Adverse Cerebral Outcomes Research Articles

Adverse Cerebral Outcomes after Coronary Artery Bypass Surgery-More Than a Decade of Experience in a Single Center.

Nonfatal strokes, transient ischemic attacks (TIAs), and reversible ischemic neurological deficits (RIND) after elective coronary artery bypass grafting (CABG) are devastating clinical problems. The anesthesiologist, surgical and intensive care teams in a community hospital adopted a strategy developed in an effort to minimize these adverse outcome events.The purpose of this study is to determine the incidence of and predictors for perioperative adverse neurologic events. A historical cohort study of 1,108 consecutive CABG patients operated between 2002 and 2014. Outcomes were defined as (1) a new neurologic damage (a new stroke, TIA, or RIND) and (2) a new neurologic damage or 30 days mortality. Adverse cerebral outcomes occurred in 16 patients (1.4 percent). Nine patients had postoperative stroke, six suffered TIAs, and one had postoperative RIND.In multivariate analysis, older age (OR 1.07, 95% CI 1.01-1.14), congestive heart failure (OR 3.57, 95% CI 1.22-10.49) and prior stroke (OR 6.27, 95% CI 1.78-22.03) were significantly associated with increased risk of new neurologic damage. These parameters were also significantly associated with increased risk of the combined outcome (new neurologic damage/mortality). A low incidence rate of adverse cerebral outcomes after CABG in community hospital can be achieved with the use of the suggested surgical intensive care, and anesthetic strategy. Advanced age, congestive heart failure, and prior stroke are associated with adverse outcomes.

Intraoperative Hypotension and Patient Outcome

Intraoperative Hypotension and Patient Outcome

The Influence of Deep Hypothermic Global Brain Ischemia on EEG in a New Rat Model

Neurological complications following deep hypothermic circulatory arrest (DHCA) occur between t 4% ≈ 25%. However, the cerebral injury mechanisms are still not well understood due to a lack of a practical and simple animal model. We aimed to establish a rodent deep hypothermic global brain ischemia (DHGBI) model, which can be used to elucidate these mechanisms in future studies. 30 Sprague-Dawley rats were divided randomly into three groups: the carotid occlusion DHGBI group, the internal carotid shunt DHGBI group, and the sham operation group. We validated the model in terms of electroencephalogram (EEG) and regional cerebral blood flow (rCBF). All rats were sacrificed for analysis of brain moisture capacity after 24 hours. In the internal carotid shunt DHGBI group the EEG activity was suppressed to "flat-line" and the relative power of the α and θ frequency bands was decreased (p < 0.05). However, in the carotid occlusion DHGBI group we only observed the relative power of the α frequency band depressed (p < 0.05). The rCBF was significantly decreased in all groups. In the internal carotid shunt DHGBI group the rCBF was significantly reduced to 4.27 ± 2.75%, and was lower than the other two groups (p < 0.05). The result of brain moisture capacity was consistent with the EEG and rCBF observations. The current study presents a novel cerebral recovery model of DHCA in the rat. This experimental model may be suitable to further elucidate the mechanisms associated with adverse cerebral outcomes after DHCA and to investigate potential neuroprotective strategies.

Cerebral monitoring to optimize outcomes after cardiac surgery

Although significant achievements have been made in the perioperative care of patients undergoing cardiac surgery, adverse cerebral outcomes remain an ongoing concern. Multiple approaches have been utilized to address neurologic complications, though definitive therapeutic strategies are lacking. This review focuses on the various cerebral monitoring options that can be used in cardiac surgery to improve perioperative outcomes. Prevention of adverse outcomes has shown promise, and central to this is the identification of conditions, through cerebral monitoring, which may put the brain at risk. Multimodal cerebral monitoring utilizing hemodynamics, temperature, electroencephalography, and near-infrared spectroscopy techniques allow for the manipulation of perioperative conditions aimed at improving cerebral outcome. The use of a comprehensive cerebral monitoring strategy can optimize cerebral outcomes after cardiac surgery.

