Transplant and Heart Failure Lecture (Neuropsych Exam 3)

What do solid organ transplants involve?

• surgically placing organs from a donor - living OR deceased - in a patient

• last resort treatment for end-stage organ failure

• commonly transplanted organs: kidney, then liver, then heart, then lung (KLHL) —> think: liver comes first because people destroy it through drinking too much

• requires lifelong commitment to maintaining a healthy lifestyle and following a highly regimented treatment plan.

People who receive organ transplants have to follow a highly regimented treatment plan. What does that treatment plan entail?

• medications

• blood draw

• biopsy

• infection precautions

• dietary precautions

• lifestyle + nutrition

• wound care

• vital sign and weight monitoring

• rehabilitation

What is the ideal timeline of psychosocial assessment and intervention (for those who receive organ transplants)?

• patient is identified as needing a transplant

• screening takes place

• psychiatric evaluation for patient

• interdisciplinary discussion

• post-operative consultation

What is the definition of heart failure? Are there multiple subtypes? Is heart failure associated with mild cognitive impairment and dementia? 

Heart failure: when the heart CANNOT meet the demands of the body

Yes, there are many different subtypes

Yes, heart failure is associated with mild cognitive impairment and dementia 

What is vascular cognitive impairment/what is it caused by?

Risk factors and/or lifestyle and genetic variants can either promote or stave off damage to large and small cerebral blood vessels, which in turn leads to neuropathological changes that result in vascular cognitive impairment….

• ….through causing white matter (axon) disease, microinfarcts/microhemorrhages, large infarcts, and brain atrophy

• this can end up leading to vascular cognitive impairment (or VCI)

We can have mild vascular cognitive impairment and major vascular cognitive impairment (or vascular dementia). What does major vascular cognitive impairment/vascular dementia lead to?

Major vascular cognitive impairment can lead to:

• post-stroke dementia (dementia developing within 6 months of stroke)

• subcortical ischemic vascular dementia

• multi-infarct (cortical) dementia

• mixed dementia (ex. comorbid pathology - patient has a nonvascular cause of dementia, like Alzheimer’s disease or dementia with Lewy bodies)

What is the difference between mild and major vascular cognitive dementia (VCI)?

Mild VCI refers to impairment in at least 1 cognitive domain, and mild to no impairment in instrumental activities of daily living (ADLs) INDEPENDENT of the motor of sensory sequelae of the vascular event

Within the guidelines for major VCI (vascular major cognitive impairment) or VaD (vascular dementia), what are the core domains for cognitive assessment + what terms do we use to reflect the degree of certainty we have about the diagnosis, assuming we don’t use an MRI scan to “confirm”? Also, are patients subcategorized into the underlying pathology, or just sorted into one large umbrella group?

• core domains for cognitive assessment should include executive function, attention, memory, language, and visuospatial function

• the terms probable and possible are used to define the available evidence

• Yes, patients given a diagnosis of major VCI or VaD are subcategorized according to the underlying pathology, as appropriate

What is post-stroke dementia defined as?

An IMMEDIATE and/or delayed cognitive decline that begins within 6 months after a stroke and does not reverse.

What brain imaging method is the gold-standard requirement for a diagnosis of VCI/VaD? What do we use in case ____ is unavailable to scan the brain, and how do we modify our language/diagnosis to reflect the degree of certainty present?

• MRI is a “gold-standard” requirement for a clinical diagnosis of VCI

• PROBABLE mild VCI or PROBABLE major VCI (VaD) is the appropriate diagnostic category if computed tomography imaging is the only means of imaging possible

What is the definition of major VCI, which is synonymous with VaD?

CLINICALLY significant deficits of sufficient severity in at least 1 cognitive domain (deficits may be present in multiple domains) and SEVERE disruption to independent activities of daily living (ADLs) (independent of the motor/sensory sequelae of the vascular event)

What do we exclude from a diagnosis of VaD or VCI (major vascular cognitive impairment)?

drug/alcohol abuse or dependence within the last three months of first recognition of impairment or delirium

For the neuroimaging of vascular cognitive impairment, what are some things that we might expect to see, or end up seeing?

MRI (where we might see small vessel disease (SVD) and resulting lesions):

• white matter hyperintensities

• lacune

• perivascular spaces

• cerebral microbleeds

• cortical superficial siderosis

Diffusion tensor imaging (DTI), where we might see increased water diffusivity in the brain of a small vessel disease patient:

• fractional anisotrophy

• mean diffusivity

Diffusion-based analysis concepts (ways we analyze DTI scans, including regional and global approaches):

• skeleton-based tract analysis

• identification of connected structures (regional)

• altered whole brain network connectivity (global)

What is an LVAD?

A LVAD is a left ventricular assist device, which is a mechanical heart pump that helps a failing heart circulate blood

• its name is relevant since the left ventricle is actually what pumps oxygenated blood out to the body

• it consists of a driveline (which connects the internal pump to the external components), batteries (which provide portable power to the LVAD so the patient can move around), and a system controller (a small computer that controls and monitors the pump, and displays pump speed, power, and flow rates.

Patients who had LVADs in the past had a ____ amount of lobar, deep, and total CMBs (cerebral microbleeds) compared to healthy controls.

Higher

This makes sense because cerebral microbleeds are a marker of CHRONIC small vessel disease, or microhemorrhages caused by abnormal blood flow