title: Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.
abstract: OBJECTIVE
  The study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury.
  
  
  METHODS
  From June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (n = 60) or antegrade (n = 61) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury.
  
  
  RESULTS
  A total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; P = .2).
  
  
  CONCLUSIONS
  Although this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment.
authors.affiliation: Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address: svenssl@ccf.org.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Apperson-Hansen
authors.affiliation: Department of Neuroradiology, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Ruggieri
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Ponnuthurai
authors.initials: P
authors.lastname: Ainkaran
authors.affiliation: Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Richard I
authors.initials: RI
authors.lastname: Naugle
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Brian
authors.initials: B
authors.lastname: Lima
authors.affiliation: Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Maxwell
authors.initials: M
authors.lastname: Cooper
authors.affiliation: Department of Perfusion Services, Cleveland Clinic, Cleveland, Ohio.
authors.forename: David
authors.initials: D
authors.lastname: Somogyi
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: E Murat
authors.initials: EM
authors.lastname: Tuzcu
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.affiliation: Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Clair
authors.affiliation: Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D001930:Brain Injuries / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D002560:Cerebrovascular Circulation; D003071:Cognition; D019610:Cytoprotection; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000379:methods*; D009483:Neuropsychological Tests; D009820:Ohio; D010477:Perfusion / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D016037:Single-Blind Method; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: aortic arch; brain protection; circulatory arrest