Perioperative genomics and neurologic outcome: we can’t change who we are

Adverse cerebral outcomes have been described in most perioperative settings; however, for quite some time, cardiac surgery has been the poster child for cognitive dysfunction as well as incrementally severe complications, such as delirium, encephalopathy and stroke. Not that these complications do not occur in other operative settings, but with the incidence of post-cardiac surgery complications being generally higher than in other settings, cardiac surgery patients are an easily identifiable group to study in detail. Understanding the factors that influence perioperative cerebral outcome has never been more relevant, as not only are patients presenting for surgery at an increasingly older age (i.e., consistent with global demographic changes) but they frequently have multiple co-morbidities (many of which are risk factors for neurologic injury). Despite changes in the management of coronary artery disease (CAD) that have lead to a gradual decline in these procedures over the past 5–10 years, coronary artery bypass graft surgery (CABG) remains one of the most commonly performed operations. Furthermore, a recent large-scale study identified that the optimal management of multivessel CAD was with CABG, as opposed to percutaneous intervention. This may lead to a resurgence of CABG surgery with a further increase in the overall number of patients manifesting neurologic dysfunction. Much has been written about the risk factors for adverse neurologic outcome. Although many factors are modifiable, such as the way to approach ascending aortic atheromatous disease, many are not, which is clearly the case regarding one’s genetic composition. Several recent trials have highlighted how our genetic milieu either increases the predisposition for neurologic injury or impairs the ability to recover once that injury has occurred. Despite pointing to identifiable yet sometimes divergent genetic risk factors, each of these studies has distinct strengths and weaknesses. However, regardless of reports of significant findings that provide provocative scientific insights, the study and understanding of perioperative genomics is in its relative infancy. Indeed, there are several thematic deficiencies present in most of the reported studies. The first and foremost shortcoming relates to the relatively small size of most trials. Although some of the trials are larger than the majority of other perioperative clinical trials, they are smaller than needed to avoid the problems of poor statistical power, multiple comparisons, and the seemingly ever-changing bioinformatics field. However, advancements in analytical techniques with expanded capability and accuracy have facilitated gathering the needed genetic information in a more cost-effective manner, making it possible to study larger populations. The incredible complexity of our genetic code presents an expanding challenge to our ability to fully understand the effects of genetic variation. Variations in genetic make-up have been described by the concept of single nucleotide polymorphisms (SNPs), where individual nucleotides (i.e., base pairs) differ within specific genes, thus producing various alleles. The limitations of analytical techniques have restricted the number of SNPs that can reasonably be interrogated. It has also led us to examine specific and pre-determined, though biologically plausible, targets. However, these a priori defined SNPs may completely miss the more important and as yet unknown variants. As a result, whole-genotype analysis, although suffering its own set of limitations, has improved the H. P. Grocott, MD (&) Departments of Anesthesia and Surgery, University of Manitoba, CR3008-369 Tache Avenue, Winnipeg, MB R2H 2A6, Canada e-mail: hgrocott@sbgh.mb.ca

Pro: All Off-Pump Coronary Artery Bypass Graft Surgeries Should Include Intraoperative Transesophageal Echocardiography Assessment

HISTORICALLY, THE cardiopulmonary bypass machine was necessary for cardiac surgeons to perform complex operations on the heart. 1 Weir I. Coronary artery bypass. Ann R Coll Surg Engl. 2006; 88: 99-102 Crossref PubMed Google Scholar Cardiopulmonary bypass (CPB) allows for a stable operative site and a bloodless field while ensuring end-organ perfusion and cooling of the patient during cardiorespiratory arrest. 1 Weir I. Coronary artery bypass. Ann R Coll Surg Engl. 2006; 88: 99-102 Crossref PubMed Google Scholar CPB has been implicated as the cause of many adverse effects of cardiac surgery including a systemic inflammatory response and end-organ damage, especially neurologic injury and cognitive decline. 2 Roach G.W. Kanchuger M. Mangano C.M. et al. Adverse cerebral outcomes after coronary bypass surgery Multicenter study of perioperative ischemia research group and the ischemia research and education foundation investigators. N Engl J Med. 1996; 335: 1863-1875 Crossref Scopus (1670) Google Scholar , 3 Yacoub M. Off-pump coronary bypass surgery: In search of an identity. Circulation. 2001; 104: 1743-1745 PubMed Google Scholar , 4 Elahi M.M. Khan J.S. Matata B.M. Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic. Acute Card Care. 2006; 8: 196-209 Crossref PubMed Scopus (33) Google Scholar In recent years, it has become possible to safely perform coronary artery bypass graft (CABG) surgery without the use of CPB. It was initially postulated that avoidance of cannulation and CPB would decrease the incidence of end-organ damage in all patients. Several clinical studies have not confirmed this, but off-pump CABG (OPCAB) surgery has been shown to be beneficial in a subset of patients that are at higher risk for developing neurologic complications. 5 Sharony R. Bizekis C.S. Kanchuger M. et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: A case control study. Circulation. 2003; 108: II15-II20 PubMed Google Scholar , 6 Sharony R. Grossi E.A. Sounders P.C. et al. Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease. J Thorac Cardiovasc Surg. 2004; 127: 406-411 Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar

