Hydroxychloroquine and Cognitive Function After Surgery
Phase: PHASE4
Conditions: Individuals Undergoing Cardiac and General Surgery
Sponsor: Duke University

 
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Hydroxychloroquine and Cognitive Function after Surgery 
 
NCT03025087 
 
Document Date: 11/29/2020

 
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Hydroxychloroquine and Cognitive Function after Surgery 
 
 
Purpose of the study  
As our population ages, the manifestations of systemic atherosclerosis (stroke, cognitive 
impairment) extend the burden on the healthcare delivery system. The consequences of 
atherosclerosis are particularly relevant during surgery, where perioperative neurologic events 
can have a dramatically detrimental effect on the duration and quality of survival. The long-term 
objective of our multidisciplinary Neurological Outcome Research Group (NORG) is to 
understand the mechanisms underlying neurologic and neurocognitive dysfunction after surgery 
and to reduce the incidence of these devastating outcomes.   
 
 
This study is a pilot investigation intended to gather preliminary information to assess the 
efficacy of hydroxychloroquine to preserve blood brain barrier integrity, decrease inflammation, 
and improve cognitive function after surgery including cardiac surgery with cardiopulmonary 
bypass (CPB). Our study is based on a model (see Figure) that surgical trauma (irrespective of 
type of surgery) with general anesthesia evokes a systemic inflammatory response.(1) Damage-
associated molecular pattern (DAMPs), including HMGB1, are released in the systemic 
circulation 
contributing 
to 
the 
permeability of the blood–brain barrier 
(BBB). Opening of the BBB allows 
peripheral cytokines and alarmins to 
enter the brain and the CNS, causing 
neuroinflammation. 
In 
the 
hippocampus, 
HMGB1 
activates 
receptor for advanced glycation end 
products 
(RAGE) 
signaling 
thus 
perpetuating 
the 
inflammatory 
response and further contributing to 
neuroinflammation, including de novo 
synthesis of cytokines like TNF-a and 
IL-1b. 
Activation 
of 
this 
positive 
feedback loop accounts for memory 
dysfunction and possibly localized 
synaptic/neuronal deficits. 
 
Preliminary data from our pilot study (Pro00045387) indicates that blood brain barrier disruption 
occurs in about 60% of cardiac surgery patients and 50% of noncardiac surgery patients. 
Including an expanded cohort of patients will allow the investigation of differences in the 
outcomes of interest by surgery type. 
The primary purposes of this pilot investigation are to: 
 
1. Obtain data on the pharmacokinetics of hydroxychloroquine during surgery. 
2. Determine the effect of hydroxychloroquine upon blood brain barrier (BBB) integrity after 
surgery. 
3. Determine the effect of hydroxychloroquine upon perioperative inflammation. 
4. Determine the relationship between hydroxychloroquine, inflammation, BBB disruption 
and neurological/neurocognitive function after surgery.  
 
 

 
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Background & Significance  
Cognitive decline after surgery has generated great scientific and public interest because brain 
dysfunction leads to a reduction in quality of life for both the patient and their family. While there 
has been substantial advancement in perioperative organ protection leading to reductions in 
mortality associated with surgery, the incidence of cognitive dysfunction has changed little over 
the last ten years, despite substantial advances in pharmacology and technology. This 
phenomenon is related in part to the changing surgical population. Although older patients are 
now able to safely undergo surgical procedures without serious concern over loss of life, these 
elderly individuals are at a substantially increased risk for central nervous system dysfunction, 
particularly, cognitive decline. The clinical and financial implications resulting from these 
problems can be profound, with prolonged hospitalization and increased resource utilization 
being associated with major and minor neurobehavioral deficits.  
 
Our investigations to date demonstrate that cognitive impairment occurs frequently in the large 
number of increasingly elderly patients undergoing cardiac operations every year. Post-
operative cognitive deficit (POCD) is present in 36% of patients at 6 weeks after surgery and 
importantly, persists in 42% of patients up to five years after surgery.(2) Similarly after 
noncardiac surgery, the incidence of POCD was over 50% at 6 weeks after surgery and 
approximately 45% at 1 year after surgery.(3) Moreover, perioperative cognitive decline predicts 
long-term cognitive dysfunction, with dysfunction resulting in reduced quality of life.(4,5)  
 
In addition to ischemia due to hypoperfusion and distal embolization, cardiac surgery elicits a 
systemic inflammatory response that may lead to a disruption of the BBB and neurologic 
dysfunction.(6) In experimental models, the use of CPB leads to opening of the BBB.(7,8) 
Disruption of the BBB can be seen on MR imaging (MRI) as enhancement of the subarachnoid 
space on post-contrast FLAIR images. Under normal conditions, gadolinium-containing 
compounds do not cross the BBB. Under ischemic conditions, however, an increase in MMP-9 
leads to proteolytic breakdown of the BBB integrity that allows passage of gadolinium to the 
CSF and the parenchyma. Because gadolinium shortens T1, it disrupts the CSF signal 
suppression of FLAIR, and CSF appears hyperintense. In a recent study of 19 cardiac surgery 
patients who underwent MRI in the postoperative period, approximately 50% of the patients 
demonstrated disruption of the blood brain barrier.(9) However, neurological/neurocognitive 
function was not assessed in this study. Furthermore, preliminary data from our pilot study 
(Pro00045387) indicates that blood brain barrier disruption occurs in about 60% of cardiac 
surgery patients and 50% of noncardiac surgery patients and that this increase in permeability 
may be associated with worsened cognitive function at 6 weeks after surgery.  
 
