{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,26]],"date-time":"2026-09-26T03:02:50Z","timestamp":1790391770863,"version":"4.1.0"},"reference-count":36,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2024,9,24]],"date-time":"2024-09-24T00:00:00Z","timestamp":1727136000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>Advances in spine surgery enable safe interventions in elderly patients, but perioperative neurocognitive disorders (pNCD), such as post-operative delirium (POD) and cognitive dysfunction (POCD), remain a serious concern. Pre-operative cognitive impairment is a major risk factor for pNCD. Comprehensive pre-operative cognitive assessments are not feasible in clinical practice, making effective screening methods desirable. This study investigates whether pre-operative cerebrovascular duplex sonography can assess subcortical (vascular) cognitive impairment and the risk for POD.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This prospective single-center study recruited patients aged \u226560\u2009years scheduled for elective spine surgery at a German university hospital. Patients underwent pre-operative assessments including cognitive abilities (CERAD test battery), structural MRI, and cerebrovascular duplex sonography. POD screening was conducted three times daily for at least 3\u2009days. The primary hypothesis, that the mean pulsatility index (PI) of both internal carotid arteries (ICA) predicts POD risk, was tested using logistic regression. Secondary analyses examined the association between POD risk and ICA flow (time-averaged peak velocities, TAPV) and correlations with cognitive profiles and MRI characteristics.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>POD occurred in 22% of patients (<jats:italic>n<\/jats:italic>\u2009=\u200922\/99) within three postoperative days. Patients with POD were significantly older (75.9\u2009\u00b1\u20095.4 vs. 70.0\u2009\u00b1\u20096.9\u2009years, <jats:italic>p<\/jats:italic>\u2009&amp;lt;\u20090.01) but did not differ by gender (<jats:italic>p<\/jats:italic>\u2009=\u20090.51). ICA PI significantly predicted POD risk (OR\u2009=\u20095.46 [95%CI: 1.81\u201316.49], <jats:italic>p<\/jats:italic>\u2009=\u20090.003), which remained significant after adjustment for age and duration of surgery (OR<jats:sub>adj<\/jats:sub>\u2009=\u20096.38 [95% CI: 1.77\u201323.03], <jats:italic>p<\/jats:italic>\u2009=\u20090.005). TAPV did not inform the POD risk (<jats:italic>p<\/jats:italic>\u2009=\u20090.68). ICA PI Pre-operative cognitive scores were significantly associated with ICA PI (mean CERAD score: <jats:italic>r<\/jats:italic>\u2009=\u2009\u22120.32, <jats:italic>p<\/jats:italic>\u2009&amp;lt;\u20090.001). ICA PI was also significantly associated with total white matter lesion volume (<jats:italic>\u03c4<\/jats:italic>\u2009=\u20090.19, <jats:italic>p<\/jats:italic>\u2009=\u20090.012) and periventricular white matter lesion volume (<jats:italic>\u03c4<\/jats:italic>\u2009=\u20090.21, <jats:italic>p<\/jats:italic>\u2009=\u20090.007).<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>This is the first study to demonstrate that cerebrovascular duplex sonography can assess the risk for POD in elderly spine surgery patients. Increased ICA PI may indicate subcortical impairment, larger white matter lesion load, and lower white matter volume, predisposing factors for POD. Pre-operative cerebrovascular duplex sonography of the ICA is widely available, easy-to-use, and efficient, offering a promising screening method for POD risk. Increased ICA PI could supplement established predictors like age to adjust surgical and peri-operative procedures to individual risk profiles.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fmed.2024.1433380","type":"journal-article","created":{"date-parts":[[2024,9,24]],"date-time":"2024-09-24T04:28:27Z","timestamp":1727152107000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["Cerebrovascular pulsatility indicates preoperative subcortical cognitive impairment and an increased risk for postoperative delirium in elderly patients undergoing elective spine surgery"],"prefix":"10.3389","volume":"11","author":[{"given":"Angelika","family":"Saar","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonas","family":"M\u00fcller","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yannick","family":"Veser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederik","family":"Behr","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eiko","family":"Rathmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henry W. S.","family":"Schroeder","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agnes","family":"Fl\u00f6el","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan-Uwe","family":"M\u00fcller","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bettina","family":"von Sarnowski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Fleischmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2024,9,24]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1259","DOI":"10.1001\/jama.2010.338","article-title":"Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults","volume":"303","author":"Deyo","year":"2010","journal-title":"JAMA"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1056\/NEJMoa1112923","article-title":"Cognitive