Leyla DEMİR, Nejat SARIOSMANOĞLU, Berna Binnur AKDEDE, Can CİMİLLİ, Eyüp HAZAN, Öztekin OTO, Meral FADILOĞLU

Kardiyovasküler cerrahi sonrasında serum S-100B protein,NSE ve nitrik oksit düzeyleri ile bilişsel işlevler arasındaki ilişki

Amaç: Her yıl dünyada birçok insan kardiyovasküler cerrahi geçirmektedir. Koroner arter by-pass grafting ameliyatında cerrahi tekniklerdeki ilerleme sonucunda yüksek risk grubundaki hastalar da (hipertansiyon ve diyabet gibi) ameliyata alınabilmektedir. Yüksek risk grubundaki ve ileri yaştaki hastalara CABG uygulanması beraberinde nörolojik komplikasyonları da getirmiştir. Ortaya çıkan nörolojik sorunlar inme, ameliyat sonrası deliryum, bilişsel bozukluklar ve depresyondur. Bu nedenle ilgi son yıllarda kalbin ameliyat sonrası durumu yerine CABG’nin beyin üzerine de olan etkilerine kaymıştır. Gereç ve yöntem: Çalışmamıza CABG ve valf replasmanı geçiren 24 olgu alındı. Bu olgularda serebral hasarı göstermek amacı ile gliadan salınan S-100B protein, nöronlardan salınan nöron spesifik enolaz ve iskemi patofizyolojisinde birçok fonksiyonu olan nitrik oksid düzeyleri ölçüldü. Ayrıca hastaların bilişsel fonksiyonlarını ölçen nöropsikolojik testler uygulandı. Bu amaçla CABG ve VR ameliyatı geçiren 24 olgudan ameliyat öncesi ve ameliyattan sonra 1., 6. ve 24. saatler ve 3. ve 7. günlerde venöz kan alınarak S-100B protein, NSE ve NO düzeyleri ölçüldü. Nöropsikolojik testler ameliyattan önce ve ameliyat sonrası 3. ve 7. günlerde uygulandı. Bulgular: Nöropsikolojik testler sonucunda 8 olguda bilişsel fonksiyon kaybı saptandı. Bu olgularda ameliyat sonrası 1. ve 6. saatteki S-100B protein düzeyleri, perfüzyon zamanı ve olguların yaş ortalaması bilişsel kayıp saptanmayan grupla karşılaştırıldığında anlamlı yüksek bulundu. NSE, VR grubunda ameliyattan sonra 7.gün ameliyat öncesi değerlere göre anlamlı yüksek bulundu ancak bunun bilişsel fonksiyon kaybıyla bir bağlantısı saptanmadı. Ameliyat öncesi ve ameliyat sonrası NO düzeylerinde ise anlamlı fark bulunmadı. Sonuç: CABG hastaları içinde yaş ortalaması yüksek ve perfüzyon zamanı uzun olanlarda bilişsel fonksiyon kaybı daha fazla görülmektedir. Artan serum S-100B protein düzeyleri serebral etkilenme ve buna bağlı bilişsel fonksiyon kaybı ile koreledir.

The relationship between serum protein S-100B,NSB and nitric oxide levels and cognitive functions of patients following cardiovascular surgery

Objective: Every year, many people undergo cardiovasculary surgery in the world. Due to improvements in coronary artery bypass surgery (CABG) tecniques, patients in high risk also in advanced age groups, CABG cause many neurological complications like stroke, postoperative delirium, depression, cognitive decline etc. Because of these problems, the effect of CABG on the brain functions gain more importance with respect to effects on postoperative heart status last years. Material and method: In our study, 24 cases undergoing CABG and valve replacement were invastigated. Neuron-specific enolase released from neurons, protein S-100B released from glial cells and nitric oxide that known to have many functions in ischemia were studied in these cases to show cerebral effects of these operations. Also neuropsychological test using for assesment of cognitive functions were performed. We analysed protein S-100B, NSE, NO concentrations in serial venous blood samples taken preoperatively and 1, 6, 24 h and 3, 7 days postoperatively in 24 patients undergoing VR or CABG surgery. Neuropsychological tests were performed preoperatively, and 3. and 7 days after surgery. Results: After performing of neuropsychological tests, cognitive decline was seen in 8 cases. Protein S-100B levels at postoperative 1. and 6. hours and also the mean levels of age and perfusion times were significantly higher in these cases. NSE levels were significantly higher in VR group at postoperative7. days with respect to preoperative levels also. However there was no significant differance between preoperative and postoperative NO levels. Conclusions: Cognitive decline is seen in CABG patients with advanced age and with long perfusion time frequently. Increased protein S-100B levels in these patients are correlated with cerebral influence which cause distrubtion in cognitive functions.