Hydroxychloroquine (HCQ) is an antimalarial compound that has been reported to have 
therapeutic effects in a wide array of conditions, including diabetes mellitus, dyslipidemias, 
coagulopathies, infectious diseases and malignancies. Mechanisms of action responsible for 
these effects likely include altered signaling through cellular receptors, post-glycosylation 
modifications of infectious agents, decreases in levels of inflammatory mediators and inhibition 
of autophagy. Many of the pathways are likely dependent on drug-induced changes in intra-
endosomal acidity.(10,11) Therapeutic activity in autoimmune diseases may also be due to its 
activity as a toll-like receptor 9 (TLR 9) antagonist and through inhibition of quinone reductase 2 
(QR2).(12,13) 
 
Although use of the antimalarials in cutaneous lupus dates to the 1890s with J.S.Payne’s 
description of the efficacy of quinine in inducing pallor in a patient with photosensitive malar 
rash, it was not until the 1950s that their usefulness in cutaneous lupus erythematosus and, 

 
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subsequently, SLE became widely recognized.(14) For years chloroquine, followed by the less 
toxic HCQ, were limited to use in mild RA and for the joint and skin manifestations of SLE. With 
a broadening understanding of its mechanisms of action, HCQ has become a cornerstone of 
therapy in SLE, reducing its morbidity and mortality. HCQ, like quinine and the other 
antimalarials, is a weak base capable of easily gaining entry into cells and gravitating to the 
acidic compartments of lysosomes and other cytoplasmic vesicles, raising their pH incrementally 
and altering protein processing. This long-recognized effect, by hindering antigen presentation, 
receptor recycling, and protein excretion, is thought to lead to a downstream reduction in 
autoantibody formation and T-cell activation.(15,16) More recently, HCQ has been shown to 
disrupt even earlier events in the immune activation cascade by inhibiting the function of TLRs 
3, 7, and 9 stationed on the lysosomal membranes. By inhibiting the triggering of these TLRs by 
self DNA, RNA, and immune complexes, HCQ interrupts and deescalates the ongoing 
inflammatory processes of RA and SLE.(17-19) In vitro, aminoquinoline compounds are 
specifically 
effective 
against 
beta-amyloid 
protein 
induced 
neurotoxicity.(20) 
Hydroxychloroquine 
suppresses 
acute-phase 
reactants, 
lymphocyte 
responsiveness, 
macrophage function, and cytokine release.(20-23) 
 
HCQ is now considered a mainstay of therapy in lupus. Its clinical effects in SLE include 
improvement in rash and joints, reduction in flares, improved renal outcomes, a reduction in 
vascular events, and improved mortality.(24-27) It also has efficacy in mild to moderate RA and 
has been shown in multiple studies to have a protective effect against arterial and venous 
thrombosis in SLE patients.(28) HCQ has been shown to have a potential antithrombotic role in 
the antiphospholipid (APL) antibody syndrome, possibly by interfering with the binding of APL 
antibodies to the endogenous anticoagulant annexin A5.(29) It also has a favorable effect on 
lipid profiles and glucose metabolism, which may improve the cardiovascular profiles of our 
patients with these atherogenic diseases. 
 
In animal models, the aminoquinolines have been shown to be protective against BBB 
dysfunction. In one study, mice were pretreated with either chloroquine or saline for six 
consecutive days and then given a dose of kainic acid, which is known to induce seizures and 
cause BBB dysfunction.(30) Animals treated with chloroquine had less IgG and serum protein 
extravasation into the brain compared with controls, indicating better preservation of the BBB.  
 
In a recently completed study at Duke (unpublished data), adult male Sprague-Dawley rats 
underwent 60 minutes of deep hypothermic circulatory arrest (DHCA) at 18°C after being 
pretreated with either Chloroquine (25mg/kg) vs. PBS vehicle, or a selective quinone reductase 
2 (QR2) inhibitor (25mg/kg) vs. 50% DMSO vehicle administered intraperitoneally 2 hours 
before CPB (n=3-4). Brain magnetic resonance imaging (MRI) was performed on postoperative 
day (POD) 1 using a 7T Bruker Biospec horizontal bore scanner, and neurologic function scores 
were assessed on POD 1 and 2. Brain samples harvested 48 hours after CPB/DHCA were used 
to quantify necrotic neurons (acid fuchsin-celestine blue) in 5 representative areas of cortex and 
CA1 hippocampus. MRI analysis revealed a decrease in blood brain barrier permeability as 
measured by gadolinium chelate in animals treated with chloroquine or selective QR2 inhibitor 
compared to their respective control groups (p< 0.05). Histologically, animals treated with 
chloroquine or QR2 inhibitor exhibited lower numbers of cortical and hippocampal necrotic cells 
compared to vehicle-treated animals (p<0.05, respectively). QR2 inhibition also improved 
neurologic function on POD1 (neurologic score 2.33 ± 0.58 in QR2 inhibitor vs 4.33 ± 0.58 in 
DMSO vehicle; p< 0.05). 
 

