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Objective: To assess the correlation between 2 clinical sedation scales and 2 electroencephalographic (EEG)-based monitors used during surgical procedures that required mild to moderate sedation.Patients and Methods: Patients scheduled for elective surgery participated in this Institutional review board-approved study from March 2003 to February 2004. Level of sedation was determined both clinically using the Ramsay and the Observer's Assessment of Alertness/Sedation scales and with 2 EEG measures (the Bispectral Index version XP [BIS XP] or the Patient State Analyzer [PSA 4000]). Correlation between these 2 measures of sedation were tested using nonparametric statistical tests.Results: The BIS XP monitor was used in 26 patients, and the PSA 4000 monitor was used in 24 patients. The Ramsay and Observer's Assessment of Alertness/Sedation scores correlated with each other (r = -0.96; P < .001) and with both the BIS XP (r = -0.89 and r = 0.91, respectively; P < .001) and the PSA 4000 (r = -0.80 and r = 0.80, respectively; P < .001) values. However, this correlation was strongest only at the extremes. Between the BIS XP and PSA 4000 values of 61 and 80, the clinical sedation scores varied greatly.Conclusion: On the basis of our results, these EEG-based monitors cannot reliably distinguish between light and deep sedation. [ABSTRACT FROM AUTHOR]

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Chronic unresolved inflammation plays a causal role in the development of advanced atherosclerosis, but the mechanisms that prevent resolution in atherosclerosis remain unclear. Here, we use targeted mass spectrometry to identify specialized pro-resolving lipid mediators (SPM) in histologically-defined stable and vulnerable regions of human carotid atherosclerotic plaques. The levels of SPMs, particularly resolvin D1 (RvD1), and the ratio of SPMs to pro-inflammatory leukotriene B 4 (LTB 4 ), are significantly decreased in the vulnerable regions. SPMs are also decreased in advanced plaques of fat-fed Ldlr -/- mice. Administration of RvD1 to these mice during plaque progression restores the RvD1:LTB 4 ratio to that of less advanced lesions and promotes plaque stability, including decreased lesional oxidative stress and necrosis, improved lesional efferocytosis, and thicker fibrous caps. These findings provide molecular support for the concept that defective inflammation resolution contributes to the formation of clinically dangerous plaques and offer a mechanistic rationale for SPM therapy to promote plaque stability.

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.

Background: Early cognitive dysfunction (eCD) is a subtle form of neurological injury observed in ∼25% of carotid endarterectomy (CEA) patients. Statin use is associated with a lower incidence of eCD in asymptomatic patients having CEA., Objective: To determine whether eCD status is associated with worse long-term survival in patients taking and not taking statins., Methods: This is a post hoc analysis of a prospective observational study of 585 CEA patients. Patients were evaluated with a battery of neuropsychometric tests before and after surgery. Survival was compared for patients with and without eCD stratifying by statin use. At enrollment, 366 patients were on statins and 219 were not. Survival was assessed by using Kaplan-Meier methods and multivariable Cox proportional hazards models., Results: Age ≥75 years (P = .003), diabetes mellitus (P < .001), cardiac disease (P = .02), and statin use (P = .014) are significantly associated with survival univariately (P < .05) by use of the log-rank test. By Cox proportional hazards model, eCD status and survival adjusting for univariate factors within statin and nonstatin use groups suggested a significant effect by association of eCD on survival within patients not taking statin (hazard ratio, 1.61; 95% confidence interval, 1.09-2.40; P = .018), and no significant effect of eCD on survival within patients taking statin (hazard ratio, 0.98; 95% confidence interval, 0.59-1.66; P = .95)., Conclusion: eCD is associated with shorter survival in patients not taking statins. This finding validates eCD as an important neurological outcome and suggests that eCD is a surrogate measure for overall health, comorbidity, and vulnerability to neurological insult., Abbreviations: aHR, adjusted hazards ratiosCEA, carotid endarterectomyCI, confidence intervalDM, diabetes mellituseCD, early cognitive dysfunctionNDI, National Death IndexNLR, neutrophil/lymphocyte ratioSD, standard deviationSEM, standard error of the mean.