trajectories after postoperative delirium","volume":"367","author":"Saczynski","year":"2012","journal-title":"N Engl J Med"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1093\/bja\/aex053","article-title":"Association between delirium and cognitive change after cardiac surgery","volume":"119","author":"Sauer","year":"2017","journal-title":"Br J Anaesth"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"CD013307","DOI":"10.1002\/14651858.CD013307.pub3","article-title":"Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients","volume":"2021","author":"Burton","year":"2021","journal-title":"Cochrane Database Syst Rev"},{"key":"ref5","volume-title":"Duration of Surgery and Intraoperative Blood Pressure Management are Modifiable Risk Factors for Postoperative Neurocognitive Disorders Following Spine Surgery: Results of the Prospective CONFESS Study. Spine (Phila Pa 1976)","author":"Muller","year":"2023"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"2133","DOI":"10.1111\/jgs.18843","article-title":"Gaps in cognitive care among older patients undergoing spine surgery","volume":"72","author":"Barreto Chang","year":"2024","journal-title":"J Am Geriatr Soc"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"109724","DOI":"10.1016\/j.jclinane.2020.109724","article-title":"Rapid in-person cognitive screening in the preoperative setting: Test considerations and recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI)","volume":"62","author":"Arias","year":"2020","journal-title":"J Clin Anesth"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"e15488","DOI":"10.2196\/15488","article-title":"Evaluating Mechanisms of Postoperative Delirium and Cognitive Dysfunction Following Elective Spine Surgery in Elderly Patients (CONFESS): Protocol for a Prospective Observational Trial","volume":"9","author":"Muller","year":"2020","journal-title":"JMIR Res Protoc"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"2291","DOI":"10.1161\/01.STR.30.11.2291","article-title":"Diagnostic impact of cerebral transit time in the identification of microangiopathy in dementia: A transcranial ultrasound study","volume":"30","author":"Puls","year":"1999","journal-title":"Stroke"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"95835","DOI":"10.3390\/jcm11195835","article-title":"The role of vascular risk factors in post-stroke delirium: a systematic review and meta-analysis","volume":"11","author":"Siokas","year":"2022","journal-title":"J Clin Med"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"2672","DOI":"10.1161\/STR.0b013e3182299496","article-title":"Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association\/american stroke association","volume":"42","author":"Gorelick","year":"2011","journal-title":"Stroke"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"3398","DOI":"10.1093\/brain\/awr253","article-title":"Arterial stiffness, pressure and flow pulsatility and brain structure and function: the Age, Gene\/Environment Susceptibility--Reykjavik study","volume":"134","author":"Mitchell","year":"2011","journal-title":"Brain"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1161\/01.STR.31.1.147","article-title":"Color duplex measurement of cerebral blood flow volume in healthy adults","volume":"31","author":"Scheel","year":"2000","journal-title":"Stroke"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1016\/S0022-510X(02)00256-3","article-title":"Similarities between Alzheimer\u2019s disease and vascular dementia","author":"Kalaria","year":"2002","journal-title":"J Neurol Sci"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"829","DOI":"10.1097\/ALN.0000000000002194","article-title":"Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms","volume":"129","author":"Berger","year":"2018","journal-title":"Anesthesiology"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"106981","DOI":"10.1016\/j.jstrokecerebrovasdis.2023.106981","article-title":"Associations of carotid artery flow parameters with MRI markers of cerebral small vessel disease and patterns of brain atrophy","volume":"32","author":"Ellstrom","year":"2023","journal-title":"J Stroke Cerebrovascular Diseases Off J Natl Stroke Assoc"},{"key":"ref17","volume-title":"S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der extracraniellen Carotisstenose","author":"D\u00f6rfler","year":"2020"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"215","DOI":"10.1111\/j.1552-6569.2010.00523.x","article-title":"Practice standards for transcranial Doppler (TCD) ultrasound. Part II. Clinical indications and expected outcomes","volume":"22","author":"Alexandrov","year":"2012","journal-title":"J Neuroimaging"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1751","DOI":"10.1161\/01.STR.30.9.1751","article-title":"The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients","volume":"30","author":"Ferguson","year":"1999","journal-title":"Stroke"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1097\/JGP.0b013e318209dd08","article-title":"The assessment of changes in cognitive functioning: age-, education-, and gender-specific reliable change indices for older adults tested on the CERAD-NP battery: results of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (Age CoDe)","volume":"20","author":"Stein","year":"2012","journal-title":"Am J Geriatr Psychiatr