C E R E B R A L D A M A G E B E F O R E AND A F T E R CARDIAC SURGERY

DEVELOPMENTS IN

CRITICAL CARE MEDICINE AND ANESTHESIOLOGY

Volume 27

The titles published in this series are listed at the end of this volume.

Cerebral Damage before and after Cardiac Surgery edited by

ALLEN WILLNER Long Island Jewish Medical Center, Albert Einstein College of Medicine, Glen Oaks, New York, USA

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Al l Rights Reserve d © 1993 Springer Science+Busines s Media Dordrecht Originall y published by Kluwer Academic Publishers in 1993

Softcover reprint of the hardcover 1st edition 1993

No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.

Table of contents

Preface by T. Aberg List of contributors Acknow ledgements

ix xi

xvii

PART ONE: Causes of pre- and post-operative cerebral damage 1.

The causes of pre-operative psychopathology in cardiac surgery patients by R. Meyendorf

2.

Cardiac surgery and acute neurological injury by J. C. Opie

3.

Prevalence and causes of cerebral complications in cardiac surgery by K. A. Sotaniemi

37

Perfusion related parameters affecting cerebral outcome after cardiac surgery by M. Kurusz

47

The role of the surgical team in minimizing postoperative cerebral dysfunction by J. D. Katz

57

4.

5.

3

15

6.

The causes of postoperative cerebral damage by P.L.e. Smith and S.P. Newman

69

7.

Central nervous risk factors in cardiac surgery by G. Rodewald, B. Dahme, Th. Emskotter, P. Gatze, L. Lachenmeyer, U. Lamparter, P. Kalmar, H.-J. Krebber, H.-J. Meffert and H. Pokar

83

v

vi PART TWO: Techniques for assessing cerebral damage 8. Neuropsychological methods for evaluating regional brain dysfunction by R.Gur 9. Computerized EEG in cardiac surgery by E.H.J.F. Boezeman, J.A. Leusink and EE.E. Vermeulen

101

113

10. Clinical electroencephalographic assessment of cerebral impairment by E Struve

127

11. The promise and peril of topographic mapping of quantified brain electrical activity by E Struve

147

12. Real-time multichannel quantitative EEG monitoring by R.J. Chabot, E.R. John, L.S. Prichep, P.M. Landau, W.O. Isom and L.D. Gugino

163

PART THREE: Psychological damage 13. Impairment in basic cognitive functioning: attention, concentration, and mental flexibility by H.-J. Meffert and B. Dahme

185

14. The use of neuropsychological tests as criteria of brain dysfunction in cardiac surgery research by A.E. Willner

195

15. Neuropsychological dysfunction before and after cardiac surgery by A.E. Willner

203

PART FOUR: Psychopathology 16. Emotional reactions to cardiac surgery by P. GOtze, B. Dahme, G. Huse-Kleinstoll and H.-J. Meffert

219

17. Adjustment disorder in cardiac surgery patients by P. Tienari

239

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18. Major depression and adjustment disorder with depressed mood or depressive disorders by C.J. Rabiner

249

19. Organic mental disorders in cardiac surgery by K.A. Sotaniemi

255

Index

265

Preface

Talking to a fellow physician some time ago about the results of coronary bypass operations, we contemplated what we would fear the most if we had to have the operation ourselves. After dwelling some time on major myocardial damage, multiple organ failure and multiple graft occlusion, we decided that the complications to be dreaded most were the cerebral ones. The overt complications with hemiplegia, etc., were bad enough, but, due to their relative rarity, to be taken as a matter of risk. The more subtle complications affecting intellect, memory, personality and emotional life were much more frightening as they seem to be more common, effect parts of the "inner self', are less understood, are less accepted, and may make the patient somewhat of a social cripple. My friend and I also agreed, that for the more common operations using extracorporeal circulation, cerebral protection was the major remaining perioperative challenge from a scientific point of view. It is surprising that this field has not been more exploited by basic brain researchers. Here they have a brain injury model where we know that a proportion of the patients operated upon will have some degree of brain damage. There is no lack of study objects, the scientific design can be made impeccable with a before and after design, possibly combined with a randomised comparison of various routines or treatments. Why, then, has this field been somewhat disregarded? I think there are several reasons for this. The function of the brain is notoriously difficult to measure. Working within this field requires an expertise that many medical specialists lack, among them many cardiac surgeons, who are fully occupied in perfecting the cardiac results of the operation. Furthermore, many of the effects of open heart surgery on the brain are subtle, require special knowledge or interest in their diagnosis, are difficult to treat once they have occurred, and may in some institutions be put down to normal, temporary effects of anesthesia, operation and extracorporeal circulation in a very effective and necessary surgical treatment, an attitude that becomes an obstacle to the scientific exploration of this field. There may also be an element of wishful ix

