Anesthesia-related factors in the pathogenesis of postoperative cognitive dysfunction: a mechanistic perspective

Postoperative cognitive dysfunction (POCD) is a significant complication resulting from interactions between anesthesia-related neural disturbances and pre-existing vulnerability. This perspective delineates three major mechanisms: neuroinflammatory activation, oxidative mitochondrial injury, and impaired synaptic plasticity. These interconnected pathways collectively disrupt neuronal homeostasis and contribute to cognitive decline. Clinically, anesthetic choice influences risk, with volatile agents showing stronger neurotoxic potential, whereas dexmedetomidine provides anti-inflammatory benefits. Evidence-based strategies-such as processed electroencephalogram-guided titration, regional anesthesia to reduce opioid use, and cerebral oxygenation monitoring-have demonstrated measurable reductions in POCD incidence. Integrating these findings into a two-hit framework highlights anesthesia as a secondary insult superimposed on age-, frailty-, or metabolism-related vulnerability. Diabetes mellitus exemplifies this first-hit state by creating chronic neuroinflammation, mitochondrial dysfunction, and blood-brain barrier impairment that heighten susceptibility to perioperative stress. Future progress requires precision approaches, including genetic and biomarker-based risk stratification and mechanism-targeted neuroprotective therapies. Methodological limitations-such as heterogeneous assessments and underpowered studies-necessitate standardized multicenter trials with harmonized cognitive testing and extended follow-up. This perspective provides an integrated model of POCD pathogenesis and outlines priorities for advancing individualized perioperative neuroprotection.