Off J Am Assoc Geriatr Psychiatr"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"801","DOI":"10.1097\/JGP.0b013e3181cab764","article-title":"Total scores of the CERAD neuropsychological assessment battery: validation for mild cognitive impairment and dementia patients with diverse etiologies","volume":"18","author":"Seo","year":"2010","journal-title":"Am J Geriatr Psychiatr Off J Am Assoc Geriatr Psychiatr"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1177\/0271678X18803956","article-title":"Small vessel disease is associated with altered cerebrovascular pulsatility but not resting cerebral blood flow","volume":"40","author":"Shi","year":"2020","journal-title":"J Cereb Blood Flow Metab"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"491","DOI":"10.1093\/biomet\/93.3.491","article-title":"Adaptive linear step-up procedures that control the false discovery rate","volume":"93","author":"Benjamini","year":"2006","journal-title":"Biometrika"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1186\/1476-7120-5-3","article-title":"Low prevalence of significant carotid artery disease in Iranian patients undergoing elective coronary artery bypass","volume":"5","author":"Tarzamni","year":"2007","journal-title":"Cardiovasc Ultrasound"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"S2","DOI":"10.1016\/j.jvs.2008.08.042","article-title":"The Society for vascular surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access","volume":"48","author":"Sidawy","year":"2008","journal-title":"J Vasc Surg"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"e335","DOI":"10.3390\/ijms241210335","article-title":"Serum biomarkers of a pro-neuroinflammatory state may define the pre-operative risk for postoperative delirium in spine surgery","volume":"24","author":"Ruhnau","year":"2023","journal-title":"Int J Mol Sci"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"2036","DOI":"10.1212\/WNL.0000000000003951","article-title":"Relationship between carotid arterial properties and cerebral white matter hyperintensities","volume":"88","author":"Rundek","year":"2017","journal-title":"Neurology"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"688","DOI":"10.1111\/ane.12787","article-title":"Accelerated atherosclerosis in ANCA-associated vasculitis","volume":"136","author":"Gonzalez-Suarez","year":"2017","journal-title":"Acta Neurol Scand"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"c3666","DOI":"10.1136\/bmj.c3666","article-title":"The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis","volume":"341","author":"Debette","year":"2010","journal-title":"BMJ"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"1450","DOI":"10.1161\/01.STR.30.7.1450","article-title":"Success rate of transcranial color-coded duplex ultrasonography in visualizing the basal cerebral arteries in vascular patients over 60 years of age","volume":"30","author":"Hoksbergen","year":"1999","journal-title":"Stroke"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1038\/s41572-020-00223-4","article-title":"Delirium","volume":"6","author":"Wilson","year":"2020","journal-title":"Nat Rev Dis Primers"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"171","DOI":"10.1097\/CCM.0000000000002149","article-title":"Improving hospital survival and reducing brain dysfunction at seven california community hospitals: implementing PAD guidelines via the ABCDEF Bundle in 6, 064 Patients","volume":"45","author":"Barnes-Daly","year":"2017","journal-title":"Crit Care Med"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"679933","DOI":"10.3389\/fnagi.2021.679933","article-title":"Presurgical screening improves risk prediction for delirium in elective surgery of older patients: the PAWEL RISK study","volume":"13","author":"Eschweiler","year":"2021","journal-title":"Front Aging Neurosci"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1513\/AnnalsATS.201507-454OC","article-title":"Reduced cerebral perfusion pressure during lung transplant surgery is associated with risk, duration, and severity of postoperative delirium","volume":"13","author":"Smith","year":"2016","journal-title":"Ann Am Thorac Soc"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"101886","DOI":"10.1016\/j.inat.2023.101886","article-title":"Position-dependent hemodynamic changes in neurosurgery patients: A narrative review","volume":"36","author":"Emamimeybodi","year":"2024","journal-title":"Interdiscipl Neurosurg"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"2676591241239823","DOI":"10.1177\/02676591241239823","article-title":"The association between cerebral blood flow variations during on-pump coronary artery bypass grafting surgery and postoperative delirium","volume":"2024","author":"Sampaolesi","year":"2024","journal-title":"Perfusion"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2024.1433380\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,9,24]],"date-time":"2024-09-24T04:28:30Z","timestamp":1727152110000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2024.1433380\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,9,24]]},"references-count":36,"alternative-id":["10.3389\/fmed.2024.1433380"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2024.1433380","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,9,24]]},"article-number":"1433380"}}