The effect of relative cerebral hyperperfusion during cardiac surgery with cardiopulmonary bypass to delayed neurocognitive recovery

Abstract

Objective: Delayed neurocognitive recovery (dNCR) remains a common complication after surgery and the incidence of it is determined 30-80% after cardiac surgery with cardiac bypass (CPB) in eldery patients. Many researchers have identified that neuropsychological complications emerge from insufficient cerebral perfusion. Relative cerebral hyperperfusion also disrupts cerebral autoregulation and might play a significant role in dNCR development. The aim of this study is to determine hyperperfusion in the middle cerebral artery during CPB influence to dNCR development and brain biomarker glial fibrillary acidic protein (GFAP) impact in diagnosing dNCR.

Designs and methods: This prospective - case control study included patients undergoing elective coronary artery bypass grafting or/and valve surgery with CPB. For cognitive evaluation 101 patients completed Addenbrooke's cognitive examination - ACE-III. To determine mild cognitive dysfunction, cut - off 88 was chosen. Mean BFV was monitored with transcranial Doppler ultrasonography (TCD) and performed before surgery, after induction of anaesthesia, during CPB and after surgery. Preoperative BFV was converted to 100% and used as a baseline. The percentage change of cerebral blood flow velocity during CPB was calculated from baseline. Patients with decreased blood flow velocity were included for further investigation. To measure glial fibrillary acidic protein, blood samples were collected after anaesthesia induction, 24 and 48 h after the surgery. According to the ACE-III test results, patients with relative hyperperfusion were divided into two groups: with Delayed neurocognitive recovery and without dNCR (non-dNCR group).

Results: 101 patients were examined, 67 (69.1%) men and 29 (29.9%) women, age 67.9 (SD 9.2) Increased percentage of BFV was determined for 40 (39.60%) patients. There were no differences in sex, haematocrit, paCO₂, aortic cross-clamping or CPB time between the two groups. Percentage change of BFV was 105.60% in the non-dNCR group and 132.29% in the dNCR group, p = .033. Patients who developed dNCR in the early post-surgical period were significantly older, p < .001 and had a lower baseline of BFV, p = .004. GFAP concentration significantly increased in the dNCR group 48 hours after surgery, compared to the non-dNCR group, p = .01.

Conclusions: Relative hyperperfusion during CPB may cause dNCR. Elderly patients are sensitive to blood flow velocity acceleration during CPB. GFAP concentration increased 48 h after surgery in dNCR group but did not have any connection with risk factors.

Keywords: GFAP; addenbrooke’s cognitive examination; brain biomarker; cardiac surgery; cardiopulmonary bypass; cerebral blood flow velocity; delayed neurocognitive recovery; middle cerebral artery; relative hyperperfusion; transcranial doppler ultrasonography.

Figure 1.

Study design and patient flow. MCA, Middle Cerebral Artery; BFV, Blood Flow Velocity; CPB, Cardiopulmonary Bypass, GFAP, Glial Fibrillary Acid Protein, ACE-III, Addenbrooke’s Cognitive Evaluation III.

Figure 2.

Percentage changes of BFV in non-dNCR and dNCR groups. MCA, Middle Cerebral Artery; BFV, Blood Flow Velocity; dNCR, Delayed Neurocognitive Recovery.

Figure 3.

Relation analysis of age and the patient postoperative ACE-III score in both groups. ACE–III, Addenbrooke’s Cognitive Examination III.

Figure 4.

Relation analysis of age and the MCA BFV during CPB in both groups. MCA, Middle Cerebral Artery; BFV, Blood Flow Velocity; CPB, Cardiopulmonary Bypass.