Intraoperative impaired cerebrovascular autoregulation and delayed neurocognitive recovery after major oncologic surgery: a secondary analysis of pooled data

Abstract

Cerebral blood flow is tightly regulated by cerebrovascular autoregulation (CVA), and intraoperative impairment of CVA has been linked with perioperative neurocognitive disorders. We aim to assess whether impairment of CVA during major oncologic surgery is associated with delayed neurocognitive recovery (DNCR) postoperatively. We performed a secondary analysis of prospectively collected data. Patients were included if they had undergone complete pre- and postoperative neuropsychological assessments, continuous intraoperative measurement of CVA, and major oncologic surgery for visceral, urological, or gynecological cancer. Intraoperative CVA was measured using the time-correlation method based on near-infrared-spectroscopy, and DNCR was assessed with a neuropsychological test battery. A decline in cognitive function before hospital discharge compared with a preoperative baseline assessment was defined as DNCR. One hundred ninety-five patients were included in the analysis. The median age of the study population was 65 years (IQR: 60–68); 11 patients (5.6%) were female. Forty-one patients (21.0%) fulfilled the criteria for DNCR in the early postoperative period. We found a significant association between impaired intraoperative CVA and DNCR before hospital discharge (OR = 1.042 [95% CI: 1.005; 1.080], p = 0.028). The type of surgery (radical prostatectomy vs. other major oncologic surgery; OR = 0.269 [95% CI: 0.099; 0.728], p = 0.010) and premedication with midazolam (OR = 3.360 [95% CI: 1.039; 10.870], p = 0.043) were significantly associated with the occurrence of DNCR in the early postoperative period. Intraoperative impairment of CVA is associated with postoperative neurocognitive function early after oncologic surgery. Therefore, intraoperative monitoring of CVA may be a target for neuroprotective interventions. The initial studies were retrospectively registered with primary clinical trial registries recognized by the World Health Organization (ClinicalTrials.gov Identifiers: DRKS00010014, 21.03.2016 and NCT04101006, 24.07.2019).

Effect of internal jugular vein catheterization on intracranial pressure and postoperative cognitive function in patients undergoing robot-assisted laparoscopic surgery

“…Several previous studies have demonstrated excellent specificity and sensitivity between the ONSD and ICP, so intraoperative ICP changes can be evaluated by monitoring the ONSD ( 19 , 20 ). The cut-off value of the ONSD corresponding to intracranial hypertension (ICP > 20 mmHg) in previous studies was 5 mm ( 21 , 22 ). Our research showed that regardless of whether or not the IJV catheterization was performed, the ONSD reached more than 5 mm before returning to the supine position at the end of surgery.…”

Preoperative Midazolam and Patient-Centered Outcomes of Older Patients

“…We also did not find any reduction in health status, such as reduced rate of early postoperative cognitive recovery, as previously described with lorazepam premedication . Notably, delayed neurocognitive recovery was previously reported after midazolam premedication . One reason why the I-PROMOTE trial was not able to detect differences in neurocognitive recovery might be the applied low dose of midazolam, 3.75 mg. A further reason might be that only legally competent patients without neuropsychiatric disorders were eligible, and thus patients with enhanced risk were missed.…”

“… 8 Notably, delayed neurocognitive recovery was previously reported after midazolam premedication. 33 , 34 One reason why the I-PROMOTE trial was not able to detect differences in neurocognitive recovery might be the applied low dose of midazolam, 3.75 mg. A further reason might be that only legally competent patients without neuropsychiatric disorders were eligible, and thus patients with enhanced risk were missed. We acknowledge that there may be valid reasons that justify midazolam premedication, like improved psychological recovery along with reduced postoperative infections 23 or prevention of explicit recall of perioperative events.…”

The impact of cognitive reserve on delayed neurocognitive recovery after major non-cardiac surgery: an exploratory substudy

“…Baseline cognitive function was assessed on the day of hospital admission and postoperative cognitive function was evaluated between day three post-procedure and before hospital discharge. Each assessment included a battery of four neuropsychological tests, as reported in detail previously (Beck et al, 2020;Kahl et al, 2022). Briefly, we used the German version of the California Verbal Learning Test to evaluate verbal learning and memory (Testzentrale, Göttingen, Germany) (Niemann et al, 2008), the Trail Making Test A and B to evaluate executive function (Reitan, 1958;Rodewald et al, 2012), the Grooved Pegboard Test to assess visuomotor skills (Liu et al, 2021) (Lafayette Instrument Company, Lafayette, IN), and the Digit Span Forward task to assess attention for the pre-and postoperative assessment of multiple domains of cognitive function.…”