Pharmacologic Unmasking of Neurologic Deficits

Vlisides, Phillip E.; Mashour, George A.

doi:10.1097/aln.0000000000002775

Cited by 10 publications

(5 citation statements)

References 5 publications

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“…While we do not yet understand how to use EEG monitoring to understand brain structure and function to the same degree as electrocardiograms can be used to provide insight into cardiac structure, function and rhythms, it is important to recognize how much we have learned about the human brain and mechanisms of anesthesia in the last near century since EEG alpha waves were first discovered [ 171 ]. This history provides reason to believe that the coming century will witness significant advances in the use of translational perioperative EEG to gather information from the perioperative “stress test” of anesthesia and surgery and to modify care for the benefit of older patients [ 172 ], rather than simply waiting for the development of delirium or aging-related neurodegenerative disease in the longer term (Fig. 3 ).…”

Section: Discussionmentioning

confidence: 99%

A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients

et al. 2023

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As of 2022, individuals age 65 and older represent approximately 10% of the global population [1], and older adults make up more than one third of anesthesia and surgical cases in developed countries [2, 3]. With approximately > 234 million major surgical procedures performed annually worldwide [4], this suggests that > 70 million surgeries are performed on older adults across the globe each year. The most common postoperative complications seen in these older surgical patients are perioperative neurocognitive disorders including postoperative delirium, which are associated with an increased risk for mortality [5], greater economic burden [6, 7], and greater risk for developing long-term cognitive decline [8] such as Alzheimer’s disease and/or related dementias (ADRD). Thus, anesthesia, surgery, and postoperative hospitalization have been viewed as a biological “stress test” for the aging brain, in which postoperative delirium indicates a failed stress test and consequent risk for later cognitive decline (see Fig. 3). Further, it has been hypothesized that interventions that prevent postoperative delirium might reduce the risk of long-term cognitive decline. Recent advances suggest that rather than waiting for the development of postoperative delirium to indicate whether a patient “passed” or “failed” this stress test, the status of the brain can be monitored in real-time via electroencephalography (EEG) in the perioperative period. Beyond the traditional intraoperative use of EEG monitoring for anesthetic titration, perioperative EEG may be a viable tool for identifying waveforms indicative of reduced brain integrity and potential risk for postoperative delirium and long-term cognitive decline. In principle, research incorporating routine perioperative EEG monitoring may provide insight into neuronal patterns of dysfunction associated with risk of postoperative delirium, long-term cognitive decline, or even specific types of aging-related neurodegenerative disease pathology. This research would accelerate our understanding of which waveforms or neuronal patterns necessitate diagnostic workup and intervention in the perioperative period, which could potentially reduce postoperative delirium and/or dementia risk. Thus, here we present recommendations for the use of perioperative EEG as a “predictor” of delirium and perioperative cognitive decline in older surgical patients.

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Section: Discussionmentioning

confidence: 99%

A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients

et al. 2023

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“…Secondly, our restricted enrolment of patients with glioma may not be generalizable to the entire surgical population. However, POD might be the result of a failed “stress test” for the brain, revealing underlying neurological injury in the presence of a surgical strike ( Vlisides and Mashour, 2019 ). Brain injury and brain compensation always go together.…”

Section: Discussionmentioning

confidence: 99%

Higher Grade Glioma Increases the Risk of Postoperative Delirium: Deficient Brain Compensation Might Be a Potential Mechanism of Postoperative Delirium

Huang

Zhang

et al. 2022

Front. Aging Neurosci.