 
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As a consequence of its anti-inflammatory, antimicrobial, and BBB preservation properties and 
its long history of safety, particularly with short-term use, HCQ may be an ideal candidate for 
evaluation as a neuroprotective agent following surgery. 
 
Design & Procedures  
This study is a pilot investigation intended to gather preliminary information to assess the 
efficacy of hydroxychloroquine to preserve blood brain barrier integrity and improve cognitive 
function after surgery. In this clinical trial, up to 50 informed and consenting patients >50 years 
of age will be prospectively enrolled over a 1-year period to provide 30 evaluable subjects.  
 
Study Procedure 
Patients selected for enrollment will be informed of the study, as well as the risks and benefits of 
participation.  Patients will be invited to participate and a log of all patients and those that accept 
and reject the invitation will be kept. As part of enrollment, a Mini Mental Status Exam (MMSE) 
will be performed and all patients scoring < 26 will be excluded to minimize the possibility of 
early dementia in our patient samples. Similarly patients scoring >27 on the Center for 
Epidemiological Studies – Depression (CES-D) scale (indicating severe depression) will be 
excluded. If patients develop renal failure (GFR < 30 ml/min/1.73 sq.m) postoperatively (after 
consent), they will not receive gadolinium based contrast for MRI. 
 
Hydroxychloroquine Administration 
The average adult dose of HCQ in the initial management of lupus is 400 mg once or twice 
daily. Similarly, the initial dose in rheumatoid arthritis is 400-600 mg daily.(31) Recently, HCQ 
has been administered safely to 19 subjects at a dose of 1000 mg daily as an adjuvant to lung 
cancer chemotherapy (median follow-up 9.1 months).(32) We therefore propose a dose 
escalation protocol as follows: 
• Phase 1 – 6 evaluable subjects (3 cardiac, 3 noncardiac): 1000 mg HCQ on the day prior 
to surgery. 
• Phase 2 – 6 evaluable subjects (3 cardiac, 3 noncardiac): 1000 mg HCQ on the day prior 
to surgery followed by 400 mg daily until the day of MRI imaging on postoperative day 1-
5. 
• Phase 3 – 6 evaluable subjects (3 cardiac, 3 noncardiac): 1000 mg HCQ on the day prior 
to surgery followed by 400 mg twice daily (800 mg total) until the day of MRI imaging on 
postoperative day 1-5. 
• Phase 4 – 6 evaluable subjects (3 cardiac, 3 noncardiac): 1000 mg HCQ on the day prior 
to surgery followed by 500 mg twice daily (1000 mg total) until the day of MRI imaging on 
postoperative day 1-5. 
• Phase 5 – 6 evaluable subjects (3 cardiac, 3 noncardiac): 1000 mg HCQ 1-2 hours after 
separation from CPB or at end of noncardiac surgery followed by the highest tolerated 
dose from the previous 4 phases divided into 2 equal daily doses until the day of MRI 
imaging on postoperative day 1-5. 
 
All doses will be provided per oral or per nasogastric tube that is routinely placed after cardiac 
surgery. A total of 50 patients are proposed to account for drop-outs (drug intolerance, MRI 
exclusions; unwilling to return at 6 weeks). Subject who do not complete MRI during their 
hospitalization will continued to be followed at 6 weeks and 1 year, however, they will not be 
included as an evaluable subject and will need to be replaced to meet the required number of 
evaluable subject per phase.  
 

 
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A safety review will be done prior to dose escalation. After all subjects in each dose group have 
completed study procedures through post-operative Day 4-5, all available safety information will 
be reviewed by the principal investigator (PI) and Dr. Eddie Jooste (Anesthesiology CRU 
Director). If there are no clinically significant safety concerns at a given dose, the study may 
continue escalation to the next higher dose. 
 
Safety will be assessed by the following outcome measures: 
• Examination of adverse events 
  Examination of QTc values 
• Examination of abnormal changes in hemodynamic measurements (heart rate, blood pressure) 
• Clinically significant abnormal changes in laboratory values compared with baseline 
(hematology, chemistry, urinalysis) 
• Evaluation of concomitant medications and CPB procedure parameters (time on CPB, cross-
clamp time, urine output during surgery, any difficulty separating from CPB [such as the need 
for intra-aortic balloon pump, left ventricular assist device or reinstitution of CPB]) will also be 
taken into consideration in the evaluation of subject safety. 
 
 
Neuropsychological Assessment Procedures 
Once identified as meeting study criteria and consented for participation, patients will be tested 
prior to surgery, at 6 weeks (± 2 weeks) and 1 year (± 1 month) post-surgery with the cognitive 
battery detailed below. All testing will be conducted by experienced psychometricians either in 
the patient’s hospital room or in the Behavioral Testing Laboratory located in Duke South. 
 
1. Hopkins Verbal Learning Test - Revised (HVLT-R) - The Hopkins Verbal Learning Test is 
a word-list learning task used to assess memory. Over three trials, a 12-word list of three 
semantic categories is presented to the examinee who then recalls as many words as 
possible, in any order. After a 20-30 minute, a delayed recall and a delayed recognition 
trial are administered. 
 
2. Randt Short Story Memory Test – The Randt requires subjects to repeat a brief 
paragraph that has been read aloud to them. Verbatim and gist recall is evaluated 
immediately and after a 30-minute delay. The test is used to assess discourse memory 
(immediate and delayed) and oral language comprehension. 
 
