Comparison of postoperative cognitive dysfunction with the use of propofol versus desflurane in patients undergoing surgery for clipping of aneurysm after subarachnoid hemorrhage

Abstract

<jats:sec id="st1"> <jats:title>Background: </jats:title> <jats:p>Cerebral aneurysm rupture is a distinct entity among various causes of cerebrovascular accident. Despite the current concept of early surgical clipping to prevent consequences of ruptured aneurysm in good grade subarachnoid hemorrhage patients, 40–50% have postoperative cognitive dysfunction (POCD) on a long- term basis. Here, we compared the effect of two commonly used anesthetic agents on cognitive function following cerebral aneurysmal surgery, i.e., propofol and desflurane.</jats:p> </jats:sec> <jats:sec id="st2"> <jats:title>Methods: </jats:title> <jats:p>We conducted a prospective double-blind clinical study in 70 patients who were randomized to receive maintenance anesthetic agents either propofol or desflurane. The cognitive functions of patients were studied at the time of the discharge from a hospital or at 2 weeks following surgery whichever was early using the Hindi version of the Montreal Cognitive Assessment scale. The hemodynamic parameters, brain relaxation score at the different time intervals, were also studied.</jats:p> </jats:sec> <jats:sec id="st3"> <jats:title>Results: </jats:title> <jats:p>There was no difference between the two anesthetic agents in terms of incidence of POCD (65.4% vs. 82.6%, <jats:italic>P</jats:italic> &gt; 0.05) at the time of discharge or at 2 weeks following surgery. The mean POCD score in propofol and desflurane group was 22.81 ± 4.45 and 19.09 ± 5.66 which was statistically significant (<jats:italic>P</jats:italic>-value-0.01). The scores for domains of executive function, attention, and orientation were better with propofol group than desflurane group. Intraoperative hemodynamics and brain relaxation scores were similar in both groups.</jats:p> </jats:sec> <jats:sec id="st4"> <jats:title>Conclusion: </jats:title> <jats:p>A significant number of patients undergoing aneurysmal neck surgery experienced POCD although incidence remained similar in both groups. However, it appears that mean cognitive score and certain domains of cognitive functions especially the executive function, attention, and orientation were better preserved with the use of propofol when compared to desflurane at the time of discharge or on 2 weeks following surgery whichever was early.</jats:p> </jats:sec>

Intravenous versus inhalational anesthesia trial for outcome following intracranial aneurysm surgery: A prospective randomized controlled study

“…ere is an apprehension about the direct cerebral vasodilatory property of desflurane at >1.5 MAC which may increase ICP in vulnerable patients. [1,9,14] However, one may surmise that the cerebral vasodilatation may benefit the patients predisposed to a common complication of cerebral vasospasm following SAH. Despite the differences in the neurophysiological properties of these anesthetics, there is a paucity of evidence regarding the efficacy of one anesthetic over the other for long-term outcomes in patients undergoing aneurysmal neck clipping.…”

“…[1,3] Propofol reduces cerebral blood flow (CBF) as well as the cerebral metabolic rate of oxygen consumption (CMRO2) and offers neuroprotection. [5,14] Desflurane reduces CMRO2 but may not result in a corresponding decline in CBF. [1,9] A study analyzing perioperative outcomes using burst suppression dosages of propofol and desflurane reported identical brain conditions and awakening times in patients posted for clipping following aneurysmal SAH.…”

Role of Anesthetics and Their Adjuvants in Neurovascular Protection in Secondary Brain Injury after Aneurysmal Subarachnoid Hemorrhage

“…However, it is important to note that no impact on functional outcome at discharge was found in both studies as measured by modified Rankin scale (mRS). More recently, a preliminary prospective study comparing the effects of desflurane vs propofol on post-operative cognitive dysfunction (POCD) in SAH patients undergoing aneurysm clipping procedure did not find a difference in the POCD incidence between the groups [ 38 ].…”

“…Propofol was found to reduce the occurrence of spreading depolarization clusters, though the underlying mechanism behind this protection was not explored. Recently, two preliminary prospective studies examining the impact of propofol during aneurysm clipping in SAH patients did not find an effect on cognitive function (as measured by a modified form of MMSE and MoCA scores) at the time of hospital discharge [ 38 , 41 ].…”

Letter to the Editor regarding “Comparison of postoperative cognitive dysfunction with the use of propofol versus desflurane in patients undergoing surgery for clipping of aneurysm after subarachnoid hemorrhage,” which is the right time to evaluate?

“…The authors conclude that although there was no significant difference between groups, there was a significant difference in the average scores of certain domains of cognitive function. [ 9 ]…”