Evaluation of the risk factors for neurological and neurocognitive impairment after selective cerebral perfusion in thoracic aortic surgery.

PURPOSE: Neurologic complications are seen often after the surgery of the thoracic aorta that uses selective antegrade cerebral perfusion. The objective of this study was to evaluate the impact of atherosclerotic risk factors on neurologic complications in patients who underwent surgery to the thoracic aorta using SCP. METHODS: Data were collected retrospectively on 94 patients who underwent elective ascending aorta/aortic arch replacement. Concomitant procedures were performed as needed. All patients had magnetic resonance imaging (MRI), angiography (MRA) and carotid ultrasound before surgery. Individual cognitive status was measured using four neuropsychological tests before surgery and 7 days after extubation. We compared perioperative factors for risk factors associated with postoperative stroke and postoperative cognitive decline (POCD). RESULTS: 11 patients had strokes after surgery. Operation and extracorporeal circulation times were significantly longer in patients with stroke than those without stroke. Coronary artery disease and SCP time > 150 min were independently associated with postoperative stroke. Of the 83 patients without postoperative stroke, 20 suffered POCD. POCD patients had a significantly higher rate of heterogeneous carotid plaque, and operation time was significant longer in patients with POCD than those without POCD. Independent predictors of POCD were concomitant CABG, heterogeneous carotid plaque, history of cerebrovascular disease and operation time > 450 min. CONCLUSIONS: We found that prolonged SCP time and coronary artery disease increased the risk of postoperative stroke. Heterogeneous carotid plaque, history of cerebrovascular disease, concomitant CABG and prolonged operation time were further significant predictors of POCD.

Low pre-existing gray matter volume in the medial temporal lobe and white matter lesions are associated with postoperative cognitive dysfunction after cardiac surgery.

OBJECTIVES: Postoperative cognitive dysfunction (POCD) is recognized as a complication in the elderly after cardiac surgery. Imaging of the brain provides evidence of neurodegeneration in elderly patients; however, abnormalities in brain structure and their relation to POCD are uncertain. This pilot study investigated whether loss of gray matter in the bilateral medial temporal lobe (MTL), seen in preoperative MRI, was associated with POCD. METHODS: Data were collected prospectively on 28 elderly patients scheduled for elective cardiac surgery. MRI of the brains of all patients were assessed for prior cerebral infarctions, and carotid and intracranial arterial stenosis. Patients also completed six neuropsychological tests of memory, attention and executive function before and after surgery. POCD was defined as an individual decrease in more than two tests of at least 1 standard deviation from the group baseline mean for that test. The degree of gray matter loss in the MTL of each patient was calculated using voxel-based morphometry with three-dimensional, T1-weighted MRI. This represented the degree of gray matter change as a Z score. RESULTS: Postoperative cognitive dysfunction was identified in 8 of the 28 patients (29%). Patients with POCD had significantly more white matter lesions on MRI, and greater loss of gray matter in the bilateral MTL (average Z score 2.0±0.9) than patients without POCD. An analysis by stepwise logistic regression identified gray matter loss in the MTL and cerebral infarctions on MRI as independent predictors of POCD. CONCLUSIONS: These preliminary findings suggested that reduced gray matter in the bilateral MTL and white matter lesions existed in brains of elderly cardiac surgery patients who experienced POCD. Additional studies with larger sample sizes are needed to confirm these findings.

[Postoperative cognitive dysfunction in off-pump versus on-pump coronary artery bypass surgery].

Patients referred for coronary artery bypass grafting (CABG) are older and more likely to have extensive vascular diseases than those referred for such procedures in the past. Undiagnosed cerebral small vessel diseases (SVD), such as lacunar infarctions or white matter lesions, and dementia are common. Postoperative cognitive dysfunction (POCD) remains a major concern in these elderly patients. POCD is caused by cerebral emboli, hypoperfusion, and inflammation attributed largely to the use of cardiopulmonary bypass. Off-pump CABG is a surgical strategy proposed to decrease the risk of POCD. Although some researchers have found that off-pump CABG is associated with improved cognitive outcome in the early postoperative period, many studies have shown no difference at any time points. Consequently, efforts to reduce the incidence of POCD are focusing on patient-related rather than procedure-related factors. Surgical procedures could exacerbate neuroinflammation and accelerate cognitive dysfunction, especially in patients with SVD and dementia. Mild cognitive impairment may serve as a surrogate marker for underlying SVD or dementia. Preoperative cerebrovascular evaluation, such as MRI, MRA, or cervical ultrasound, and cognitive screening may be effective to identify high-risk patients, making it possible to individualize surgical approaches aimed at reducing POCD.

Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery.

OBJECTIVES: Delirium is a common and critical clinical syndrome in older patients. We examined whether abnormalities in the brain that could be assessed by magnetic resonance imaging predisposed patients to develop delirium after coronary artery bypass graft surgery. We also analysed the association between delirium and cognitive dysfunction after coronary artery bypass graft surgery. METHODS: Data were collected prospectively on 153 patients aged 60 years or older who consecutively underwent elective isolated coronary artery bypass graft surgery. All patients were assessed for prior cerebral infarctions and craniocervical artery stenosis by magnetic resonance imaging (MRI) and angiography of their brains. Atherosclerosis of the ascending aorta was examined by epiaortic ultrasound at the time of surgery. Individual cognitive status was measured using four tests in all the patients before surgery and on the seventh postoperative day. A single psychiatrist diagnosed delirium using the Diagnostic and Statistical Manual of Mental Disorders 4th edition IV criteria. RESULTS: Postoperative delirium occurred in 16 patients (10.5%). Compared with patients who did not develop postoperative delirium, delirious patients had significantly higher rates of peripheral artery disease, preoperative decline in global cognitive function and pre-existing multiple cerebral infarctions on MRI. In addition, 9 (56%) of the delirious patients suffered postoperative cognitive dysfunction. Stepwise logistic regression analysis found significant independent predictors of postoperative delirium to be preoperative cerebral infarcts on MRI (odds ratio [OR], 2.26; 95% confidence interval [CI] 1.10-4.78), preoperative decline in global cognitive function (OR 4.54; 95% CI 1.21-16.51) and atherosclerosis of the ascending aorta (OR 2.44; 95% CI 1.03-5.62). CONCLUSIONS: Our findings suggested that postoperative delirium was associated with pre-existing multiple cerebral infarctions on MRI, preoperative decline in global cognitive function and ascending aortic atherosclerosis in elderly patients undergoing coronary artery bypass graft surgery and increased risk of postoperative cognitive dysfunction.