Object: Neurocognitive performance is used to assess multiple cognitive domains, including motor coordination, before and after carotid endarterectomy (CEA). Although gross motor strength is impaired with ischemia of large cortical areas or of the internal capsule, the authors hypothesize that patients undergoing CEA demonstrate significant motor deficits of hand coordination contralateral to the operative side, which is more clearly manifest in the nondominant hand than in the dominant hand with ischemia of smaller cortical areas., Methods: The neurocognitive performance of 374 patients was evaluated with a battery of neuropsychometric tests. Both asymptomatic and symptomatic patients undergoing CEA were included. The authors evaluated the patients' dominant and nondominant hand performance on the Grooved Pegboard test, a test of hand coordination, to demonstrate their functional laterality. Neurocognitive dysfunction was evaluated as the difference in performance before and after CEA according to group-rate and event-rate analyses. The z scores were generated for all tests using a reference group of patients who were having simple spine surgery. Dominant and nondominant motor coordination functions were evaluated as raw scores and as calculated z scores., Results: According to event-rate analysis, significantly more patients undergoing CEA of the opposite carotid artery demonstrated nondominant than dominant hand deficits of coordination (41.2% vs 26.4%, respectively, p = 0.02). Similarly, according to group-rate analysis, in patients undergoing CEA of the opposite carotid artery, raw difference scores from the Grooved Pegboard test reflected greater nondominant than dominant hand deficits of coordination (21.0 ± 54.4 vs 9.7 ± 37.0, respectively, p = 0.02)., Conclusions: Patients undergoing CEA of the opposite carotid artery are more likely to demonstrate nondominant than dominant hand deficits of coordination because of greater dexterity in the dominant hand before surgery.

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.

Object: Approximately 25% of patients exhibit cognitive dysfunction 24 hours after carotid endarterectomy (CEA). One of the purported mechanisms of early cognitive dysfunction (eCD) is hypoperfusion due to inadequate collateral circulation during cross-clamping of the carotid artery. The authors assessed whether poor collateral circulation within the circle of Willis, as determined by preoperative CT angiography (CTA) or MR angiography (MRA), could predict eCD., Methods: Patients who underwent CEA after preoperative MRA or CTA imaging and full neuropsychometric evaluation were included in this study (n = 42); 4 patients were excluded due to intraoperative electroencephalographic changes and subsequent shunt placement. Thirty-eight patients were included in the statistical analyses. Patients were stratified according to posterior communicating artery (PCoA) status (radiographic visualization of at least 1 PCoA vs of no PCoAs). Variables with p < 0.20 in univariate analyses were included in a stepwise multivariate logistic regression model to identify predictors of eCD after CEA., Results: Overall, 23.7% of patients exhibited eCD. In the final multivariate logistic regression model, radiographic absence of both PCoAs was the only independent predictor of eCD (OR 9.64, 95% CI 1.43-64.92, p = 0.02)., Conclusions: The absence of both PCoAs on preoperative radiographic imaging is predictive of eCD after CEA. This finding supports the evidence for an underlying ischemic etiology of eCD. Larger studies are justified to verify the findings of this study. Clinical trial registration no.: NCT00597883 ( http://www.clinicaltrials.gov ).

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., (© 2014 American Heart Association, Inc.)

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.

Background: Multilevel spinal decompressions and fusions often require long anesthetic and operative times, which may result in airway edema and prolonged postoperative intubation. Delayed extubation can lead to bronchopulmonary infections and other complications. This study analyzed which factors correlated with the decision to delay extubation after multilevel spine surgery., Methods: We reviewed the records of 289 patients who underwent multilevel spine surgery lasting ≥8 hours in the prone position from 2006 to 2012. Variables hypothesized to affect the decision of the anesthesiologist to delay extubation at the end of the surgery were collected. These included preoperative factors (age, sex, ASA class, history of obstructive sleep apnea, BMI, previous spine surgery, current cervical surgery, anterior in addition to posterior spine surgery, emergency surgery) and intraoperative factors (difficult intubation, number of surgical levels, case time, estimated blood loss, fluid and blood administration, attending handoff and resident handoff, and case end time). We also compared the incidence of pulmonary postoperative complications between patients extubated at the end of the case to patients who had a delayed extubation., Results: A total of 126 patients (44%) were kept intubated after multilevel spine surgery. Multiple linear regression analysis showed factors that correlated with prolonged intubation which included age, ASA class, procedure duration, extent of surgery, total crystalloid volume administered, total blood volume administered, and the case end time. Patients who had a delayed extubation had a 3-fold higher rate of postoperative pneumonia., Conclusions: Our study found that age, ASA class, procedure duration, extent of surgery, and total crystalloid and blood volume administered correlate with the decision to delay extubation in multilevel prone spine surgery. It also finds that the time the case ends is an independent variable that correlates with the decision not to extubate at the end of a long multilevel spinal surgery. The incidence of postoperative pneumonia is higher in patients who had a delayed extubation after surgery.

