The American Journal of Surgery
Volume 197, Issue 1 , Pages 55-63 , January 2009

Intraoperative cerebral high-intensity transient signals and postoperative cognitive function: a systematic review

  • Kristin K. Martin, D.O., M.S.

      Affiliations

    • Plaza Medical Center, General Surgery Residency, Fort Worth, TX, USA
    • University of North Texas Health Sciences Center, Fort Worth, TX, USA
  • ,
  • Jeremy B. Wigginton, B.S.

      Affiliations

    • University of Mississippi Medical School, Jackson, MS, USA
  • ,
  • Viken L. Babikian, M.D.

      Affiliations

    • Department of Neurology, VA Boston Healthcare System, Boston, MA, USA
    • Boston University School of Medicine, Boston, MA, USA
  • ,
  • Val E. Pochay

      Affiliations

    • Department of Neurology, VA Boston Healthcare System, Boston, MA, USA
  • ,
  • Michael D. Crittenden, M.D.

      Affiliations

    • Division of Cardiac Surgery, VA Boston Healthcare System, Boston, MA, USA
  • ,
  • James L. Rudolph, M.D., S.M.

      Affiliations

    • Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, JP-182, 150 South Huntington Ave., Boston, MA 02130, USA
    • Harvard Medical School, Boston, MA, USA
    • Corresponding Author InformationCorresponding author. Tel.: +1-857 364-6812; fax: +1-857 364-4544

