Patel, RV; (2008) Intraoperative cerebral microembolisation and neuropsychological outcome following total hip and knee arthroplasty. Doctoral thesis , UCL (University College London).

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Abstract

Objective: A prospective controlled clinical trial assessing intraoperative cerebral microembolisation during total hip (THA) and total knee (TKA) arthroplasty and neuropsychological outcome. Detection of a patent formaen ovale (PFO) was performed to determine whether its presence or absence affected cerebral microembolic incidence and load. Examination of microemboli load in relation to specific surgical activity was performed.;Methods: Ninety-five patients were recruited who underwent neuropsychological assessment (NP group): a battery of tests administered pre-operatively, 6 weeks and 6 months post operatively. Roughly equal numbers underwent total hip or total knee arthroplasty. Intraoperative cerebral microembolisation was recorded by transcranial Doppler monitor over the middle cerebral artery. Evidence of PFO was sought using agitated saline injected into a large peripheral vein (a validated technique). Orthopaedic and Quality of Life outcome was also measured.;Results: The groups proved well balanced in pre-operative variables. The incidence of cerebral inicroembolisation for THA was 23% and 45% for TKA. During THA the median number and range of microemboli was 0(0 - 438): for TKA this was 0(0- 83). Mean microemboli load for THA was 2.80 (excluding one outlier) and for TKA 3.76. The overall prevalence of PFO was 29%. PFO did not appear to influence microemboli load or incidence. More microemboli were seen during femoral component impaction in the THA group and after tourniquet release in the TKA group. Overall patients showed an improvement in total NP change scores at both post-operative intervals. No relationship between microemboli and neuropsychological outcome was found. Good orthopaedic and Quality of Life outcome was recorded.;Conclusion: Intraoperative cerebral microembolisation occurs in a significant proportion of patients during THA and TKA recorded by transcranial Doppler. The microemboli load is low and is not influenced by the presence of PFO. Certain surgical acvtivities seem to be responsible for greater cerebral microemboli generation. However, in this study neuropsychological outcome was not affected post-operatively by microemboli or other operative or patient variables.

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