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., (Copyright © 2014 Society for Vascular Surgery. All rights reserved.)

Transcranial Doppler (TCD) is a useful monitor that can be utilized during carotid endarterectomy (CEA). Cognitive dysfunction is a subtler and more common form of neurologic injury than stroke. We aimed to determine whether reduced middle cerebral artery (MCA) mean velocity (MV) predicts cognitive dysfunction and if so, whether a threshold of increased risk of cognitive dysfunction can be identified. One hundred twenty-four CEA patients were included in this observational study and neuropsychometrically evaluated preoperatively and 24 hours postoperatively. MCA-MV was measured by TCD and percentage of baseline during cross-clamp was calculated (MV(cross-clamp)/MV(baseline)). Patients with cognitive dysfunction had significantly lower MV during cross-clamp than those without cognitive dysfunction (33.1 ± 13.7 cm/s versus 39.6 ± 16.0 cm/s, p=0.02). In the final multivariate model, each percent reduction in MV was significantly associated with greater risk of cognitive dysfunction (odds ratio [OR]: 0.05 [95% confidence interval {CI} 0.01-0.23], p < 0.001) while statin use was associated with lower risk (OR: 0.33 [95% CI 0.12-0.92], p = 0.03). Using receiver operator characteristic curve analysis, the Youden index identified 72% of baseline MV during cross-clamp as the cutoff of maximum discrimination. Significantly more patients with MV < 72% of baseline during cross-clamp exhibited cognitive dysfunction than patients with MV ≥ 72% of baseline (74.1% versus 27.1%, p < 0.001). Reduced MCA-MV during cross-clamp is a predictor of cognitive dysfunction exhibited 24 hours after CEA. MCA-MV reduced to <72% of baseline, or a ≥28% reduction from baseline, is the threshold most strongly associated with increased risk of cognitive dysfunction. These observations should be considered by all clinicians that utilize intraoperative monitoring for CEA., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: A common practice during cross-clamp of carotid endarterectomy (CEA) is to manage mean arterial pressure (MAP) above baseline to optimize the collateral cerebral blood flow and reduce the risk of ischemic stroke., Objective: To determine whether MAP management ≥20% above baseline during cross-clamp is associated with lower risk of early cognitive dysfunction, a subtler form of neurological injury than stroke., Methods: One hundred eighty-three patients undergoing CEA were enrolled in this ad hoc study. All patients had radial arterial catheters placed before the induction of general anesthesia. MAP was managed at the discretion of the anesthesiologist. All patients were evaluated with a battery of neuropsychometric tests preoperatively and 24 hours postoperatively., Results: Overall, 28.4% of CEA patients exhibited early cognitive dysfunction (eCD). Significantly fewer patients with MAP ≥20% above baseline during cross-clamp exhibited eCD than those managed <20% above (11.6% vs 38.6%, P < .001). In a multivariate logistic regression model, MAP ≥20% above baseline during the cross-clamp period was associated with significantly lower risk of eCD (odds ratio [OR], 0.18 [0.07-0.40], P < .001), whereas diabetes mellitus (OR, 2.73 [1.14-6.61], P = .03) and each additional year of education (OR, 1.19 [1.06-1.34], P = .003) were associated with significantly higher risk of eCD., Conclusion: The observations of this study suggest that MAP management ≥20% above baseline during cross-clamp of the carotid artery may be associated with lower risk of eCD after CEA. More prospective work is necessary to determine whether MAP ≥20% above baseline during cross-clamp can improve the safety of this commonly performed procedure.

