Subtle cognitive decline following CEA occurs and persists for at least several weeks after surgery. This decline was absent in a control group.

Background and Purpose-One hundred twelve patients undergoing elective carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis were enrolled in a prospective study to evaluate the incidence of change in postoperative cerebral function. Methods-Patients were evaluated preoperatively and postoperatively before hospital discharge and at follow-up 1 and 5 months later with a battery of neuropsychometric tests. The results were analyzed by both event-rate and group-rate analyses. For event-rate analysis, change was defined as either a decline or improvement in postoperative neuropsychometric performance by 25% or more compared with a preoperative baseline. Results-Approximately 80% of patients showed decline in one or more test scores, and 60% had one or more improved test scores at the first follow-up examination. The percentage of declined test scores decreased and the percentage of improved test scores increased with subsequent follow-up examinations. Group-rate analysis was similar for group performance on individual tests. However, a decline in performance was seen most commonly on verbal memory tests, and improved performance was seen most commonly on executive and motor tests. Conclusions-Neuropsychometric evaluation of patients undergoing carotid endarterectomy for significant carotid artery stenosis demonstrates both declines and improvements in neuropsychometric performance. The test changes that showed decreased performance may be associated with ischemia from global hypoperfusion or embolic phenomena, and the improvement seen may be related to increased cerebral blood flow from removal of stenosis. (Stroke. 1998;29:1110-1115.)

In a consecutive series of 1930 carotid endarterectomies there were eight cases of postoperative intracerebral hemorrhage. One of these patients was operated on 2 weeks following cerebral infarction and had severe uncontrollable hypertension after surgery. A second patient had an intraoperative embolus and bled while fully heparinized on the 3rd postoperative day. Only one patient in the series bled into an area of documented cerebral infarction. The remainder of the cases represented hemorrhage into essentially normal brain. Seven of the eight patients with intracerebral hemorrhage had high-grade internal carotid artery stenosis preoperatively. Although several factors have contributed to the brain hemorrhages in this series of patients, postoperative cerebral hyperperfusion which often follows endarterectomy may have played an important role. Defective cerebrovascular autoregulation in chronically ischemic brain regions may predispose patients to intracerebral hemorrhage after removal of a high-grade stenosis of the internal carotid artery.

The computational burden created by the integration of these complex components often limits the fluidity of real-time interactive simulators. Although haptic interfaces have become increasingly sophisticated, the production of realistic tactile sensory feedback remains a formidable and costly challenge. The rate of future progress may be contingent upon international collaboration between research groups and the establishment of common simulation platforms. Given current limitations, the most potential for growth lies in the innovative design of models that expand the procedural applications of neurosurgery simulation environments.

Advising and mentoring programs for medical students vary in their official names, scope, and structures. Catalyzed by negative student feedback regarding career advising and a perceived disconnection between faculty and students, in academic year 2003-2004, Columbia University College of Physicians and Surgeons implemented its formal Advisory Dean (AD) Program and disbanded its former advising system that used faculty volunteers. The AD Program has become a key element for enhancing the students' professional development throughout their student training, focusing on topics including, but not limited to, career counseling, professionalism, humanism, and wellness resources. Advisory deans and the dean for student affairs, familiar with resources for academic development, student support, and extracurricular activities, operate at the nexus of the program, providing personalized mentoring and advising for each student. Fully supported by administration and faculty, the program has shown early success according to student feedback. Early feedback from the Class of 2006, who had been involved in our AD Program for three years, has been encouraging. Out of 152 students, 104 (68%) provided feedback, with 93 (89%) of the respondents reporting the AD Program as a valuable initiative. Expecting to further improve on this early positive response, the AD Program will continue to foster an environment conducive to a seamless transition from student to physician.

To determine the effect of mannitol on blood viscosity, serial measurements were carried out on venous blood in patients undergoing craniotomies for intracranial aneurysms. Blood samples were drawn immediately prior to, and 30 minutes, 2, and 4 hours after administration of mannitol. Complete blood counts, serum osmolarities, and erythrocyte microsieving studies were also performed on each sample. Whole-blood viscosity decreased at 30 minutes and 2 hours, but not at 4 hours after mannitol administration. This decreased appeared at high shear rates only, where erythrocyte deformability is critical viscosity. This effect was independent of the hematocrit. Removal of mannitol from the suspension returned red cell deformability to preadministration values indicating that the increased erythrocyte deformability required the presence of mannitol and the relative hyperosmolarity induced by this agent. The reduced erythrocyte rigidity and subsequent decreased whole-blood viscosity should enhance tissue perfusion in the microcirculation.

Background: Between 9% and 23% of patients undergoing otherwise uncomplicated carotid endarterectomy (CEA) develop subtle cognitive decline 1 month postoperatively. The APOE-ε4 allele has been associated with worse outcome following stroke. Objective: To investigate the ability

Background Cognitive dysfunction is fairly common after noncardiac surgery and may be related to intraoperative blood pressure management. The authors present an analysis of risk factors for cognitive deterioration after spine surgery in older patients, with particular emphasis on intraoperative blood pressure in normotensive and hypertensive patients. Methods This is a post hoc cohort analysis of 45 patients enrolled before undergoing lumbar laminectomy or microdiscectomy. The patients underwent a battery of 5 neuropsychometric tests preoperatively, and 1 day and 1 month postoperatively. Computerized anesthesia records were used to obtain intraoperative mean arterial pressure (MAP) data. Simple linear regressions between intraoperative MAP and postoperative cognitive performance were performed, and multivariate linear regression models of postoperative cognitive performance were constructed to analyze potential risk factors for cognitive decline after surgery. Results Twenty-one normotensive patients (mean age, 62.4 yr) and 24 hypertensive patients (mean age, 67.9 yr) were included in this analysis. There was a significant positive relationship between minimum intraoperative MAP values and 1-day cognitive performance by simple linear regression in hypertensive (P = 0.003), but not normotensive, patients. In multivariate linear regression analysis of cognitive performance, there was a significant interaction between hypertension and minimum intraoperative MAP at 1 day and 1 month. Conclusions In hypertensive patients, there was a significant relationship between minimum intraoperative MAP and decline in cognitive function 1 day and 1 month after surgery. A prospective controlled trial of intraoperative blood pressure control, especially during induction of anesthesia when MAP values typically drop, is needed to confirm these findings.