[Transfusion-related acute lung injury caused by anti-leukocyte antibodies found in patient's serum and donor plasma].

We report a case of transfusion-related acute lung injury (TRALI) with anti-leukocyte antibodies detected both in the patient's serum and in the causative fresh frozen plasma. The patient was a 72-year-old Japanese woman who had undergone colectomy and stoma closure under general anesthesia. Intraoperatively she received 8 units of red cell concentrate and 12 units of fresh frozen plasma. At the end of surgery she was fully awake and extubated. Shortly after extubation her oxygen saturation dropped (90%) and she developed dyspnea. A chest X-ray revealed bilateral diffuse pulmonary edema without cardiac enlargement. The patient was re-intubated and placed on respiratory support with positive end-expiratory pressure ventilation. Her pulmonary edema improved and she was extubated again at 20 hours after surgery. Antibodies to human leukocyte antigen were detected in serum from the patient and in serum samples of the freshly frozen donor plasma; a crossmatch test of the patient's lymphocytes and donor serum was positive. We believe that anti-leukocyte antibodies caused TRALI via an immune-mediated mechanism.

[A case of Vibrio vulnificus infection presenting with invagination].

A 73-year-old man with advanced lung cancer ate raw fish the day before being admitted to our hospital with severe abdominal pain, fever and vomiting. Soon afterward he fell into shock and disseminated intravenous coagulation. A CT scan revealed invagination and emergency surgery was performed. On the first day after surgery, Vibrio vulnificus was cultured from his ascites and blood. The infection was controlled by antibiotic treatment and he was discharged 23 days after the surgery. Vibrio vulnificus infection is an opportunistic infection that develops mostly in patients with liver cirrhosis within two days after eating raw seafood or having the injured skin exposed to sea water in the summer. Mortality is 70%, and more than half of these patients die within 72 hours of onset. Early diagnosis and treatment are very important. In addition, the public should be educated to protect immuno-compromised individuals from this infection.

Visual hallucinations on eye closure after orthopedic surgery under general anesthesia.

A 61-year-old woman suffering from rheumatoid arthritis without a contributory neurological, mental, or psychological history experienced visual hallucinations solely on eye closure after total hip arthroplasty under general anesthesia combined with epidural anesthesia. The visual hallucinations first appeared when she arose from sleep early on postoperative day 1, approximately 12 h after the end of surgery. Only on closing her eyes, she had a clear view of colored clothes, lace curtains, handbags, hats, and sofas, all of which were vivid, realistic, complex, of natural size, and in normal perspective without distortion and appeared independently and randomly in succession. The hallucinations disappeared when she opened her eyes even in the dark. The visual hallucinations gradually decreased as the days elapsed and they had entirely subsided on postoperative day 4. The level and content of her consciousness seemed entirely normal throughout her hospital course. Although postoperative visual hallucinations are not uncommon, they do not always show the closed-eye variation. The causes and underlying mechanisms of this type of visual hallucination remain to be elucidated.

[Anesthetic management of a patient with relapsing polychondritis].

A 71-year-old male patient with relapsing polychondritis was scheduled for elective sigmoidectomy. Relapsing chondritis often causes inflammation of the tracheal cartilages, leading to fragile trachea and bronchus. Preoperative evaluation with 3-dimensional computed tomography showed rightward tracheal shift and nearly 50% narrowing of the right bronchus during expiration phase. His trachea was intubated with fiberoptic-guided intubation under light sedation. General anesthesia was maintained with sevoflurane 2.0% and air 50% in oxygen under mechanical ventilation employing PEEP (5cmH2O). No respiratory complication occurred during general anesthesia. But he suffered pleural effusion and atelectasis on the post-surgical day 2. We should pay attention to 3-dimensional structure of the airway when we perform general anesthesia for a patient with relapsing chondritis.

Two cases of transient left ventricular apical ballooning syndrome associated with subarachnoid hemorrhage.

Electrocardiogram (ECG) abnormalities secondary to subarachnoid hemorrhage are well known, but the etiology remains unclear. Transient left ventricular apical ballooning syndrome is characterized by acute onset myocardial infarction-like symptoms, transient (reversible) cardiac dysfunction, and shapes resembling ampulla on left ventriculography. We managed general anesthesia for two patients with transient left ventricular apical ballooning and ECG abnormalities associated with subarachnoid hemorrhage. During anesthesia, their hemodynamic status was almost stable although their cardiac performance analyzed by transthoracic echocardiography and transesophageal cardiography was poor. Anesthetic management of this syndrome may be simplified if less cardiosuppressive anesthetic management is used. We recommend evaluating cardiac function with transthoracic echocardiography or transesophageal cardiography when an subarachnoid hemorrhage patient has ECG abnormalities.