3. Modified Visual Reproduction Test from the Wechsler Memory Scale – This test 
measures short- and long-term figural memory and requires subjects to reproduce from 
memory several geometric shapes both immediately and after a 30-minute delay. 
 
4. Selected subtests from the WAIS-R –  
a) Digit Span – This is a test of short-term auditory memory and attention that requires 
subjects to repeat a series of digits that have been orally presented to them both 
forward and, in an independent test, in reverse order. 
b) Digit Symbol – This test measures psychomotor processing speed and attention 
and requires subjects to reproduce, within 90 seconds, as many coded symbols as 
possible in blank boxes beneath randomly generated digits, according to a coding 
scheme for pairing digits with symbols. 
c)  WRAT 3 Reading Subtest -The WRAT-3 test assesses the basic reading skills. It 
has two alternative testing forms (blue and tan). One form is administered with the 
second form available if needed. Each reading test consists of 15 letters and 42 
individual words printed on a plastic card. The examinee is asked to read the words 
loudly while the examiner follows a phonetic guide for each reading item. One point is 

 
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given for each correct letter and word. A maximum of 57 points can be earned on 
either the blue or the tan form. The raw scores are recorded at the bottom of the word 
reading section. 
 
5. Trail Making Test, Part A and B – Trails is a test of processing speed and attention. In 
Part A, subjects are required to connect a series of numeric circles as quickly as 
possible. In Part B, subjects connect a series of numeric and alphabetic circles in order 
(e.g., 1-A-2-B etc.) as quickly as possible. 
 
6. Grooved Pegboard – Timed test of motor speed and coordination recommended by 
consensus panels on the assessment of cognitive decline after surgery. This test is used 
to control for generalized slowing in performance which might confound performance on 
some of the other timed neuropsychological tests. 
 
8. Stroop Test - The Stroop Task is a psychological test of our mental (attentional) vitality 
and flexibility. The task takes advantage of our ability to read words more quickly and 
automatically than we can name colors. If a word is printed or displayed in a color 
different from the color it actually names; for example, if the word "green" is written in 
blue ink we will say the word "green" more readily than we can name the color in which it 
is displayed, which in this case is "blue." The cognitive mechanism involved in this task is 
called directed attention, you have to manage your attention, inhibit or stop one 
response in order to say or do something else.  
 
The series of test listed above will be recorded using a digital voice recorder for quality 
assurance purposes. Quality assurance activities will include reviewing of testing audio files, 
generating performance review documents, and providing feedback on accuracy and 
completeness. There is no risk to the study subject since patient identifiers will not be provided. 
Study subjects will not be identified by name on the recording. Only the study number, test date 
and initials of the tester will be provided on the digital file label. The link between study number 
and patient identifiers will be maintained only at the study site. Digital files will be sent to the 
Duke University Neurocognitive Core Laboratory office located at Duke University Medical 
Center, Room 215 Baker House, Durham, North Carolina 27710. These files will be stored on 
locked computers within locked offices to which only authorized research personnel will have 
access. These files will be destroyed after the primary outcome analysis of this research study is 
complete. 
 
Delirium Assessment 
 Subjects will undergo a 3D CAM prior to surgery and nonintubated patients will have the 3D 
CAM on post-operative days 1, 2, and 3.  If the patient is intubated during their post-operative 
course, a CAM-ICU delirium assessment will be performed in place of the 3D CAM. 
 
Neurological Testing  
Neurologic history and physical exam will be completed preoperatively (baseline), six weeks (± 
2 weeks), and one-year (± 1 month) after surgery. To allow comparison with stroke trials, the 
NIH Stroke Scale (NIHSS) will be used. NIHSS, a serial measure of neurologic deficit, is a 42-
point scale that quantifies neurologic deficits in 11 categories, and is a sensitive and reliable 
measure to detect a change in neurologic function. To ensure consistency and to enhance the 
detection of subtle neurologic changes, each patient will have repeated examinations by the 
same examiner when possible.  
 
Neuroimaging Procedures   
Imaging will be performed on a 3T scanner (Siemans Healthcare, Erlangen Germany) in the 
Center for Advanced Magnetic Resonance Development in the Department of Radiology. 

 
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Patients are expected to undergo postoperative MR imaging once hemodynamically stable, 
typically around 1-5 days after surgery. Imaging protocol will include standard product pulse 
sequences, including high resolution structural T1-weighted images co-localized with contiguous 
multidirection diffusion-weighted imaging with b value of 1000. In addition, contiguous T2-FLAIR 
images will be obtained prior to and following administration of a standard dose of gadolinium 
contrast agent (e.g. 0.3 ml/kg gadobutrol or 0.1 mmol/kg gadopentetate dimeglumine). Gadavist 
(generic name gadobutrol) or MultiHance (generic name gadobenate dimeglumine) will be 
injected as a rapid intravenous bolus during which a time series of 8 T1 maps acquired with a 
fast T1-mapping sequence with partial inversion recovery will be performed, following a single 
pre-contrast T1 map.  Total imaging time is approximately 45 minutes.  Patients who develop a 
GFR <30 after surgery will not receive gadolinium but will continue to be followed for adverse 
events until they are discharged from the hospital, at Week 6 and 1 Year study follow up. 
If an orbital radiograph is requested for MRI clearance, it will be completed prior to the 
scheduled MRI and will be done here at Duke facility. The orbital x-ray will be completed if the 
subject has no medical records acceptable for clearance.   
 