Neuroprotection during cardiac surgery

Cardiac surgery continues to be associated with significant adverse cerebral outcomes, ranging from stroke to cognitive decline. The underlying mechanism of the associated cerebral injury is incompletely understood but is believed to be primarily caused by cerebral embolism and hypoperfusion, exacerbated by ischemia/reperfusion injury. Extensive research has been undertaken in an attempt to minimize the incidence of perioperative cerebral injury, and both pharmacological and nonpharmacological strategies have been investigated. Although many agents demonstrated promise in preclinical studies, there is currently insufficient evidence from clinical trials to recommend the routine administration of any pharmacological agents for neuroprotection during cardiac surgery. The nonpharmacological strategies that can be recommended on the basis of evidence include transesophageal echocardiography and epiaortic ultrasound-guided assessment of the atheromatous ascending aorta with appropriate modification of cannulation, clamping or anastomotic technique and optimal temperature management. Large-scale randomized controlled trials are still required to address further the issues of optimal pH management, glycemic control, blood pressure management and hematocrit during cardiopulmonary bypass. Past, present and future directions in the field of neuroprotection in cardiac surgery will be discussed.

Microemboli detection on extracorporeal bypass circuitsa

Numerous authors have associated gaseous microembolization with adverse cerebral outcomes during cardiopulmonary bypass (CPB). The introduction to this review provides background on the connection between microemboli and adverse cerebral outcomes. This connection is often difficult to quantify, as outcomes depend on a number of factors, including the size of the bubble, where it passes through the patient, patient comorbidities and other factors. Nonetheless, numerous studies have shown statistically significant differences in the mean number of cerebral emboli detected in patients that stroked and those that did not, as well as for patients with major cardiac complications and patients with a longer length of hospital stay. Our introduction is followed by case reports and laboratory studies showing how monitoring for gaseous microemboli (GME) can be used to reduce the embolic load delivered to the patient through the bypass circuit. These methods include improved qualification of bypass circuit design prior to surgery, modification of priming procedures to reduce air in the circuit at the start of surgery, new methods for injecting drugs into the circuit during surgery, and better detection of removal of sources of air during surgery. The review concludes with background on the ultrasonic detection of GME, comparing through-transmission gross air detectors and Doppler ultrasound technology with fixed-beam ultrasonic imaging of emboli, a new ultrasonic technique that images moving emboli in the blood using a single ultrasound transducer element in a fixed position. This overview is meant to shed light on why different ultrasonic detection technologies report widely varying counts and emboli loads, and why fixed-beam ultrasonic imaging represents an improvement in the ability to monitor, measure and quantitate embolic load during CPB.

Perfluorocarbon Administration During Cardiopulmonary Bypass in Rats: An Inflammatory Link to Adverse Outcome?

