSE concentrations of the moderate- and high-dose groups at 1 and 6 h after the cessation of CPB were significantly lower than that of the control group. The 24 h postoperative MMSE scores of the moderate- and high-dose groups were significantly higher than those of the low-dose and control groups. An inhaled optimal concentration of sevoflurane may be beneficial for cerebral oxygen balance during CPB, and may ameliorate cognitive damage. However, the effect is dose-dependent.

Cerebral protective effect of nicorandil premedication on patients undergoing liver transplantation

Neurological injury is a common complication in the early period after liver transplantation, posing an enormous obstacle to treatment efficiency and patient survival. Nicorandil is a mitochondrial ATP-sensitive potassium channel (mitoKATP) opener. It has been reported to be effective in reducing brain injury in recent studies. However, it is still unclear whether nicorandil has cerebral protective effect in patients undergoing liver transplantation. Fifty patients scheduled for liver transplantation were randomly divided into a nicorandil group (group N) (n=25), in which patients received 10 mg nicorandil through a nasogastric tube 30 minutes before induction of anesthesia, and a control group (group C) (n=25) who received 10 mL normal saline. The Mini-Mental State Examination (MMSE) was performed before anesthesia (day 0), and on days 3 and 7 after surgery. Blood samples were obtained before induction of anesthesia (T1), and at 12 (T2) and 36 hours (T3) after surgery for determination of serum neuron-specific enolase (NSE) and S100β protein (S100β) concentrations. During surgery, 5 patients in each group were eliminated due to severe reperfusion or renal insufficiency. Therefore, 20 patients remained in each group. The MMSE scores after operation were significantly lower than those before operation in group C. However, there was no difference at days 3 and 7 compared with day 0 in group N. Serum NSE concentrations after surgery were significantly higher than baseline (at T1) in both groups, except at T3 in group N. Serum S100β concentration after surgery was significantly higher than baseline (at T1) in both groups. The MMSE scores at days 3 and 7 in group N were significantly higher than those in group C. The concentrations of serum NSE and S100β at T2 and T3 in group N were significantly lower than those in group C. Oral nicorandil, as a premedication before liver transplantation, improves postoperative MMSE scores. It also attenuates the increase of NSE and S100β in blood, indicating its cerebral protective effect.

Does Depth of Anesthesia Influence Postoperative Cognitive Dysfunction or Inflammatory Response Following Major ENT Surgery?

The aim of this study was to evaluate the role of depth of anesthesia on POCD after major ENT surgery and to assess changes in postoperative inflammatory markers in patients undergoing major ENT surgery. Thirty two patients aged 40 to 94 yrs, scheduled for surgery under general anesthesia were randomly assigned to one of two groups. In group A (AEP group) depth of anesthesia (DOA) was measured with auditory evoked potential (AEP). In the control group (group C) DOA was monitored according to clinical signs. Cognitive function was evaluated using Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM) and Cognitive Failure Questionnaire (CFQ). Inflammatory markers were measured before and after anesthesia. Perioperative requirements for desflurane and fentanyl were significantly lower in group A. On the first postoperative day MMSE changes indicating POCD were noted in 1 patient in group A and 7 patients in group C (P<0.03). One month follow up did not show any difference between the groups regarding POCD. Our study indicates that AEP-guided anesthesia allows dose reduction of anesthetic agents including opioids leading to better cardiovascular stability and less early POCD. Anesthesia depth did not influence the inflammatory response to surgery.

Comparative study on carotid revascularization (endarterectomy vs stenting) using markers of cellular brain injury, neuropsychometric tests, and diffusion-weighted magnetic resonance imaging

Subclinical alterations of cerebral function can occur during or after carotid revascularization and can be detected by a variety of standard tests. This comparative study assessed the relationship among serum levels for two biochemical markers of cerebral injury, postoperative diffusion-weighted magnetic resonance imaging (DW-MRI), and neuropsychometric testing in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) for high-grade asymptomatic carotid stenosis. Forty-three consecutive asymptomatic patients underwent carotid revascularization by endarterectomy (CEA, 20) or stenting (CAS, 23). They were evaluated with DW-MRI and the Mini-Mental State Examination (MMSE) test preoperatively and <or=24 hours after carotid revascularization. Venous blood samples to assess serum levels of neuron-specific enolase (NSE) and S100beta protein were collected for each patient preoperatively and five times in a 24-hour period postoperatively and assayed using automated commercial equipment. The MMSE test was repeated at 6 months. The relationship between serum marker levels and neuropsychometric and imaging tests and differences between the two groups of patients were analyzed by chi(2) test, with significance at P < .05. No transient ischemic attacks or strokes were clinically observed. CAS caused more new subcortical lesions at postoperative DW-MRI and a significant decline in the MMSE postoperative score compared with CEA (P = .03). In CAS patients, new lesions at DW-MRI were significantly associated with a postoperative MMSE score decline >5 points (P = .001). Analysis of S100beta and NSE levels showed a significant increase at 24 hours in CAS patients compared with CEA patients (P = .02). The MMSE score at 6 months showed a nonsignificant increase vs the postoperative score in both groups. Biochemical markers measurements of brain damage combined with neuropsychometric tests and DW-MRI can be used to evaluate silent injuries after CAS. The mechanisms of rise in S100beta and NSE levels at 24 hours after CAS may be due to increased perioperative microembolization rather than to hypoperfusion. Further studies are required to assess the clinical significance of those tests in carotid revascularization.