MR Image review for presence of BBB disruption 
A board-certified neuroradiogist, blinded to the clinical and surgical variables, will read the MRI, 
and also review the precontrast and postcontrast FLAIR images for the presence of HARM 
(hyperintense acute reperfusion marker) and classify it by location (sulcal, ventricular, and/or 
generalized) and severity (mild, moderate, or severe), according to the classification scheme 
described by Merino et al.(9) 
 
Quantitative DCE MRI of BBB disruption 
Using T1 time series data, we will calculate the rate at which the contrast agent passes from the 
vascular compartment into the tissue compartment, Ki, using the Patlak formulation of tracer 
leakage.(33) Plasma levels of gadolinium will be sampled from a region-of-interest in the sagittal 
sinus. Parenchymal region-of-interest measurements will be made in the white matter. 
 
Quality of Life Assessment  
Quality of life will be measured in conjunction with each cognitive assessment at baseline, 6-
weeks (± 2 weeks),, and 1-year (± 1 month)  in all enrolled patients. We will use an instrument 
that includes a measure of functional status derived for use in cardiovascular populations (the 
Duke Activity Status Index or DASI), psychological measures including depression (the CES-D), 
the State Trait Anxiety Inventory (STAI), the Hopkins Symptom Checklist (SCL-90), social/role 
functioning (including employment status), and the Short Form 36 question (SF 36) generic 
quality of life instrument. 
 
Blood Sampling 
Blood samples will be drawn for analysis as a part of this study. One 10 ml sample of peripheral 
blood will be obtained from each patient prior to surgery and stored. Genomic DNA for analysis 
will be obtained from this sample and analyzed for the presence of candidate SNPs (single 
nucleotide polymorphisms) including APOE. 10 ml of blood will also be sampled at baseline, end 
of CPB, postoperative days 1, 2 and day of the MRI scan, and at 6 weeks (± 2 weeks), and 1 
year (± 1 month) follow-up for assessment of inflammatory and proteomic markers. In addition, 
10ml of blood will be drawn to assess HCQ drug levels at end of CPB and day of the MRI scan. 
Subjects will have the option to sign the Genomic and Proteomic Database Repository 
(IRB#00015651) consent form, allowing the banking of any remaining plasma and DNA samples 
for future research. If a creatinine level is not drawn for standard of care post-operatively, one 
6ml blood sample will be drawn to assess kidney function (GFR ≥ 30 ml/min/1.73 sq.m) for 

 
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gadolinium administration safety.  Up to 106 ml of blood will be collected during the 12 month 
study participation period. 
 
Ophthalmic Assessments 
Hydroxychloroquine associated retinopathy is rare and thought to be associated with cumulative 
dosage and with chronic administration. Although toxicity is not expected in the short-term 
dosing schedule in this protocol, ophthalmic assessment will be performed on every subject 
consented as an additional measure of safety. Ophthalmic assessments will occur at baseline 
and at 6 weeks after surgery.  Each assessment will take approximately 1.5 hrs and will include 
visual acuity, optical coherence tomography (OCT) of the macula, and multi-focal 
electroretinogram (ERG).  Ophthalmic assessments will be performed in the undilated eye, but 
the eye may need to be dilated in the event of minuscule pupils. A report confirming the 
absence of retinal abnormalities (that are contraindications to hydroxychloroquine administration 
– see exclusion criteria #18) will be provided to the study team by an ophthalmologist (Dr. 
Iannaccone) prior to initial dosing. The 6-week report will document serial changes and will be 
evaluated as part of the safety profile.       
 
ECG for QTc evaluation 
 Standard of care (SOC) ECG will be used to evaluate QTc prior to HCQ dosing. For males 
QTc>450msec and for females>470msec will be ineligible to receiving HCQ dosing that day. If 
no ECG will be obtained per SOC, the research team will perform an ECG at baseline and prior 
to daily HCQ dosing. 
 
Standard of Care 
• 
Anesthesia (premedication, choice of anesthetic technique and drugs to be administered) 
per standard of care 
• 
Surgical and postoperative care per standard of care 
• 
Clinical status will be monitored throughout the duration of the procedure 
•    Standard of Care ECG if performed will be used for evaluation of QTc prior to HCQ dosing         
     throughout the study. 
 
Selection of Subjects  
To be eligible for inclusion into the study, each patient will have to fulfill the following criteria: 
 
 Inclusion Criteria 
1. Male or female, age ≥ 50 years old. 
2. Patients scheduled to undergo cardiac surgery (CABG, CABG + Valve, Valve) with CPB 
or general surgery (e.g. orthopedic, abdominal, urological). 
3. Patient has voluntarily signed and dated the study-specific informed consent form 
approved by Duke University Health System Institutional Review Board (DUHS IRB)  
 
Exclusion Criteria 
1. Cardiac surgery scheduled to be performed without cardiopulmonary bypass 
2. Patients requiring emergent operation 
3. Patients with a history of myocardial infarction within 7 days of surgery 
4. Patients with a history of porphyria, psoriasis, chronic dermatitis, or retinal disease  
5. Patients receiving preoperative digoxin 
6. Patients with symptomatic cerebrovascular disease with substantial residual deficit  
7. Patients with a history of alcohol abuse within 2 years of screening  
8. Patients with history of psychiatric illness 