Approximately 25% of patients undergoing carotid endarterectomy (CEA) exhibit cognitive dysfunction (CD) 1 day and 1 month after CEA. The apolipoprotein E (apoE)-ε4 polymorphism has been previously identified as a robust independent risk factor for CD 1 month after CEA. We aimed to determine whether the apoE-ε4 polymorphism is also an independent risk factor for CD as early as 1 day after CEA and to confirm the previous findings at 1 month. Patients undergoing elective CEA (n=411) were enrolled with written informed consent in this follow-up observational study. CD was evaluated via an extensive neuropsychometric battery. apoE-ε4 carriers exhibited significantly more CD 1 day (30.1% versus 17.9%, p=0.01) and 1 month (25.7% versus 9.8%, p=0.001) after CEA compared to non-carriers. Multivariate regression models were generated to determine independent predictors of CD. At 1 day, apoE-ε4 was significantly associated with higher risk of CD (odds ratio [OR]: 2.24 [95% confidence interval 1.29-3.84], p=0.004), while statin use was significantly associated with lower risk (OR: 0.40 [0.24-0.67], p<0.001). At 1 month, apoE-ε4 was significantly associated with higher risk of CD (OR: 3.14 [1.53-6.38], p=0.002), while symptomatic status was significantly associated with lower risk (OR: 0.45 [0.20-0.94], p=0.03). The apoE-ε4 polymorphism is an independent risk factor for CD as early as 1 day after CEA and is confirmed to be an independent risk factor for CD at 1 month as well., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Object: Transcranial Doppler (TCD) is frequently used to evaluate peripheral cerebral resistance and cerebral blood flow (CBF) in the middle cerebral artery prior to and during carotid endarterectomy (CEA). Patients with symptomatic carotid artery stenosis may have reduced peripheral cerebral resistance to compensate for inadequate CBF. The authors aim to determine whether symptomatic patients with reduced peripheral cerebral resistance prior to CEA demonstrate increased CBF and cognitive improvement as early as 1 day after CEA., Methods: Fifty-three patients with symptomatic CEA were included in this observational study. All patients underwent neuropsychometric evaluation 24 hours or less preoperatively and 1 day postoperatively. The MCA was evaluated using TCD for CBF mean velocity (MV) and pulsatility index (PI). Pulsatility index ≤ 0.80 was used as a cutoff for reduced peripheral cerebral resistance., Results: Significantly more patients with baseline PI ≤ 0.80 exhibited cognitive improvement 1 day after CEA than those with PI > 0.80 (35.0% vs 6.1%, p = 0.007). Patients with cognitive improvement had a significantly greater increase in CBF MV than patients without cognitive improvement (13.4 ± 17.1 cm/sec vs 4.3 ± 9.9 cm/sec, p = 0.03). In multivariate regression model, a baseline PI ≤ 0.80 was significantly associated with increased odds of cognitive improvement (OR 7.32 [1.40-59.49], p = 0.02)., Conclusions: Symptomatic CEA patients with reduced peripheral cerebral resistance, measured as PI ≤ 0.80, are likely to have increased CBF and improved cognitive performance as early as 1 day after CEA for symptomatic carotid artery stenosis. Revascularization in this cohort may afford benefits beyond prevention of future stroke. Clinical trial registration no: NCT00597883 ( ClinicalTrials.gov ).

Background: Phosphodiesterase 4D (PDE4D), through the regulation of cyclic AMP, modulates inflammation and other processes that affect atherosclerosis and stroke. A PDE4D polymorphism, single-nucleotide polymorphism (SNP) 83 (rs966221), is associated with ischemic stroke. The association of SNP 83 with postoperative cognitive dysfunction has never been investigated., Objective: To determine whether SNP 83 is associated with cognitive dysfunction 1 day and 1 month following carotid endarterectomy (CEA)., Methods: Three hundred fourteen patients with high-grade carotid stenosis scheduled for CEA consented to participate in this single-center cohort study of cognitive dysfunction., Results: Patients with the C/C genotype of SNP 83 exhibited significantly more cognitive dysfunction at 1 day (29.7%) than the C/T (15.8%, P = .008) and T/T (12.7%, P = .01) genotypes. In a multivariate logistic regression model, C/T and T/T genotypes were both associated with significantly decreased odds of cognitive dysfunction compared with the C/C genotype (odds ratio, 0.45 [0.24-0.83], P = .01 and odds ratio, 0.33 [0.12-0.77], P = .02). There were no significant associations at 1 month., Conclusion: The C/C genotype of SNP 83 is significantly associated with the highest incidence of cognitive dysfunction 1 day following CEA in comparison with the C/T and T/T genotypes. This PDE4D genotype may lead to accelerated cyclic AMP degradation and subsequently elevated inflammation 1 day after CEA. These observations, in conjunction with previous studies, suggest that elevated inflammatory states may be partially responsible for the development of cognitive dysfunction after CEA, but more investigation is required.