Received 26 September 2007 ,Revised 6 December 2007

References 

  1. Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001;344:395–402
  2. van Dijk D, Jansen EW, Hijman R, et al. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMA. 2002;287:1405–1412
  3. Russell D. Cerebral microemboli and cognitive impairment. J Neurol Sci. 2002;203–204:211–4
  4. Borger MA, Peniston CM, Weisel RD, et al. Neuropsychologic impairment after coronary bypass surgery: effect of gaseous microemboli during perfusionist interventions. J Thorac Cardiovasc Surg. 2001;121:743–749
  5. Blauth CI. Macroemboli and microemboli during cardiopulmonary bypass. Ann Thorac Surg. 1995;59:1300–1303
  6. Newman SP, Harrison MJ. Coronary-artery bypass surgery and the brain: persisting concerns. Lancet Neurol. 2002;1:119–125
  7. Aly A, Babikian VL, Barest G, et al. Brain microembolism. J Neuroimaging. 2003;13:140–146
  8. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326–343
  9. Stygall J, Newman SP, Fitzgerald G, et al. Cognitive change 5 years after coronary artery bypass surgery. Health Psychol. 2003;22:579–586
  10. Diegeler A, Hirsch R, Schneider F, et al. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg. 2000;69:1162–1166
  11. Bowles BJ, Lee JD, Dang CR, et al. Coronary artery bypass performed without the use of cardiopulmonary bypass is associated with reduced cerebral microemboli and improved clinical results. Chest. 2001;119:25–30
  12. Wang D, Wu X, Li J, et al. The effect of lidocaine on early postoperative cognitive dysfunction after coronary artery bypass surgery. Anesth Analg. 2002;95:1134–1141
  13. Motallebzadeh R, Bland JM, Markus HS, et al. Neurocognitive function and cerebral emboli: randomized study of on-pump versus off-pump coronary artery bypass surgery. Ann Thorac Surg. 2007;83:475–482
  14. Whitaker DC, Newman SP, Stygall J, et al. The effect of leucocyte-depleting arterial line filters on cerebral microemboli and neuropsychological outcome following coronary artery bypass surgery. Eur J Cardiothorac Surg. 2004;25:267–274
  15. Whitaker D, Stygall J, Harrison M, et al. Relationship between white cell count, neuropsychologic outcome, and microemboli in 161 patients undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2006;131:1358–1363
  16. Hammon JW, Stump DA, Kon ND, et al. Risk factors and solutions for the development of neurobehavioral changes after coronary artery bypass grafting. Ann Thorac Surg. 1997;63:1613–1618
  17. Gaunt ME, Martin PJ, Smith JL, et al. Clinical relevance of intraoperative embolization detected by transcranial Doppler ultrasonography during carotid endarterectomy: a prospective study of 100 patients. Br J Surg. 1994;81:1435–1439
  18. Spencer MP. Transcranial Doppler monitoring and causes of stroke from carotid endarterectomy. Stroke. 1997;28:685–691
  19. Ackerstaff RG, Moons KG, van de Vlasakker CJ, et al. Association of intraoperative transcranial doppler monitoring variables with stroke from carotid endarterectomy. Stroke. 2000;31:1817–1823
  20. Muller M, Reiche W, Langenscheidt P, et al. Ischemia after carotid endarterectomy: comparison between transcranial Doppler sonography and diffusion-weighted MR imaging. AJNR Am J Neuroradiol. 2000;21:47–54
  21. Heyer EJ, Sharma R, Rampersad A, et al. A controlled prospective study of neuropsychological dysfunction following carotid endarterectomy. Arch Neurol. 2002;59:217–222
  22. Heyer EJ, Adams DC, Solomon RA, et al. Neuropsychometric changes in patients after carotid endarterectomy. Stroke. 1998;29:1110–1115
  23. Babikian VL, Cantelmo NL. Cerebrovascular monitoring during carotid endarterectomy. Stroke. 2000;31:1799–1801
  24. Stork JL, Levi CR, Chambers BR, et al. Possible determinants of early microembolism after carotid endarterectomy. Stroke. 2002;33:2082–2085
  25. Crawley F, Stygall J, Lunn S, et al. Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke. 2000;31:1329–1334
  26. Patterson BM, Healey JH, Cornell CN, et al. Cardiac arrest during hip arthroplasty with a cemented long-stem component (A report of seven cases). J Bone Joint Surg Am. 1991;73:271–277
  27. Colonna DM, Kilgus D, Brown W, et al. Acute brain fat embolization occurring after total hip arthroplasty in the absence of a patent foramen ovale. Anesthesiology. 2002;96:1027–1029
  28. Yeon HB, Ramappa A, Landzberg MJ, et al. Paradoxic cerebral embolism after cemented knee arthroplasty: a report of 2 cases and prophylactic option for subsequent arthroplasty. J Arthroplasty. 2003;18:113–120
  29. Weiss SJ, Cheung AT, Stecker MM, et al. Fatal paradoxical cerebral embolization during bilateral knee arthroplasty. Anesthesiology. 1996;84:721–723
  30. Sulek CA, Davies LK, Enneking FK, et al. Cerebral microembolism diagnosed by transcranial Doppler during total knee arthroplasty: correlation with transesophageal echocardiography. Anesthesiology. 1999;91:672–676
  31. Pell AC, Christie J, Keating JF, et al. The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing (A study of 24 patients with femoral and tibial fractures). J Bone Joint Surg Br. 1993;75:921–925
  32. Christie J, Burnett R, Potts HR, et al. Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br. 1994;76:409–412
  33. Rodriguez RA, Letts M, Jarvis J, et al. Cerebral microembolization during pediatric scoliosis surgery: a transcranial doppler study. J Pediatr Orthop. 2001;21:532–536
  34. Droste DW, Kuhne K, Schaefer RM, et al. Detection of microemboli in the subclavian vein of patients undergoing haemodialysis and haemodiafiltration using pulsed Doppler ultrasound. Nephrol Dial Transplant. 2002;17:462–466
  35. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study (ISPOCD investigators). International Study of Post-Operative Cognitive Dysfunction (Lancet). 1998;351:857–861