 
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9. Patients with impaired liver functions (AST, ALT 2 times the upper limit of normal) 
10. Patients with impaired renal functions (GFR <30ml/min) 
11. Patients with less than a 7th grade education or unable to read and thus unable complete 
the neuropsychological testing 
12. Patients scoring < 26 on a baseline Mini Mental State examination (MMSE) or scoring 
>27 on the Center for Epidemiological Studies – Depression (CES-D) scale  
13. Female subjects of childbearing potential who have had menstrual period within the past 
two years  
14. Patients with bodily implants unsafe for MRI use  
15. Patients with a history of claustrophobia  
16. Known or suspected hypersensitivity to quinine (chloroquine or hydroxychloroquine) 
17. Patient with pre-existing diagnosis of G6PD deficiency  
18. Patients who have participated in another interventional clinical study within the previous 
30 days 
19. Any other concurrent disease or illness that, in the opinion of the investigator, makes the 
patient unsuitable for the study  
20. Major ophthalmologic comorbidities (ex: ruptured globe, retinal vascular occlusive 
disease, retinal artery occlusion, anterior ischemic optic neuropathy, media opacification 
due to corneal abnormalities or cataract that prevent ocular and optical coherence 
tomography examination, glaucoma, age-related macular degeneration, history of 
intravitreal injections, and macular edema) 
21. Patients who have received chemotherapy in the last 12 months 
22. Patient with elevated QTc (male>450msec, female>470msec) noted from baseline ECG 
 
Risk/benefit assessment 
There is no direct benefit of this study to the enrolled subjects. Data gathered from this pilot 
study may benefit future patients. Up to 106 ml of blood will be drawn during the 12 month 
study participation period. The patient's informed consent document discusses this risk, but it is 
unlikely that this will contribute significantly to the patient's need for blood transfusion. To 
minimize any potential risk to the patient from genetic data, and to not adversely affect their 
quality of life in any way, investigators and patients will be blinded to the individual patient's 
genotype. This information will not be included in the patient chart, will remain absolutely 
confidential and will not be given to the patient or their family. Samples sent to the IGSP for 
genotyping will be identified only by a code number whose relation to the patient’s name and 
other identifiers is available only to the data manager. In any publications, the identity of the 
patient will remain anonymous.  Appropriate medical therapy for any adverse events from study 
participation is always available. 
 
Following HCQ administration in doses adequate for the treatment of an acute malarial attack, 
mild and transient headache, dizziness, and gastrointestinal complaints (diarrhea, anorexia, 
nausea, abdominal cramps and, on rare occasions, vomiting) may occur.(31) In the treatment 
of lupus as well, adverse events associated with HCQ use is infrequent and generally mild 
(gastrointestinal, cutaneous).(26,34) When used as an adjuvant to lung cancer chemotherapy, 
the most commonly observed treatment-related adverse events were rash (37%), nausea 
(33%), diarrhea (33%), and fatigue (30%). Vomiting, dyspepsia, anorexia, and dry skin 
occurred in less than 20% of patients.(32) Dose-related retinal damage has been observed in 
some patients who had received long-term aminoquinoline therapy for lupus or rheumatoid 
arthritis but is unlikely in our study which is limited to 6 days of therapy at doses well below the 
cumulative dose/duration reported to be a threshold for injury (5-7 years of therapy or 1000 
grams).(35) To optimize safety, ophthalmic assessments will be done prior to dosing in an 

 
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effort to ensure subjects do not have existing macular damage and are appropriate to 
participate.  Concomitant hydroxychloroquine and digoxin therapy may result in increased 
serum digoxin levels; serum digoxin levels should be closely monitored in patients receiving 
combined therapy. Concomitant hydrocychloroquine and propofol may be associated with QT-
prolongation, QTc values should be closely monitored in patients receiving combined therapy.  
As hydroxychloroquine may enhance the effects of a hypoglycemic treatment, a decrease in 
doses of insulin or antidiabetic drugs may be required. In summary, we expect that headache, 
dizziness, diarrhea, anorexia, nausea, and abdominal cramps to be the most likely side effects 
to short-term HCQ therapy. 
 
The risks of the ophthalmic assessments are very low. Minor fatigue from testing is possible; 
breaks will be introduced as needed during the testing.  If eye dilation is needed, standard 
dilating eye drops will be employed. Minor discomfort from the lights employed during 
ophthalmic assessments are possible but unlikely outcomes.  Subjects may directly benefit 
from the study by receiving an ophthalmic exam.  The main findings of the eye examination can 
be given to the subject and appropriate referral, if needed, will be made by the ophthalmologist 
(Dr. Iannaccone).  The study will not provide refractive prescription to the participants. 
 