Objective: Type 2 diabetic patients have a high incidence of cerebrovascular disease, elevated inflammation, and high risk of developing cognitive dysfunction following carotid endarterectomy (CEA). To elucidate the relationship between inflammation and the risk of cognitive dysfunction in type 2 diabetic patients, we aim to determine whether elevated levels of systemic inflammatory markers are associated with cognitive dysfunction 1 day after CEA., Research Design and Methods: One hundred fifteen type 2 diabetic CEA patients and 156 reference surgical patients were recruited with written informed consent in this single-center cohort study. All patients were evaluated with an extensive battery of neuropsychometric tests. Preoperative monocyte counts, HbA1c, C-reactive protein (CRP), intercellular adhesion molecule 1, and matrix metalloproteinase 9 activity levels were obtained., Results: In a multivariate logistic regression model constructed to identify predictors of cognitive dysfunction in type 2 diabetic CEA patients, each unit of monocyte counts (odds ratio [OR] 1.76 [95% CI 1.17-2.93]; P=0.005) and CRP (OR 1.17 [1.10-1.29]; P<0.001) was significantly associated with higher odds of developing cognitive dysfunction 1 day after CEA in type 2 diabetic patients., Conclusions: Type 2 diabetic patients with elevated levels of preoperative systemic inflammatory markers exhibit more cognitive dysfunction 1 day after CEA. These observations have implications for the preoperative medical management of this high-risk group of surgical patients undergoing carotid revascularization with CEA.

Object: The role of genetic polymorphisms in the neurological outcome of patients after carotid endarterectomy (CEA) remains unclear. There are single nucleotide polymorphisms (SNPs) that predispose patients to postoperative cognitive dysfunction (CD). We aim to assess the predictability of three complement cascade-related SNPs for CD in patients having CEAs., Methods: In 252 patients undergoing CEA, genotyping was performed for the following polymorphisms: complement component 5 (C5) rs17611, mannose-binding lectin 2 (MBL2) rs7096206, and complement factor H (CFH) rs1061170. Differences among genotypes were analyzed via the chi-square test. Patients were evaluated with a neuropsychometric battery for CD 1 day and 1 month after CEA. A multiple logistic regression model was created. All variables with univariate p < 0.20 were included in the final model., Results: The C5 genotypes A/G (OR 0.26, 95% CI 0.11-0.60, p = 0.002) and G/G (OR 0.22, 95% CI 0.09-0.52, p < 0.001) were significantly associated with lower odds of exhibiting CD at 1 day after CEA compared with A/A. The CFH genotypes C/T (OR 3.37, 95% CI 1.69-6.92, p < 0.001) and C/C (OR 3.67, 95% CI 1.30-10.06, p = 0.012) were significantly associated with higher odds of exhibiting CD at 1 day after CEA compared with T/T. Statin use was also significantly associated with lower odds of exhibiting CD at 1 day after CEA (OR 0.43, 95% CI 0.22-0.84, p = 0.01). No SNPs were significantly associated with CD at 1 month after CEA., Conclusions: The presence of a deleterious allele in the C5 and CFH SNPs may predispose patients to exhibit CD after CEA. This finding supports previous data demonstrating that the complement cascade system may play an important role in the development of CD. These findings warrant further investigation.

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.