Perfluorocarbon (PFC) emulsions are artificial oxygen carriers that have been shown to attenuate the effects of air embolism. Cerebral air embolism, known to occur during cardiopulmonary bypass (CPB), may contribute to adverse cerebral outcomes after cardiac surgery. We designed this study to evaluate the effect of a 60% PFC emulsion (perfluoro-tert-butylcyclohexane; PTBCH) on the inflammatory response and neurocognitive outcome of rats after CPB. Twenty-eight Sprague Dawley rats subjected to 60 min of CPB were randomly divided into two groups: PTBCH CPB animals receiving 3 mL/kg of PTBCH into the venous reservoir and control CPB animals receiving 3 mL/kg of 0.9% saline. At several time points, the cytokines interleukin (IL)-1beta, IL-6, IL-10, and tumor necrosis factor (TNF)-alpha were measured. Neurocognitive testing was planned postoperatively using the Morris water maze. Histologic samples were obtained in a separate series of experiments. Physiologic variables were comparable between groups, but the PTBCH CPB animals required more phenylephrine compared with the controls. Cytokine levels in the PTBCH CPB group were significantly higher than in the control group at 2 and 4 h after CPB (P < 0.05). Neurocognitive outcome could not be evaluated as none of the animals in the PTBCH CPB group survived. Myocardial histological analysis revealed increased areas of contraction band necrosis in the PTBCH CPB animals (P = 0.034). Administration of PTBCH during CPB was associated with an excessive release of cytokines. This enhanced inflammatory response with subsequent hypotension may have contributed to mortality in rats receiving PTBCH. The observed patterns of myocardial injury indicate global hypoperfusion and catecholamine excess.

Cerebral Air Emboli Differentially Alter Outcome after Cardiopulmonary Bypass in Rats Compared with Normal Circulation

Cerebral air emboli (CAE) are thought to contribute to adverse cerebral outcomes following cardiac surgery with cardiopulmonary bypass (CPB). This study was designed to investigate the effect of escalating volumes of CAE on survival and neurologic and histologic outcomes. In addition, the effect of xenon administration during CAE on these outcomes was determined. With institutional review board approval, four groups were studied (n = 15). In two CPB-CAE groups, rats were subjected to 90 min CPB with 10 repetitively administered CAE. Rats in two sham-CAE groups were also exposed to CAE but not to CPB. Rats were randomly assigned to sequential dose cohorts receiving CAE ranging from 0.2 to 10 microl in a dose-escalating fashion. Groups were further subdivided into xenon (56%) and nitrogen groups. Rats with severe neurologic damage were killed; others were neurologically tested until postoperative day 7, when infarct volumes were determined. Survival and neurologic and histologic outcomes were tested with logistic regression analyses (P < 0.05). This study demonstrates a dose-dependent relation between CAE volumes and survival, neurologic outcome, and histologic outcome. For all outcomes, CPB adversely affected the dose-effect curves compared with sham-CAE groups (P < 0.05). Xenon demonstrated no impact on either outcome. This study describes the successful incorporation of CAE in a rodent CPB model and allows identifying suitable CAE volumes for subsequent studies. CAE exhibit a differential effect on outcome in rats undergoing CPB versus those not exposed to CPB. Perioperative administration of xenon remained without any effect on outcome.

Reduction in Air Bubble Size Using Perfluorocarbons During Cardiopulmonary Bypass in the Rat

Perfluorocarbon (PFC) emulsions are artificial oxygen-carrying compounds with a high solubility for gases that have experimentally been shown to ameliorate cerebral air embolism. Cerebral air embolism has been associated with adverse cerebral outcomes after cardiac surgery using cardiopulmonary bypass (CPB). We designed this study to test whether PFC emulsions could reduce the volume of bubbles within the CPB circuit. Male Sprague-Dawley rats undergoing 60 min of normothermic nonpulsatile CPB were randomized to one of the three groups. The PFC group (n = 10) received 60% O(2)/36% N(2)/4% CO(2) via the membrane oxygenator and 2.7 g/kg (4.5 mL/kg) of PFC into the venous reservoir; the control group (n = 10) received the same gas mixture and 4.5 mL/kg of saline; the N(2)O group (n = 6) was exposed to 36% N(2)O/60% O(2)/4% CO(2) and received 4.5 mL/kg of saline. After 10 min and 35 min of CPB, 400 microL of air was injected into a bubble chamber in the CPB circuit. After 20 min, the bubble was removed for volumetric analysis. Compared with baseline, the bubble decreased 13% +/- 5% in size in the PFC group and increased 46% +/- 9% in the nitrous oxide group, both of these changes significantly different from the control group (P < 0.0001). The results suggest that PFC administration may be useful in reducing the volume of gaseous bubbles present during CPB.

