Haematological changes and state of hydration during delirium tremens and related clinical states

An exploratory research report on brain mineralization in postoperative delirium and cognitive decline

Delirium is a severe postoperative complication associated with poor overall and especially neurocognitive prognosis. Altered brain mineralization is found in neurodegenerative disorders but has not been studied in postoperative delirium and postoperative cognitive decline. We hypothesized that mineralization-related hypointensity in susceptibility-weighted magnetic resonance imaging (SWI) is associated with postoperative delirium and cognitive decline. In an exploratory, hypothesis-generating study, we analysed a subsample of cognitively healthy patients ≥65 years who underwent SWI before (N = 65) and 3 months after surgery (N = 33). We measured relative SWI intensities in the basal ganglia, hippocampus and posterior basal forebrain cholinergic system (pBFCS). A post hoc analysis of two pBFCS subregions (Ch4, Ch4p) was conducted. Patients were screened for delirium until the seventh postoperative day. Cognitive testing was performed before and 3 months after surgery. Fourteen patients developed delirium. After adjustment for age, sex, preoperative cognition and region volume, only pBFCS hypointensity was associated with delirium (regression coefficient [90% CI]: B = -15.3 [-31.6; -0.8]). After adjustments for surgery duration, age, sex and region volume, perioperative change in relative SWI intensities of the pBFCS was associated with cognitive decline 3 months after surgery at a trend level (B = 6.8 [-0.9; 14.1]), which was probably driven by a stronger association in subregion Ch4p (B = 9.3 [2.3; 16.2]). Brain mineralization, particularly in the cerebral cholinergic system, could be a pathomechanism in postoperative delirium and cognitive decline. Evidence from our studies is limited because of the small sample and a SWI dataset unfit for iron quantification, and the analyses presented here should be considered exploratory.

Delirium tremens and related clinical states: changes in calcium and inorganic phosphate concentrations in plasma and cerebrospinal fluid

Calcium and inorganic phosphate were measured in blood and cerebrospinal fluid (CSF) in 11 patients during impending delirium tremens (grade 2) and in nine patients with fully developed delirium tremens (grade 3). The initial sampling of blood and CSF was performed at admission before treatment was initiated. The blood sampling was repeated daily until recovery and at this time a second lumbar puncture was also performed. In grade 3 patients the plasma calcium concentration showed a transient increase after admission; in grade 2 patients the plasma calcium concentration was also somewhat elevated. The changes in plasma calcium concentration after admission correlated significantly with the changes in blood alcohol concentration. In grade 3 patients the CSF calcium concentration decreased between admission and recovery, this possibly relating to an increased cerebral binding capacity in the post intoxication period. No statistically significant changes were seen in either of the diagnostic categories as far as plasma inorganic phosphate concentrations are concerned. CSF inorganic phosphate concentration decreased in a fashion correlated with CSF alcohol concentration and, finally, CSF inorganic phosphate at admission was somewhat lower in grade 3 patients as compared to grade 2, this possibly reflecting a more severe disturbance of cerebral metabolism in grade 3 patients. Essentially, grade 3 patients had lower CSF concentrations of both calcium and inorganic phosphate as compared to grade 2 patients and thus there may exist real differences in the metabolism of these two ions when a severe withdrawal reaction (grade 2) is compared to fully developed delirium tremens (grade 3).

Delirium tremens: some clinico-chemical features. A study of alanine-aminotransferase, alcaline phosphatase, prothrombine and enolase

The relationship between variables reflecting liver disease (serum-alanine-aminotransferase (SGPT), serum alcaline phosphatase and plasma prothrombine) and the clinical signs and symptoms during delirium tremens (DT; grade 3) and related clinical states (grade 2) was studied. Furthermore, it was investigated whether the two isoenzymes of enolase which predominante in brain tissue were present in plasma or cerebrospinal fluid (CSF) in DT patients. A correlation between SGPT and clinical state was not observed, which indicates that a causal relationship does not exist between acute liver cell damage and clinical state during DT of grade 3 or 2. In grade 2 patients, but not in grade 3 patients, both SGPT and serum alcaline phosphatase decreased between admission and recovery. This difference between the groups may be due to a higher alcohol consumption and a shorter interval between last drink and admission in grade 3. The difference in recent drinking history may also account for the finding of a higher plasma prothrombine index in grade 3 compared with grade 2, because chronic ethanol intoxication may be accompanied by enhanced hepatic protein synthesis. "Brain-enolase" was not present in detectable amounts in blood or CSF during DT thus suggesting that brain cell damage resulting in leakage of this enzyme from the cells did not prevail during DT.