Our previous work demonstrates that asymptomatic carotid endarterectomy (CEA) patients demonstrate less perioperative neurologic injury, defined as stroke and early cognitive dysfunction (eCD) observed within 24hr of CEA, when taking statins pre-operatively. This study examines whether the incidence of eCD observed 24hr after asymptomatic CEA varies as a function of statin type or dose. Patients with asymptomatic carotid stenosis scheduled for CEA consented to participate in an observational IRB-approved study (N=324). Patients were evaluated with an extensive battery of neuropsychometric tests pre-operatively and 24hr post-operatively. Of the 324 consented patients, 200 were taking statins. Patients taking pravastatin and fluvastatin exhibited no eCD, while patients taking lovastatin (17.7%) and rosuvastatin (16.7%) exhibited incidences of eCD similar to those not taking statins (20.2%). Patients taking simvastatin exhibited a significantly lower incidence of eCD than those taking atorvastatin (3.0% vs. 16.0%, P=0.005). Patients taking a maximal dose of any statin exhibited a significantly lower incidence of eCD than patients taking sub-maximal doses (2.7% vs. 15.9%, P=0.002). These observations suggest that the incidence of eCD may in fact vary as a function of statin type and that maximal doses may be the optimal dose for patients undergoing CEA. This variation may be due to the physico-chemical properties of statins such as lipophilicity, molecular size, and blood brain barrier penetrability. These findings should be used to inspire randomized prospective work to determine the safety, feasibility, and outcomes of optimizing statin use prior to CEA.

Stroke remains a significant risk of carotid revascularization for atherosclerotic disease. Emboli generated at the time of treatment either using endarterectomy or stent-angioplasty may progress with blood flow and lodge in brain arteries. Recently, the use of protection devices to trap emboli created at the time of revascularization has helped to establish a role for stent-supported angioplasty compared with endarterectomy. Several devices have been developed to reduce or detect emboli that may be dislodged during carotid artery stenting to treat carotid artery stenosis. A significant challenge in assessing the efficacy of these devices is precisely determining when emboli are dislodged in real time. To address this challenge, we devised a method of simultaneously recording fluoroscopic images, transcranial Doppler data, vital signs, and digital video of the patient/physician. This method permits accurate causative analysis and allows procedural events to be precisely correlated to embolic events in real time.

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 Education–approved 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.

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.

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.

Approximately 25% of elderly patients scheduled for carotid endarterectomy (CEA) develop post-operative cognitive dysfunction (CD). We tested the hypothesis that the plasma levels of matrix metalloproteinase 9 (MMP-9) are predictive of moderate to severe CD after CEA. A total of 73 patients were prospectively enrolled in this Institutional Review Board-approved study. Plasma samples were obtained at baseline and day 1 post-surgery. We measured the plasma concentrations of both MMP-9 and its inhibitor, tissue inhibitor of metalloproteinases 1 (TIMP-1). We estimated the MMP-9 activity by calculating the MMP-9:TIMP-1 ratio. The cognitive performance day 1 post-surgery was quantified with z-scores, using a control group who were undergoing spinal surgery. The criteria used to define CD was performance of >or=1.5 standard deviations worse than the control group; approximately 19% of eligible patients developed CD. Compared to patients without CD, this group had both higher total (81.66+/-12.25 ng/mL versus [vs.] 43.18+/-4.44 ng/mL, p=0.005) and activity (0.88+/-0.24 ng/mL vs. 0.54+/-0.06 ng/mL, p=0.003) MMP-9 levels at baseline. All of the results were adjusted for age, diabetes and neurovascular symptoms., ((c) 2009 Elsevier Ltd. All rights reserved.)

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.

Elderly patients have medical and psychological problems affecting all major organ systems. These problems may alter the pharmacokinetics and/or pharmacodynamics of medications, or expose previous neurologic deficits simply as a result of sedation. Delayed arousal, therefore, may arise from structural problems that are pre-existent or new, or metabolic or functional disorders such as convulsive or nonconvulsive seizures. Determining the cause of delayed arousal may require clinical, chemical, and structural tests. Structural problems that impair consciousness arise from a small number of focal lesions to specific areas of the central nervous system, or from pathology affecting the cerebrum. In general, focal or multifocal lesions can be identified by computerized tomography, or diffusion-weighted imaging. An algorithm is presented that outlines a workup for an elderly patient with delayed arousal.