Evaluation of the Early Hemodynamic Changes in Carotid Arteries During Ventricular and Dual Chamber Pacing

In spite of a wide choice of pacemakers, there are some problems in making more rational clinical decisions for individual patients since mode selection and programming is usually performed on the basis of a clinical hunch. The aim of this study was to measure the differences in carotid flow in patients with a pacemaker programmed in the dual chamber and in the single chamber pacing modes. Sixty patients with implanted bipolar DDD pacemakers were enrolled in this study. Blood peak systolic velocity (PSV) and end-diastolic velocity (EDV), cross-sectional area, resistive index (RI), and pulsatility index (PI) were measured in the common (CCA), internal (ICA), and external (ECA) carotid arteries before pacemaker implantation and after dual chamber and ventricular pacing at 60 beats/min. PSVs in the left CCA (79.3 +/- 24.9 cm/s) and right CCA (84.1 +/- 18.7) were shown to significantly decrease after VVI pacing (60.1 +/- 16.6 and 62.1 +/- 20.0, respectively). There was also a similar significant decrease in PSV in the left and right ICAs and ECAs. Besides PSV, RI, and PI in the left and right CCAs, ICAs, and ECAs significantly decreased after VVI pacing. There was no similar decrease after DDD pacing. Cross-sectional area and flow volume in the CCA, ICA, and ECA were similar after DDD and VVI pacing and before pacemaker implantation suggesting that cardiac output was similar when the measurements were recorded. Carotid artery PSVs, pulsatility, and RIs were found to be significantly decreased during VVI pacing compared to baseline and DDD pacing. The greater incidence of adverse cerebral outcomes in patients with VVI rather than DDD pacing may be partly due to decreased carotid PSVs.

New paradigms and improved results for the surgical treatment of acute type A dissection.

To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). Mean age was 59 +/- 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 +/- 50 minutes. Mean HCA with RCP time was 42 +/- 12 minutes (range 19-84). Mean cardiac ischemic time was 140 +/- 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.

Adverse cerebral outcomes after coronary bypass surgery

More than 800 thousand myocardial revascularization operations are performed annually in the world. Among the most common complications of such operations are neurological disorders, including encephalopathy and stroke. Data on the incidence of these complications are given in the materials of many observational studies, although the exact magnitude of the risk is still unknown.

Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter Study of Perioperative Ischemia Research Group (McSPI) and the Ischemia Research Education Foundation (IREF) Investigators.

Cerebral injury after cardiac surgery is now recognized as a serious and costly healthcare problem mandating immediate attention. To effect solution, those subgroups of patients at greatest risk must be identified, thereby allowing efficient implementation of new clinical strategies. No such subgroup has been identified; however, patients undergoing intracardiac surgery are thought to be at high risk, but comprehensive data regarding specific risk, impact on cost, and discharge disposition are not available. We prospectively studied 273 patients enrolled from 24 diverse US medical centers, who were undergoing intracardiac and coronary artery surgery. Patient data were collected using standardized methods and included clinical, historical, specialized testing, neurological outcome and autopsy data, and measures of resource utilization. Adverse outcomes were defined a priori and determined after database closure by a blinded independent panel. Stepwise logistic regression models were developed to estimate the relative risks associated with clinical history and intraoperative and postoperative events. Adverse cerebral outcomes occurred in 16% of patients (43/273), being nearly equally divided between type I outcomes (8.4%; 5 cerebral deaths, 16 nonfatal strokes, and 2 new TIAs) and type II outcomes (7.3%; 17 new intellectual deterioration persisting at hospital discharge and 3 newly diagnosed seizures). Associated resource utilization was significantly increased--prolonging median intensive care unit stay from 3 days (no adverse cerebral outcome) to 8 days (type I; P<0.001) and from 3 to 6 days (type II; P<0.001), and increasing hospitalization by 50% (type II, P=0.04) to 100% (type I, P<0.001). Furthermore, specialized care after hospital discharge was frequently necessary in those with type I outcomes, in that only 31% returned home compared with 85% of patients without cerebral complications (P<0.001). Significant risk factors for type I outcomes related primarily to embolic phenomena, including proximal aortic atherosclerosis, intracardiac thrombus, and intermittent clamping of the aorta during surgery. For type II outcomes, risk factors again included proximal aortic atherosclerosis, as well as a preoperative history of endocarditis, alcohol abuse, perioperative dysrhythmia or poorly controlled hypertension, and the development of a low-output state after cardiopulmonary bypass. These prospective multicenter findings demonstrate that patients undergoing intracardiac surgery combined with coronary revascularization are at formidable risk, in that 1 in 6 will develop cerebral complications that are frequently costly and devastating. Thus, new strategies for perioperative management--including technical and pharmacological interventions--are now mandated for this subgroup of cardiac surgery patients.