The MRI procedures follow guidelines set by the FDA with regard to specific absorption ratio 
(SAR), limits on gradient slew rate (dB/dt), and noise. The presence of non-MR safe metal body 
implants is determined by the interviewing each potential subject; reviewing the patient’s 
medical history for any operative reports denoting the make, model, and type of any implant; 
and completing a detailed screening questionnaire with the patient and patient caregiver.  MR 
safe implants will be determined as those listed in the Reference Manual for Magnetic 
Resonance Safety, Implants, and Devices, 2012 Edition (Shellock, Biomedical Research 
Publishing Group) as being tested safe at 3-Tesla magnet strength. For those subjects 
determined to have MR safe implants, these must be located below the neck to prevent data 
acquisition artifacts. Participants and staff are instructed to remove all metal objects, including 
clothing with metal clasps before entering the magnet room. The magnetic properties of 
unknown material are tested outside the magnet room with a strong permanent magnet.  
Participants and staff are also instructed to enter the magnet room slowly and pause at the 
entrance to determine if any items on their person may be pulling toward the magnet. 
Participants are required to wear insert earplugs during scanning to reduce noise levels below 
FDA limits. Some participants may feel uncomfortable or confined once positioned within the 
bore of the MRI system. This potential reaction is reduced by discussing the procedure before 
entry into the magnet room, by providing the subject with a mirror through which they can look 
out into the room, and by communicating with the subject over the intercom. During set-up and 
anatomical imaging, participants can choose to listen to music or radio over their headphones. 
Nevertheless, if participants continue to feel uncomfortable, the imaging procedure is terminated 
and the subject is removed from the magnet. 
 
Evaluation of the BBB on MRI will require intravenous bolus injection of an FDA approved 
paramagnetic contrast agent, Gadavist (generic name gadobutrol) or MultiHance (generic name 
gadobenate dimeglumine). Review of the literature shows that administration of Gadavist or 
MultiHance in humans at a dose of0.3 ml/kg gadobutrol or 0.1mmol/kg gadobenate 
dimeglumine, has rarely been associated with adverse effects, and up to 0.4 mmol/kg can be 
given without significant side-effects.(36) The most frequently reported adverse events related 
to gadolinium-based contrast agents include headache (2%), nausea (2%), injection site 
reaction (1%), and flushing (1%). The risk for nephrogenic systemic fibrosis among patients with 
impaired elimination of the drugs is ameliorated in our study by the exclusion of subjects with 

 
Version Date:  11/29/2020                               Page 12 of 17 
GFR < 30 ml/min/1.73 sq.m.Gadavist and MultiHance were identified by The American College 
of Radiology to fall under the category of Low Risk to the development of nephrogenic systemic 
fibrosis.  No cases of death attributable to administration of this contrast agent have been 
reported. Intravenous lines inserted as part of gadolinium infusion have the same small risks as 
any other intravenous lines which will be thrombophlebitis and extravasation of the infused fluid 
into the subcutaneous tissues. These complications will be watched for and treated, if 
necessary. 
 
Subject Identification, Recruitment, & Compensation 
After obtaining permission from the operating surgeon, surgical subjects will be screened by the 
study coordinator by reviewing the surgical schedule. Prior to asking any patient for consent to 
participate, the patient will be approached first by the surgeon or one of the surgical care team 
to see if the patient is willing to consider being in the study. If so, the patient then will be called 
by one of the investigators in this study or a member of the Anesthesiology Department who will 
be responsible for the care of the patient during the surgery, and who understands the study. If 
the subject is willing to participate and they do not meet any exclusion criteria, they will be 
contacted by the research coordinator and will discuss their willingness to participate in the 
research protocol.  An IRB approved phone script will be used during this communication. If the 
subject is in agreement, the coordinator will present the research protocol in its entirety to the 
prospective participant and will answer any and all questions as they arise. If the subject agrees 
to participate, the coordinator will ask the subject to sign and date the appropriate consent form 
at their first visit. A copy of this consent form will be given to the subject and a copy of the 
consent form will be added to the patient’s medical record. 
 
 
The subject will be asked to sign a separate consent form to allow us to store portions of their 
collected   blood specimens and any data collected obtained under this research study and 
maintain these samples and data in a database/repository (PRO00015651) for possible use in 
future research studies relating to surgical outcomes. 
 
Subjects will be reimbursed $50 for participating in each of the two follow-up return visits to 
Duke Medical Center to defray travel costs and time. Subjects will also receive a $9 parking 
pass upon each of their return follow-up visits to Duke. Total possible reimbursement per 
subject/caregiver pair is $177. The study may pay for your hotel accommodation, with prior 
approval, if required for subject's baseline visit. 
 
Costs to the subject 
Subjects will not incur any costs as a result of participation. Costs of all study procedures will be 
incurred by the study.  
  
Data analysis & Monitoring 
 
Neurocognitive Analyses 
Definition of cognitive deficit: Because we are proposing a cognitive test battery that results in 
many scores per patient, it is essential to assess the results with an analytic approach that 
makes use of all the information without redundancy. We plan to define cognitive deficit from our 
raw test scores by using a factor analysis. Factor analysis is a technique that has the objective 
of representing the large, overlapping set of raw test scores by a smaller set of factors through 
transformation based on the intercorrelations among the test scores. Each “factor” represents a 
hypothetical, unobservable characteristic that can be interpreted as a discrete domain of 

 
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cognitive functioning. The first factor is based on the computation of principal components and is 
the linear combination of the items, subject to a normalizing constraint, which accounts for the 
greatest amount of variance across patients. The second factor is that linear combination, 
uncorrelated with the first, which accounts for the next largest amount of variance, and so on. 
An orthogonal rotation will be done for interpretability of the results. The factor analysis can thus 
identify the independent (orthogonal) domains of cognitive function, as measured by the full 
battery of cognitive tests, and reduces the number of outcomes to be analyzed. Factor analysis 
makes use of all the information provided by the patient to return independent, continuous and 
standardized summary measures for assessment. By measuring each domain with several 
tests, and combining the scores using the factor analytic solution, we will also enhance the 
reliability of the overall measurement of each domain. Based on our extensive experience with 
the test battery, we expect to obtain factor scores for four separate domains of cognitive 
function. 
 