Objective: Approximately 25% of patients with carotid artery stenosis treated with carotid endarterectomy develop cognitive dysfunction (CD) between 1 day and 1 month after surgery compared with a control group. We hypothesized that patients with carotid artery stenosis treated with carotid artery stenting (CAS) performed under cerebral embolic protection also develop CD at similar time points compared with a control group., Methods: Twenty-four patients scheduled for elective CAS were enrolled in a prospective institutional review board-approved study to evaluate cognitive function with a battery of 6 neuropsychometric tests before, and 1 day and 1 month after, CAS. Test performance was compared with 23 patients undergoing coronary artery procedures (control group). The mean and standard deviation of the difference scores in the control group were used to generate Z scores. We used a previously described point system to transform negative Z scores into injury points for each neuropsychometric test. Global performance is presented as average deficit score (sum of injury points divided by the number of completed tests). All patients underwent the procedures with mild sedation. Results were analyzed in 2 ways: group-rate and event-rate analysis. Outcome was dichotomized by defining moderate to severe CD as average deficit score at least 1.5 standard deviations worse than the control group. Fisher tests and multivariate logistic regression models were used to analyze group performance., Results: Control patients tended to be younger and had a lower incidence of stroke or previous transient ischemic attack. One day after surgery, 41% of patients (10 of 24) treated with CAS developed moderate to severe CD (P = 0.0422). Average deficit score was also significantly higher in the CAS group at 1 day (P = 0.0265). These differences were independent of age and history of stroke/transient ischemic attack. Interestingly, we found that the absence of oral statin medication may increase the probability of CD. By 1 month, 9% of patients (1 of 11) treated with CAS presented with CD. Other patients were lost to follow-up., Conclusion: CAS is associated with a decline in cognitive performance that is at least moderate 1 day after surgery.

Background: Intracranial artery stenosis is assumed to represent atherosclerotic plaque. Catheter cerebral arteriography shows that intracranial stenosis may progress, regress, or remain unchanged. It is counterintuitive that atherosclerotic plaque should spontaneously regress, raising questions about the composition of intracranial stenoses. Little is known about this disease entity in vivo. We provide the first demonstration of in vivo atherosclerotic plaque with intraplaque hemorrhage using intravascular ultrasound (IVUS)., Case Description: A 35-year-old man with multiple vascular risk factors presented with recurrent stroke failing medical therapy. Imaging demonstrated left internal carotid artery occlusion, severe intracranial right internal carotid artery stenosis, and cerebral perfusion failure. Cerebral arteriography with IVUS confirmed 85% stenosis of the petrous right carotid artery due to atherosclerotic plaque with intraplaque hemorrhage. Intracranial stent-supported angioplasty was performed with IRB approval. The patient recovered without complication., Conclusions: This case supports the premise that symptomatic intracranial stenosis can be caused by atherosclerotic plaque complicated by intraplaque hemorrhage similar to coronary artery plaque. IVUS provides additional characteristics that define intracranial atherosclerosis and high-risk features. To our knowledge, this is the first report of stroke due to unstable atherosclerotic plaque with intraplaque hemorrhage in vivo.

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.

Takotsubo cardiomyopathy is a form of transient, reversible left ventricular dysfunction that can mimic an acute coronary event. However, cardiac catheterization often reveals normal coronary arteries. Patients are often postmenopausal women who experience acute physical or emotional distress. The prognosis for this entity is quite favorable. In this report, we present three cases of Takotsubo cardiomyopathy in patients having procedures involving anesthesia. Each case illustrates a different etiology for the syndrome: Patient, procedure, and anesthetic management.

Background: Previous studies have demonstrated that elevated pre-operative monocyte count is an independent predictor of acute neurocognitive decline following carotid endarterectomy (CEA). Monocyte chemoattractant protein-1 (MCP-1), secreted by human endothelial and monocyte-like cells, is a potent mediator of inflammation and mononuclear cell trafficking. This study examines the relationship between peri-operative serum MCP-1 elevation and post-operative neurocognitive injury following CEA., Methods: Fifty-two patients undergoing CEA and 67 lumbar laminectomy (LL) controls were administered a battery of five neuropsychological tests pre-operatively and on post-operative day 1 (POD 1). Change in individual test scores from baseline to POD 1 were converted into Z-score and used to develop a point system quantifying the degree of neurocognitive dysfunction relative to change within the LL group. Neurocognitive injury following CEA was defined as a score greater than 2 standard deviations above mean total deficit scores of LL controls. Serum MCP-1 levels were measured pre-operatively and on POD 1 by enzyme-linked immunosorbent assay., Findings: Mean percent MCP-1 elevation was higher for the 13 injured CEA patients (147.7 +/- 32.4%) in our cohort compared to 39 age- and sex-matched uninjured CEA patients (76.0 +/- 16.5%). In unconditional multivariate logistic regression analysis, percent elevation in serum MCP-1 level was associated with neurocognitive injury one day after CEA (OR = 2.19, 95% CI = 1.13-4.26, P = 0.021, for a 100% elevation from pre-operative levels)., Conclusions: Peri-operative elevations in serum MCP-1 levels correlate with acute neurocognitive dysfunction following CEA. These data implicate an inflammatory mechanism in the pathogenesis of Ischaemic neurocognitive decline.