Risk-stratification parameters in patient selection for coronary artery bypass grafting

This article reviews mortality data from several large databases reporting coronary artery bypass graft (CABG) results, with particular emphasis on the New York State experience. It reports effects of major risk factors, including recent myocardial infarction, comorbidities, age, and gender. Data relating individual surgeons’ practice volume to outcome are reviewed, as are studies on adverse cerebral outcomes after CABG. Also discussed are risk stratification by standard and nuclear stress testing and the implications of risk assessment for the choice of either surgical intervention or medical therapy.

NEUROLOGIC COMPLICATIONS OF VASCULAR SURGERY

Technological advances in the management of cardiovascular disorders have resulted in an expansion of eligibility criteria for treatment, as well as an increased demand for improved outcomes. Neurologic complications after coronary artery bypass surgery, particularly stroke and cognitive dysfunction, substantially increase mortality, strain health care resources, and reduce the clinical effectiveness of the procedure. Carotid endarterectomy can be both the optimum stroke preventative strategy as well as a cause of stroke. The trend toward minimally invasive endovascular procedures, which has provided non-surgical options for both coronary and cerebral vascular occlusive lesions, is slowly being compared to conventional surgical and medical therapies. The identification of risk factors and mechanisms of adverse cerebral outcomes of these myriad vascular procedures is essential in improving their clinical effectiveness and patient applicability.

Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators.

Acute changes in cerebral function after elective coronary bypass surgery is a difficult clinical problem. We carried out a multicenter study to determine the incidence and predictors of -- and the use of resources associated with -- perioperative adverse neurologic events, including cerebral injury. In a prospective study, we evaluated 2108 patients from 24 U.S. institutions for two general categories of neurologic outcome: type I (focal injury, or stupor or coma at discharge) and type II (deterioration in intellectual function, memory deficit, or seizures). Adverse cerebral outcomes occurred in 129 patients (6.1 percent). A total of 3.1 percent had type I neurologic outcomes (8 died of cerebral injury, 55 had nonfatal strokes, 2 had transient ischemic attacks, and 1 had stupor), and 3.0 percent had type II outcomes (55 had deterioration of intellectual function and 8 had seizures). Patients with adverse cerebral outcomes had higher in-hospital mortality (21 percent of patients with type I outcomes died, vs. 10 percent of those with type II and 2 percent of those with no adverse cerebral outcome; P<0.001 for all comparisons), longer hospitalization (25 days with type I outcomes, 21 days with type II, and 10 days with no adverse outcome; P<0.001), and a higher rate of discharge to facilities for intermediate- or long-term care (69 percent, 39 percent, and 10 percent ; P<0.001). Predictors of type I outcomes were proximal aortic atherosclerosis, a history of neurologic disease, and older age; predictors of type II outcomes were older age, systolic hypertension on admission, pulmonary disease, and excessive consumption of alcohol. Adverse cerebral outcomes after coronary bypass surgery are relatively common and serious; they are associated with substantial increases in mortality, length of hospitalization, and use of intermediate- or long-term care facilities. New diagnostic and therapeutic strategies must be developed to lessen such injury.