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 (551) 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<0.001). The incidence of cognitive dysfunction was significantly higher in patients with NLR ≥5 than NLR <5 (34.7% vs. 12.8%, P<0.001). Significantly fewer patients in the low tertile had cognitive dysfunction than in the high tertile (6.9% vs. 25.9%, P<0.001) and middle tertile (6.9% vs. 17.4%, P=0.006). In the final multivariate model, diabetes mellitus (OR: 2.03 [1.08–3.75], P=0.03) and NLR ≥5 (OR: 3.38 [1.81–6.27], P<0.001) were significantly associated with higher odds of cognitive dysfunction, while statin use was significantly associated with lower odds (OR: 0.48 [0.27–0.84], P=0.01). 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 while statin use is significantly associated with decreased odds.

Background and Purpose Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins prior to asymptomatic carotid endarterectomy (CEA) exhibit a lower incidence of neurologic injury (clinical stroke and cognitive dysfunction). Methods Three hundred twenty-eight (328) patients with asymptomatic carotid stenosis scheduled for elective CEA consented to participate in this observational study of perioperative neurologic 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 (OR: 0.51 [0.27-0.96], P=0.04). Conclusions Pre-operative statin use was associated with less neurologic injury following asymptomatic CEA. These observations suggest that it may be possible to further reduce the perioperative morbidity of CEA. Clinical Trial Registration-URL: http://www.ClinicalTrials.gov. Unique Identifier: NCT00597883.

Background Multi-level spinal decompressions and fusions often require long anesthetic and operative times which may result in airway edema and prolonged post-operative intubation. Delayed extubation can lead to broncho-pulmonary 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 having multilevel spine surgery lasting 8 hours or more 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, gender, 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 post-operative complications between patients extubated at the end of the case to patients who had a delayed extubation. Results 126 patients (44%) were kept intubated after multilevel spine surgery. Multiple linear regression analysis showed factors that correlated with prolonged intubation 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 threefold higher rate of post-operative pneumonia. Conclusions Our study finds 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 that the case ends is an independent variable that correlates with the decision not to extubate at the end of a long multi-level spinal surgery. The incidence of post-operative pneumonia is higher in patients who had a delayed extubation after surgery.

No abstract

Background A common practice during cross-clamp of carotid endarterectomy (CEA) is to manage mean arterial pressure (MAP) above baseline to optimize collateral cerebral blood flow and reduce 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 neurologic 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 prior to induction of general anesthesia. MAP was managed at the discretion of the anesthesiologist. All patients were evaluated with a battery of neuropsychometric tests pre-operatively and 24hrs post-operatively. 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<0.001). In a multivariate logistic regression model, MAP ≥20% above baseline during the cross-clamp period was associated with significantly lower risk of eCD (OR: 0.18 [0.07–0.40], P<0.001), while diabetes mellitus (OR: 2.73 [1.14–6.61], P=0.03) and each additional year of education (OR: 1.19 [1.06–1.34], P=0.003) were associated with significantly higher risk of eCD. Conclusion The observations of this study suggest 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.

Introduction Motoric cognitive risk (MCR) syndrome is a recently described pre-dementia syndrome characterized by slow gait and cognitive complaints that has been implicated as a predictor of cognitive decline and dementia in older adults. Previous work suggests that cerebrovascular disease is associated with MCR. White matter hyperintensities (WMH) are postulated to be a product of cerebrovascular disease, and have been associated with impaired mobility and impaired cognition. This study aimed to determine if MCR is associated with regional WMH. Methods Two cross-cultural cohorts of non-demented older adults were examined: 174 from a French memory clinic (62.1% male, mean age 70.7 ± 4.3 years) and 184 from an Indian community-dwelling cohort (55.4% male, mean age 66.2 ± 5.2 years). Participants were evaluated for slow gait, cognitive complaints, and regional WMH via MRI (fluid attenuated inversion recovery) FLAIR sequence. Results Overall, 20.7% of participants met criteria for MCR, and 72.9% of participants had WMH on FLAIR. WMH in the frontal, parieto-occipital, temporal, basal ganglia, cerebellum, or brainstem were not associated with MCR in either of the two cohorts. Conclusion WMH was not significantly associated with MCR in this studied sample of participants, suggesting that other cerebrovascular pathophysiological mechanisms, or combination of mechanisms, might underlie MCR.

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).

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.