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ObjectiveThe brain compensation mechanism in postoperative delirium (POD) has not been reported. We uncovered the mechanism by exploring the association between POD and glioma grades, and the relationship between preoperative brain structural and functional compensation with POD in patients with frontal glioma.MethodsA total of 335 adult patients with glioma were included. The multivariable analysis examined the association between tumor grade and POD. Then, 20 patients with left frontal lobe glioma who had presurgical structural and functional MRI data and Montreal Cognitive Assessment (MoCA) in this cohort were analyzed. We measured the gray matter volume (GMV) and functional connectivity (FC) in patients with (n = 8) and without (n = 12) POD and healthy controls (HCs, n = 29) to detect the correlation between the structural and functional alteration and POD.ResultsThe incidence of POD was 37.3%. Multivariable regression revealed that high-grade glioma had approximately six times the odds of POD. Neuroimaging data showed that compared with HC, the patients with left frontal lobe glioma showed significantly increased GMV of the right dorsal lateral prefrontal cortex (DLPFC) in the non-POD group and decreased GMV of right DLPFC in the POD group, and the POD group exhibited significantly decreased FC of right DLPFC, and the non-POD group showed the increasing tendency. Partial correlation analysis showed that GMV in contralesional DLPFC were positively correlated with preoperative neurocognition, and the GMV and FC in contralesional DLPFC were negatively correlated with POD.ConclusionsOur findings suggested that insufficient compensation for injured brain regions involving cognition might be more vulnerable to suffering from POD.

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“…Thus, the differences are only manifested when the patients are under anesthesia. Recently, it has been discussed the potential ability of GABA A Rs-dependent general anesthetics to unmask neurologic deficits 22 like a “stress test for the brain.” Future studies exploring this potential usefulness of anesthetics should be performed. Additionally, EEG features associated with brain anesthesia overdose were associated with a longer emergence time in the low MoCA group (almost 5 minutes).…”

Section: Discussionmentioning

confidence: 99%

Association Between Lower Preoperative Cognition With Intraoperative Electroencephalographic Features Consistent With Deep States of Anesthesia in Older Patients: An Observational Cohort Study

Gutiérrez

Egaña

Maldonado

et al. 2020

Anesthesia &Amp; Analgesia

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BACKGROUND: Patients with low cognitive performance are thought to have a higher risk of postoperative neurocognitive disorders. Here we analyzed the relationship between preoperative cognition and anesthesia-induced brain dynamics. We hypothesized that patients with low cognitive performance would be more sensitive to anesthetics and would show differences in electroencephalogram (EEG) activity consistent with a brain anesthesia overdose. METHODS: This is a retrospective analysis from a previously reported observational study. We evaluated cognitive performance using the Montreal cognitive assessment (MoCA) test. All patients received general anesthesia maintained with sevoflurane or desflurane during elective major abdominal surgery. We analyzed the EEG using spectral, coherence, and phase-amplitude modulation analyses. RESULTS: Patients were separated into a low MoCA group (<26 points, n = 12) and a high MoCA group (n = 23). There were no differences in baseline EEG, nor end-tidal age-corrected minimum alveolar concentration (MACage). However, under anesthesia, the low MoCA group had lower α-β power (high MoCA: 2.9 [interquartile range {IQR}: 0.6–5.8 dB] versus low MoCA: −1.2 [IQR: −2.1 to 0.6 dB], difference 4.1 [1.0–5.7]) and a lower α peak frequency (high MoCA: 9.0 [IQR: 8.3–9.8 Hz] versus low MoCA: 7.5 [IQR: 6.3–9.0 Hz], difference 1.5 [0–2.3]) compared to the high MoCA group. The low MoCA group also had a lower α band coherence and a stronger peak-max phase–amplitude coupling (PAC). Finally, patients in the low MoCA group had longer emergence times (high MoCA 663 ± 345 seconds versus low MoCA: 960 ± 352 seconds, difference 297 [15–578]). Multiple linear regression shows up that both age and MoCA scores are independently associated with intraoperative α-β power. CONCLUSIONS: All these EEG features, together with a prolonged emergence time, are consistent with the possibility that older patients with low cognitive performance are receiving a brain anesthesia overdose compare to cognitive normal patients.

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Pharmacologic Unmasking of Neurologic Deficits

Cited by 10 publications

References 5 publications

A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients

A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients

Higher Grade Glioma Increases the Risk of Postoperative Delirium: Deficient Brain Compensation Might Be a Potential Mechanism of Postoperative Delirium

Association Between Lower Preoperative Cognition With Intraoperative Electroencephalographic Features Consistent With Deep States of Anesthesia in Older Patients: An Observational Cohort Study

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