PDF

___

1. Wimmer-Greinnecter G, Matheis G, Brieden M. Neuropsychological changes after cardiopulmonary bypass for coronary bypass grafting. Thorac Cardiovasc Surg 1998; 46:207-212.
2. Mills SA. Risk factors for cerebral injury and cardiac surgery. Ann Thorac Surg 1995; 59:1296-1299.
3. Fogel W, Krieger D, Veith M, et al. Serum neuronspecific enolase as early predictor of outcome after cardiac arrest. Crit Care Med 1997; 25:1133-1138.
4. Derkach DN, Okamoto H, Takahashi S. Neuronal and astroglial injuries in patients undergoing coronary artery bypass grafting and aortic arch replacement during hypothermic cardiopulmonary bypass. Anesth Analg 2000; 91:1066-1072.
5. Westaby S, Johnsson P, Parry AJ, et al. Serum S100 protein: a potential marker for cerebral events during cardiopulmonary bypass. Ann Thorac Surg 1996; 61:88-92.
6. Kunihara T, Shiiya N, Bin L, et al. Arterio-jugular differences in serum S-100 beta proteins in patients receiving selective cerebral perfusion. Surg Today 2006; 36:6-11.
7. Herrmann M, Ebert AD, Galazky I, et al. Neurobehavioral outcome prediction after cardiac surgery: role of neurobiochemical markers of damage to neuronal and glial brain tissue. Stroke 2000; 31:645-650.
8. Mielck F, Ziarkowski A, Hanekop G, et al. Cerebral inflammatory response during and after cardiac surgery. Eur J Anaesthesiol 2005; 22:347-352.
9. Jonsson H, Johnsson P, Alling C, et al. Significance of serum S100 release after coronary artery bypass grafting. Ann Thorac Surg 1998; 65:1639-1644.
10. Rothoerl RD, Brawanski A, Woertgen C. S-100B protein serum levels after controlled cortical impact injury in the rat. Acta Neurochir (Wien) 2000; 142:199-203.
11. Kilminster S, Treasure T, McMillan T, et al. Neuropsychological change and S-100 protein release in 130 unselected patients undergoing cardiac surgery. Stroke 1999; 30:1869-1874.
12. Hizli T, Gülen H, Akan P. Çocuklarda epileptik nöbet sonrası serum nöron spesifik enolaz düzeyleri. Dokuz Eylül Üniversitesi Tıp Fakültesi Dergisi 1999; 2:13-16.
13. Schoerkhuber W, Kittler H, Sterz F, et al. Time course of serum neuron-specific enolase. A predictor of neurological outcome in patients resuscitated from cardiac arrest. Stroke 1999; 30:1598-1603.
14. Herrmann M, Ebert AD, Tober D, et al. A contrastive analysis of release patterns of biochemical markers of brain damage after coronary artery bypass grafting and valve replacement and their association with the neurobehavioral outcome after cardiac surgery. Eur J Cardiothorac Surg 1999; 16:513-518.
15. Fadiloglu M, Gökmen N, Koçdor H. Serum Neuron Specific Enolase levels in experimental global serebral ischemia. Dokuz Eylül Üniversitesi Tip Fakültesi Dergisi 2000;14.
16. Castillo J, Rama R, Davalos A. Nitric oxide-related brain damage in acute ischemic stroke. Stroke 2000; 31:852- 857.
17. O'Mahony D, Kendall MJ. Nitric oxide in acute ischaemic stroke: a target for neuroprotection. J Neurol Neurosurg Psychiatry 1999; 67:1-3.
18. Green LC, Wagner DA, Glogowski J, et al. Analysis of nitrate, nitrite, and [15N]nitrate in biological fluids. Anal Biochem 1982; 126:131-138.
19. Öktem Ö. Nöropsikolojik testler ve nöropsikolojik değerlendirme. Türk Psikoloji Dergisi 1994; 9:33-44.
20. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189-198.
21. Jonsson H, Johnsson P, Backstrom M, et al. Controversial significance of early S100B levels after cardiac surgery. BMC Neurol 2004; 4:24.
22. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001; 72:1838-1844.
23. Murkin JM. Pathophysiological basis of CNS injury in cardiac surgical patients: detection and prevention. Perfusion 2006; 21:203-208.
24. Moody DM, Bell MA, Jonston WE, et al. Brain microemboli during cardiac surgery or aortography. Ann Neurol 1990; 28:477-486.
25. Selnes OA, Goldsborough MA, Borowicz LM, et al. Neurobehavioural sequelae of cardiopulmonary bypass. Lancet 1999; 353:1601-1606.