x thinking on the part of the surgeon, closing his eyes to cerebral complications in his pursuit of the perfect results. The present book is a good sign that cerebral complications - and the possibility of lessening them in the future - are taken more seriously nowadays. It is written by some well known authorities in the field, many of whom have devoted years of work to these patients. It is interesting to note that of the 19 chapters, 4 are written by psychiatrists, 3 by neurologists, 7 by psychologists, 3 by surgeons, 1 by an anesthesiologist, and 1 by a perfusionist, depicting the various views by which the brain can be regarded and also giving some idea as to the complexity of the problem. Reading the book and the contemporary literature, the following conclusions seem to be justified: Open heart surgery more or less regularly brings about symptoms from the central nervous system; symptoms form a continuum from subtle and temporary to obvious and permanent; symptoms seem to be a sign of brain cell injury; there are now multiple methods by which morphology, biochemistry, electrophysiology, and functions of the brain may be followed; the cause of brain cell injury seems to be multifactorial. Hypoxia and hypoperfusion seem to be a common effect of many causes, among them emboli of large, intermediate and small sizes; the main path in decreasing the extent of brain injury seems to be prevention; and the three responsible specialists in persuing prevention of brain injury are the surgeon, the perfusionist, and the anesthesiologist. Returning to my friend, it turned out that for some years he had had angina pectoris and now discreetly was exploring the outcome of operative treatment. He was operated upon with six peripheral anastomoses and woke up with a right-sided hemiplegia. Umea, October 1992

T. ABERG

List of contributors

Prof. Dr. med. TORKEL ABERG Head of the Thoracic and Cardiovascular Clinic University Hospital Umeli Sweden E.H.J.F. BOEZEMAN MD Department of Clinical Neurophysiology St. Antonius Hospital Nieuwegein The Netherlands ROBERT J. CHABOT PhD Department of Psychiatry New York University Medical Center New York, New York USA Prof. Dr. phil. BERNHARD DAHME Institute of Psychology III University of Hamburg Federal Republic of Germany Prof. Dr. med. THOMAS EMSKOTTER Department of Neurology University Hospital Hamburg-Eppendorf Federal Republic of Germany Prof. Dr. med PAUL GOTZE Department of Psychiatry and Nervous Diseases University Hospital Hamburg-Eppendorf Federal Republic of Germany xi

xii Prof. LAVERNE D. GUGINO PhD, MD Department of Anesthesia Brigham and Women's Hospital Harvard Medical School Boston, MA USA Prof. RUBEN C. GUR PhD Departments of Psychiatry and Neurology Brain Behavior Laboratory and the Neuropsychiatry Program University of Pennsylvania Philadelphia, Pennsylvania USA Dr. med. G. HUSE-KLEINSTOLL Department of Medical Psychiatry University Hospital Hamburg-Eppendorf Federal Republic of Germany Prof. WAYNE O. ISOM MD Formerly of the Department of Surgery New York University Medical Center Presently Chairman-Department of Cardiothoracic Surgery Cornell University Medical College New York, New York USA Prof. E. ROY JOHN PhD Department of Psychiatry New York University Medical Center, NY and the Nathan S. Kline Institute for Psychiatric Research Orangeburg, New York USA Prof. Dr. med. P. KALMAR Department of Thoracic and Cardiovascular Surgery University Hospital Hamburg-Eppendorf Federal Republic of Germany JONATHAN D. KATZ MD Assoc. Prof. of Clinical Anesthesiology Yale University School of Medicine New Haven, Ct., Attending Anesthesiologist St. Vincent's Medical Center, Bridgeport, Ct. USA

