Cerebral Microembolism Diagnosed by Transcranial Doppler during Total Knee Arthroplasty

Sulek, Cheri A.; Davies, Laurie K.; Enneking, Kayser F.; Gearen, Peter; Lobato, Emilio B.

doi:10.1097/00000542-199909000-00018

Cited by 112 publications

(56 citation statements)

References 27 publications

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“…This appears to be assessed as part of routine follow-up, though 1 study specifically undertook neurologic examinations. 20 Six studies measured cognitive function, and 1 study measured quality of life postoperatively as a proxy for cognition. 13 No study found an association between neurologic or cognitive change and embolic count.…”

Section: Resultsmentioning

confidence: 99%

Review of Transcranial Doppler Ultrasound to Detect Microemboli during Orthopedic Surgery

Silbert

Evered

Scott

et al. 2013

AJNR Am J Neuroradiol

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SUMMARY:Transcranial Doppler ultrasonography has been used to detect microemboli in the middle cerebral artery during orthopedic surgery. We conducted a comprehensive systematic literature review of transcranial Doppler ultrasonography in orthopedic surgery to evaluate its status in this setting. Fourteen studies were selected for qualitative analysis. The highest number of patients studied was 45; emboli were detected in all studies, occurring in 20%-100% of patients. Most embolic counts were below 10, but some high counts were noted. No study reported all the technical parameters of the transcranial Doppler ultrasonography. All studies assessed neurologic status, and 6 studies evaluated cognitive function postoperatively. No study identified an association between postoperative cognitive function and embolic count. Six studies sought the presence of right-to-left shunts. ABBREVIATIONS:HITS ϭ high-intensity transient signals; PFO ϭ patent foramen ovale; TCD ϭ transcranial Doppler ultrasonography; TEE ϭ transesophageal

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Section: Resultsmentioning

confidence: 99%

Review of Transcranial Doppler Ultrasound to Detect Microemboli during Orthopedic Surgery

Silbert

Evered

Scott

et al. 2013

AJNR Am J Neuroradiol

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“…Some reports have found numerous disadvantages associated with tourniquet use, including reduced early knee flexion [11,14,60,62,65], increased perioperative pain [11,14,27,56,57], increased postoperative limb swelling [11,21,47], more frequent wound complications [9,12,40,41], an increase in cardiac and cerebral microemboli [16,20,[42][43][44]55], an increased incidence of deep venous thrombosis [8,57,65], an increased risk of arterial thrombosis in subjects with preoperative vascular disease [22,26,48], a risk of peripheral nerve injury [29,39], and skin irritation from tourniquet application [13].…”

Section: Introductionmentioning

confidence: 99%

Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

Dennis

Kittelson

Yang

et al. 2016

Clinical Orthopaedics &Amp; Related Research

167

148

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Background Tourniquet use during total knee arthroplasty (TKA) improves visibility and reduces intraoperative blood loss. However, tourniquet use may also have a negative impact on early recovery of muscle strength and lower extremity function after TKA. Questions/purposes The purpose of this study was (1) to determine whether tourniquet use affects recovery of quadriceps strength (primary outcome) during the first 3 postoperative months; and (2) to examine the effects of tourniquet application on secondary outcomes: voluntary quadriceps activation, hamstring strength, unilateral limb balance as well as the effect on operative time and blood loss.Methods Twenty-eight patients (mean age 62 ± 6 years; 16 men) undergoing same-day bilateral TKA (56 lower extremities) were enrolled in a prospective, randomized study. Subjects were randomized to receive a tourniquetassisted knee arthroplasty on one lower extremity while the contralateral limb underwent knee arthroplasty without extended tourniquet use. In the former group, the tourniquet was inflated just before the incision was made and released after cementation; in the latter group, a tourniquet was not used (10 of 28 [36%]) or inflated only during component cementation (18 of 28 [64%]). The choice of no tourniquet or use just during cementation was based on surgeon choice, because some surgeons felt a tourniquet during cementation was necessary to achieve a dry surgical field to maximize cement fixation. A median parapatellar approach and the One or more of the authors (DAD, CCY, TMM, RHK) has received funding from Porter Adventist Hospital, during the study period, in the amount of USD 10,000 to USD 100,000. One of the authors (DAD) has or may receive payments or benefits from DePuy (Warsaw, IN, USA) in the amount of USD more than USD 1,000,001 not related to this work. One of the authors certifies that he (RHK) has or may receive payments or benefits from Stryker (Kalamazoo, MI, USA) and Innomed (Savannah, GA, USA) in the amount of USD 100,001 to USD 1,000,001 not related to this work. One of the authors (TMM) has or may receive payments or benefits from Zimmer (Warsaw, IN, USA) in the amount of less than USD 10,000 not related to this work. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.The surgeries for this study were performed at Porter Adventist Hospital, Denver, CO, USA, and the postoperative patient te...

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“…The former presumes that fractures of marrow containing bone have the highest incidence of FES due to disrupted venules in the marrow which are tethered open by osteous attachments that allows easy entry of marrow contents into the circulation [7]. From there on, it can enter the arterial circulation via a patent for men ovale (PFO) causing increases in pulmonary artery and right heart pressures or by micro embolism via the lung demonstrated even in the absence of a PFO; the latter could explain the neurologic disease and petechiae associated with FES [8,9]. The bio chemical theory or mechanism explains that destabilization of a plasma chylomicronemulsion lead stocoalescence off at stores [10,11].…”

Section: Discussionmentioning

confidence: 99%

Fat Embolism Syndrome – A Case Report with Literature Review

Gomez¹,

IshaVerma²,

L³

et al. 2015

MOJCR

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Background: The fat embolism syndrome (FES) has been considered a diagnostic enigma since its first description over a century ago. Varying degree of presentation along with absence of specific diagnostic criteria or a scoring system makes it difficult to be diagnosed. Simple fat embolism may be a pathologic finding with variable clinical significance; patients with the FES have fat emboli in multiple organs, causing extensive organ dysfunction. While most patients with FES fully recover, there is an estimated 5to15percent mortality rate. There is no wide accepted specific treatment beyond aggressive supportive care.Case Report: A 72 year old Caucasian female presented with dyspnea, hypoxia and altered mental status within 24 hours of admission for an inferior pubic rami fracture secondary to fall. Patient required intubation and mechanical ventilation for respiratory failure. An Echocardiogram revealed Right Ventricular strain and MRI of the brain showed multiple acute/subacute infarcts, which supported a diagnosis of FES, especially as pulmonary embolism was deemed less likely with a negative CT Chest Angiogram and US Doppler of Legs. The patient gradually recovered with supportive care, successfully extubated with eventually discharged after thirty days of hospitalization. Conclusion:Fat emboli syndrome has a variable degree of presentation, ranging from mild symptoms to severe multi organ involvement that can ultimately be fatal. It can also be associated with long term morbidity which emphasizes the need for rapid precise diagnosis and management.

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Cerebral Microembolism Diagnosed by Transcranial Doppler during Total Knee Arthroplasty

Abstract: Cerebral microembolism occurs frequently during tourniquet release, even in the absence of a patient foramen ovale. This passage most likely occurs through the pulmonary capillaries or the opening of recruitable pulmonary vessels.

Cited by 112 publications

References 27 publications

Review of Transcranial Doppler Ultrasound to Detect Microemboli during Orthopedic Surgery

Review of Transcranial Doppler Ultrasound to Detect Microemboli during Orthopedic Surgery

Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

Fat Embolism Syndrome – A Case Report with Literature Review

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