  36. Rodriguez RA, Tellier A, Grabowski J, et al. Cognitive dysfunction after total knee arthroplasty: effects of intraoperative cerebral embolization and postoperative complications. J Arthroplasty. 2005;20:763–771
  37. Koch S, Forteza A, Lavernia C, et al. Cerebral fat microembolism and cognitive decline after hip and knee replacement. Stroke. 2007;38:1079–1081
  38. Abraham P, Carter D, Millot JR, et al. Prolonged asymptomatic micro-embolism after hip or knee arthroplasty. J Bone Joint Surg Br. 1997;79:269–272
  39. Ringelstein EB, Droste DW, Babikian VL, et al. Consensus on microembolus detection by TCD (International Consensus Group on Microembolus Detection). Stroke. 1998;29:725–729
  40. Russell D, Brucher R. Online automatic discrimination between solid and gaseous cerebral microemboli with the first multifrequency transcranial Doppler. Stroke. 2002;33:1975–1980
  41. Brucher R, Russell D. Automatic online embolus detection and artifact rejection with the first multifrequency transcranial Doppler. Stroke. 2002;33:1969–1974
  42. Abu-Omar Y, Cader S, Guerrieri Wolf L, et al. Short-term changes in cerebral activity in on-pump and off-pump cardiac surgery defined by functional magnetic resonance imaging and their relationship to microembolization. J Thorac Cardiovasc Surg. 2006;132:1119–1125
  43. Jacobs A, Neveling M, Horst M, et al. Alterations of neuropsychological function and cerebral glucose metabolism after cardiac surgery are not related only to intraoperative microembolic events. Stroke. 1998;29:660–667
  44. Barry SJ, Zeger SL, Selnes OA, et al. Quantitative methods for tracking cognitive change 3 years after coronary artery bypass surgery. Ann Thorac Surg. 2005;79:1104–1109
  45. Keith JR, Cohen DJ, Lecci LB. Why serial assessments of cardiac surgery patients' neurobehavioral performances are misleading. Ann Thorac Surg. 2007;83:370–373
  46. Newman S, Stygall J, Hirani S, et al. Postoperative cognitive dysfunction after noncardiac surgery: a systematic review. Anesthesiology. 2007;106:572–590
  47. Rudolph JL, Babikian VL, Birjiniuk V, et al. Atherosclerosis is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc. 2005;53:462–466
  48. Vingerhoets G, Van Nooten G, Jannes C. Effect of asymptomatic carotid artery disease on cognitive outcome after cardiopulmonary bypass. J Int Neuropsychol Soc. 1996;2:236–239
  49. Mackensen GB, Ti LK, Phillips-Bute BG, et al. Cerebral embolization during cardiac surgery: impact of aortic atheroma burden. Br J Anaesth. 2003;91:656–661
  50. Verhoeven BA, de Vries JP, Pasterkamp G, et al. Carotid atherosclerotic plaque characteristics are associated with microembolization during carotid endarterectomy and procedural outcome. Stroke. 2005;36:1735–1740
  51. Newman MF, Croughwell ND, Blumenthal JA, et al. Predictors of cognitive decline after cardiac operation. Ann Thorac Surg. 1995;59:1326–1330
  52. Rudolph JL, Tilahun D, Treanor PR, et al. Use of a large bore syringe creates significantly fewer high intensity transient signals (HITS) into a cardiopulmonary bypass system than a small bore syringe. Perfusion. 2006;21:67–71
  53. Groom RC, Likosky DS, Forest RJ, et al. A model for cardiopulmonary bypass redesign. Perfusion. 2004;19:257–261
  54. Reimers B, Corvaja N, Moshiri S, et al. Cerebral protection with filter devices during carotid artery stenting. Circulation. 2001;104:12–15
  55. Bokeriia LA, Golukhova EZ, Breskina NY, et al. Asymmetric cerebral embolic load and postoperative cognitive dysfunction in cardiac surgery. Cerebrovasc Dis. 2007;23:50–56
  56. Stroobant N, Van Nooten G, Van Belleghem Y, et al. Relation between neurocognitive impairment, embolic load, and cerebrovascular reactivity following on- and off-pump coronary artery bypass grafting. Chest. 2005;127:1967–1976
  57. Lund C, Hol PK, Lundblad R, et al. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003;76:765–770
  58. Eifert S, Reichenspurner H, Pfefferkorn T, et al. Neurological and neuropsychological examination and outcome after use of an intra-aortic filter device during cardiac surgery. Perfusion. 2003;18(Suppl 1):55–60
  59. Nadareishvili ZG, Beletsky V, Black SE, et al. Is cerebral microembolism in mechanical prosthetic heart valves clinically relevant?. J Neuroimaging. 2002;12:310–315
  60. Browndyke JN, Moser DJ, Cohen RA, et al. Acute neuropsychological functioning following cardiosurgical interventions associated with the production of intraoperative cerebral microemboli. Clin Neuropsychol. 2002;16:463–471
  61. Fearn SJ, Pole R, Wesnes K, et al. Cerebral injury during cardiopulmonary bypass: emboli impair memory. J Thorac Cardiovasc Surg. 2001;121:1150–1160
  62. Braekken SK, Reinvang I, Russell D, et al. Association between intraoperative cerebral microembolic signals and postoperative neuropsychological deficit: comparison between patients with cardiac valve replacement and patients with coronary artery bypass grafting. J Neurol Neurosurg Psychiatry. 1998;65:573–576
  63. Clark RE, Brillman J, Davis DA, et al. Microemboli during coronary artery bypass grafting (Genesis and effect on outcome). J Thorac Cardiovasc Surg. 1995;109:249–258
  64. Bossema ER, Brand N, Moll FL, et al. Perioperative microembolism is not associated with cognitive outcome three months after carotid endarterectomy. Eur J Vasc Endovasc Surg. 2005;29:262–268
  65. Lloyd AJ, Hayes PD, London NJ, et al. Does carotid endarterectomy lead to a decline in cognitive function or health related quality of life?. J Clin Exp Neuropsychol. 2004;26:817–825
  66. Fearn SJ, Hutchinson S, Riding G, et al. Carotid endarterectomy improves cognitive function in patients with exhausted cerebrovascular reserve. Eur J Vasc Endovasc Surg. 2003;26:529–536

 K.K.M. and J.B.W. both contributed significantly and share first authorship.

PII: S0002-9610(08)00381-4

doi: 10.1016/j.amjsurg.2007.12.060

The American Journal of Surgery
Volume 197, Issue 1 , Pages 55-63 , January 2009