xiii

Dr. med. H-J. KREBBER Department of Thoracic and Cardiovascular Surgery University Hospital Hamburg-Eppendorf Federal Republic of Germany MARK KURUSZ CCP Chief Perfusionist Department of Surgery, Division of Cardiothoracic Surgery The University of Texas Medical Branch Galveston, Texas USA Prof. Dr. med. L. LACHENMEYER Department of Neurology University Hospital Hamburg-Eppendorf Federal Republic of Germany Dr. phil. U. LAMPARTER Department of Psychosomatics University Hospital Hamburg-Eppendorf Federal Republic of Germany PIERRE M. LANDAU MS Department of Psychiatry New York University Medical Center New York, New York USA LA. LEUSINK MD Department of Anaesthesiology St. Antonius Hospital Nieuwegein The Netherlands Dr. phil. HEINZ-JORG MEFFERT Department of Thoracic and Cardiovascular Surgery University Hospital Hamburg-Eppendorf Federal Republic of Germany Prof. Dr. med. RUDOLF MEYENDORF Professor of General Psychopathology University of Munich Federal Republic of Germany

xiv STANTON P. NEWMAN PhD Department of Psychiatry Middlesex Hospital London UK JOHN C. OPIE MD, FRCS(C), FRCS Cardiovascular and Thoracic Surgeon Asst. Prof. University British Columbia (1982-1987) Western Heart and Lung Surgeons, Ltd. Phoenix, Arizona USA Prof. Dr. med. H. POKAR Department of Thoracic and Cardiovascular Surgery University Hospital Hamburg-Eppendorf Federal Republic of Germany Prof. LESLIE S. PRICHEP PhD Department of Psychiatry, NY University Medical Center and The Nathan S. Kline Institute for Psychiatric Research Orangeburg, New York USA Prof. CHARLES 1. RABINER MD Medical Director, Mesa Vista Hospital and Clinical Professor, Department of Psychiatry School of Medicine, University of San Diego San Diego, California USA The Late Prof. Dr. med. GEORG RODEWALD Department of Thoracic and Cardiovascular Surgery University Hospital Hamburg-Eppendorf Federal Republic of Germany PETER L.C. SMITH MD The Royal Postgraduate Medical School Hammersmith Hospital London UK Prof. K.A. SOTANIEMI MD, PhD Department of Neurology The University of Oulu Oulu Finland

xv

Prof. FREDERICK A. STRUVE PhD Neurophysiology Research Laboratory School of Medicine in Shreveport Louisiana State University Medical Center Shreveport, Louisiana USA Prof. PEKKA TIEN ARI MD Department of Psychiatry The University of Oulu Oulu Finland F.E.E. VERMEULEN MD Department of Cardiac Thoracic Surgery St. Antonius Hospital Nieuwegein The Netherlands Assoc. Prof. ALLEN E. WILLNER PhD Department of Psychology, Long Island Jewish Medical Center New Hyde Park, NY, and Albert Einstein College of Medicine, New York USA

Acknowledgements

I would like to thank several people who helped to make this book possible: The late Prof. Dr. med. Georg Rodewald who, by his constant example, keen intelligence, good sense of humor, and wise suggestions, had much to do with the assembling of this volume; the authors of all the chapters comprising this book for their indispensible contribution; Janet Sendar, Psy.D. who was cheerful, intelligent, thorough and patient in carrying out the seemingly endless tasks required to turn a collection of manuscripts into a book; Carol Ritter, Ph.D. who aided in much of the work in organizing this book, during the earlier stages; Alice Stahl, M.D. who provided a first translation of Prof. Rodewald's chapter from German into English; Sally Lauve, Psy.D. who extensively simplified and revised two chapters; Judy Killen, M.S. for much useful advice during the latter part of the revision process; Dr. phil. Jorg Meffert for his unfailing courtesy and helpfulness during the long process of knitting the book together; and finally, thanks to the Long Island Heart Council which helped to support this work financially. ALLEN WILLNER

xvii