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.

Objective: Deep hypothermic circulatory arrest is a useful adjunct for treating complex aneurysms. Decreased cerebral metabolism and resultant ischemic tolerance create an environment suitable for devascularizing high-risk lesions. However, the advent of modern imaging modalities, innovative cerebral revascularization strategies, and the emergence of endovascular stenting and coiling limit the number of aneurysms requiring this surgical intervention. We present 66 patients with intracranial aneurysms who underwent surgical clipping under deep hypothermic arrest and attempt to identify patients well-suited for this procedure., Methods: This study was conducted during a 15-year period and examined patients with aneurysms of the anterior and posterior cerebral circulation. Demographics, aneurysm characteristics, and surgical factors were evaluated as predictors of functional outcome., Results: Patient age and the duration of cardiac arrest were independent predictors of early clinical outcome (P < 0.05). Our experience suggests that the ideal patient is younger than 60 years old and harbors few medical comorbidities. Individuals with large aneurysms of the anterior communicating artery, internal carotid artery bifurcation, posterior inferior cerebellar artery, midbasilar, or vertebral arteries and with an absence of thrombosis and calcium may be most likely to experience favorable outcomes. Circulatory arrest should not exceed 30 minutes. Postoperative computed tomographic scanning and timely anesthetic emergence allow for early detection of hemorrhage. Complete dissection of the aneurysm before bypass and avoiding extreme hypothermia yield a low incidence of life-threatening postoperative hematomas., Conclusion: Hypothermic circulatory arrest is a useful technique for neuroprotection during the clipping of complex cerebral aneurysms. This procedure, however, has several associated risks. Patient factors, pathoanatomic characteristics, and surgical parameters may be used to guide patient selection.

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.

Objective: Deep hypothermic circulatory arrest is a useful adjunct for treating complex aneurysms. Decreased cerebral metabolism and resultant ischemic tolerance create an environment suitable for devascularizing high-risk lesions. However, the advent of modern imaging modalities, innovative cerebral revascularization strategies, and the emergence of endovascular stenting and coiling limit the number of aneurysms requiring this surgical intervention. We present 66 patients with intracranial aneurysms who underwent surgical clipping under deep hypothermic arrest and attempt to identify patients well-suited for this procedure., Methods: This study was conducted during a 15-year period and examined patients with aneurysms of the anterior and posterior cerebral circulation. Demographics, aneurysm characteristics, and surgical factors were evaluated as predictors of functional outcome., Results: Patient age and the duration of cardiac arrest were independent predictors of early clinical outcome (P < 0.05). Our experience suggests that the ideal patient is younger than 60 years old and harbors few medical comorbidities. Individuals with large aneurysms of the anterior communicating artery, internal carotid artery bifurcation, posterior inferior cerebellar artery, midbasilar, or vertebral arteries and with an absence of thrombosis and calcium may be most likely to experience favorable outcomes. Circulatory arrest should not exceed 30 minutes. Postoperative computed tomographic scanning and timely anesthetic emergence allow for early detection of hemorrhage. Complete dissection of the aneurysm before bypass and avoiding extreme hypothermia yield a low incidence of life-threatening postoperative hematomas., Conclusion: Hypothermic circulatory arrest is a useful technique for neuroprotection during the clipping of complex cerebral aneurysms. This procedure, however, has several associated risks. Patient factors, pathoanatomic characteristics, and surgical parameters may be used to guide patient selection.