Our factor analysis will be performed on baseline test scores, and the factor coefficients 
(weights) of each test on each factor will be used to construct comparable domain scores at 
each of the follow-up time periods, based on the patients’ test scores for that time period. In this 
manner, the domains will be identified at preoperative baseline and will be consistent at follow-
up time points. Numeric change scores will be calculated for each of the factors, and an overall 
continuous cognitive score will be calculated by averaging the separate scores. We will define 
our primary endpoint as the 6-week change in the continuous cognitive score, which is the 
difference between the 6 week and baseline score. Overall POCD, defined as a decline from 
baseline in any of the domains equal to or greater than one standard deviation of the baseline 
domain score will also be assessed. The numeric domain scores, which treat cognitive function 
as a continuum, are sensitive to differences in functional change, including differences in 
amount of improvement, while the dichotomous POCD endpoint best focuses on the outcome of 
interest across all cognitive domains. 
 
Baseline characteristics which have been found to be important in cognitive function, including 
age, sex, baseline cognitive status, years of education, race, duration of surgery and bypass 
time, depression and anxiety will be examined for differences between the randomized groups. 
Prior to analysis, assumptions of the regression model will be conducted, including 
homogeneity, linearity, and independence. The association between the cognitive change score 
at 6 weeks and blood brain barrier disruption will be assessed using multivariable regression, 
adjusting for age, level of education, baseline cognitive score, and surgery type (cardiac vs 
noncardiac). It should be noted, however, that this is a pilot investigation intended to obtain 
preliminary data for a grant application. 
 
All neurocognitive test instruments will be scored according to the recommendations for the 
particular tests, with missing item values handled as recommended (e.g., pro-rated sum, 
average). Baseline and intraoperative variables will be evaluated for balance between the 
treatment groups. Overall significance level will be set at alpha=0.05, with adjustments for 
multiple testing made as indicated. All analyses will be conducted using SAS statistical software, 
widely respected for its power and reliability. 
 
MR Image review for presence of BBB disruption 
A board-certified neuroradiogist, blinded to the clinical and surgical variables, will read the MRI, 
and also review the precontrast and postcontrast FLAIR images for the presence of HARM 
(hyperintense acute reperfusion marker) and classify it by location (sulcal, ventricular, and/or 

 
Version Date:  11/29/2020                               Page 14 of 17 
generalized) and severity (mild, moderate, or severe), according to the classification scheme 
described by Merino et al.(9) 
 
Quantitative DCE MRI of BBB disruption 
Using T1 time series data, we will calculate the rate at which the contrast agent passes from the 
vascular compartment into the tissue compartment, Ki, using the Patlak formulation of tracer 
leakage.(33) Plasma levels of gadolinium will be sampled from a region-of-interest in the sagittal 
sinus. Parenchymal region-of-interest measurements will be made in the white matter. 
 
Privacy, Data storage & Confidentiality 
Primary study data will be images acquired from the neuroimaging procedures and patient case 
report forms. Preprocessing software will strip any MR image headers that may contain 
subjects’ names, as well as de-skull the images to prevent any visual reconstruction of subject 
identity, and will rewrite the resulting data as image volumes identified by subject identification 
number only. The post-processed imaging data will be stored electronically on a secure 
computer housed at the Center for Advanced Magnetic Resonance Development, as well as 
archived on DVD storage medium to be placed into a locked cabinet. The data collected in the 
Case Report Forms will be obtained specifically for research and internal quality assurance 
purposes. While the hemodynamic, laboratory, and historical data will be collected at the time of 
the intraoperative study, the information is all part of the routine medical record documenting the 
patient's care in the perioperative period. The patient's identity will be specifically protected and 
confidentiality will be maintained by reporting any published material by patient number. All 
genetic data will remain confidential and will not be available to the patient, the patient’s family 
or physician.  All genetic material for patients enrolled into this study will be identified only 
through unique study identification number. This unique study number will also be linked to a 
barcode affixed to each study sample, collected according to protocol.  For future review or 
database dissemination, the study number and the barcode will be the only identifying 
information associated with the subject. The subject’s name, social security number, or any 
other “identifying information” will not be linked to the individual subject. At the time of consent, 
the patient will be asked to sign an authorization of release to provide us permission to obtain 
medical information in the event the patient returns to the hospital, health care facility, or family 
doctor for indications of chest pain, congestive heart failure, heart attack, or stroke during the 
course of the study. At the one year follow-up visit, the patient will be asked to complete a 
medical condition questionnaire. This information will be used to determine any changes in 
health since surgery. Participants will not be identified by name in any analysis of these data, 
nor any presentation or publication resulting from the analysis of these data. 
 
If the patient is not eligible or does not want to participate in the study, their protected health 
information (PHI) is shredded and destroyed. For consented patient, PHI is kept in a locked 
desk or cabinet when not being used by the research staff. The information we review are on 
individual computers which are password protected. The office doors are kept locked when no 
one from the research staff is in the office. The only people who have access to the rooms are 
the PI and research staffs which are listed on the key personnel sheet.  
 

 
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