Perioperative Stroke In Patients Research Articles

Benefits of prophylactic carotid revascularization in patients with asymptomatic carotid artery stenosis undergoing coronary artery bypass surgery: A narrative review.

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Off versus on pump myocardial revascularization in patients with severe asymptomatic carotid stenosis.

Coronary artery disease is a global cause of morbidity and mortality, often managed by coronary artery bypass grafting (CABG). This study addresses a critical decision-making dilemma in CABG procedures for patients with severe asymptomatic carotid stenosis, comparing off-pump and on-pump techniques. We conducted a retrospective single-center analysis, employing propensity scored matched-pair methodology to compare perioperative outcomes in patients with asymptomatic severe carotid stenosis undergoing off-pump or on-pump CABG. The primary endpoint was the occurrence of perioperative stroke. Secondary endpoints included postoperative delirium, intrahospital mortality, intensive care unit stay, length of hospitalization and long-term survival. The study involved 243 patients with asymptomatic severe carotid stenosis operated between July 2009 and October 2018, subsequently propensity score matched into two groups of 78 patients each (off-pump and on-pump). The incidence of perioperative stroke was significantly higher in the On-Pump group compared to the off-pump group (10.3% vs. 1.3%, P=0.03). However, secondary endpoints, such as intrahospital mortality and length of hospitalization, showed no significant differences between the two groups. Long-term survival rates were also comparable. Our findings indicate that off-pump CABG significantly reduces the risk of perioperative stroke in patients with severe asymptomatic carotid stenosis compared to on-pump CABG, without compromising long-term outcomes. These results support the preference for off-pump CABG in this high-risk patient population, highlighting the need for tailored surgical approaches based on individual patient risk profiles.

Re-conceptualization of the “Chinese Expert Guidelines for the Prevention of Stroke Associated with Patent Foramen Ovale” for the Management of Perioperative Stroke in Patients with Lung Cancer

The Chinese Heart Journal published the “Chinese Expert Guidelines for the Prevention of Stroke Associated with Patent Foramen Ovale” (hereafter referred to as “the Guidelines”) in 2021. The Guidelines were initiated by Professor Yushun Zhang of the No.1 Affiliated Hospital of Xi’an Jiaotong University, and 55 domestic experts participated in their discussion and formulation. The Guidelines focus on eight key issues in the prevention of stroke associated with patent foramen ovale (PFO), including definition and epidemiology, anatomical features, ultrasound diagnosis, clinical screening, and prevention and treatment of PFO-associated stroke. The prevention and treatment of PFO-associated stroke include pharmacological prevention, prevention of PFO with transcatheter occlusion and transcatheter occlusion of PFO. Patients with PFO are at elevated risk of perioperative stroke. In China, lung cancer ranks first in incidence among malignant tumors. The number of lung cancer surgeries is increasing each year, and the incidence of PFO in the population is approximately 25%. Although perioperative stroke in patients with lung cancer due to the presence of PFO has rarely been reported, given the high disability rate of stroke, incidence of PFO, and incidence of lung cancer, herein, we consider the Guidelines for the management of perioperative stroke in lung cancer. Our aim is to provide further perspectives in decreasing the risk of perioperative stroke in patients with lung cancer and PFO, to improve their quality of life and increase the safety of surgery.

Abstract 11204: Intraoperative Vital Parameters Improve the Accuracy of Machine Learning Based Prediction Model for Perioperative Stroke in Patients With Non Cardiac Surgery

Introduction: Perioperative stroke is one of the most devastating events after surgery. To prevent perioperative stroke and stratify the patients at risk, several prediction models or scores based on the preoperative factors were suggested. However, there had been never reported a prediction model using intraoperative physiologic parameters. Aim: We aimed to develop a prediction model for perioperative stroke by analyzing pre- and intraoperative factors using machine learning techniques. Methods: This retrospective cohort study included patients who underwent non-cardiac surgery between 2016 and 2019 at Seoul National University Hospital. Perioperative stroke was defined as a newly developed ischemic lesion at diffusion weighted imaging within 30 days after surgery. Preoperative factors were age, risk factors and laboratory data. Intraoperative variables were blood pressure, heart rate, saturation monitoring value, total amount of fluid and urine volume during surgery. We developed a random forest based prediction model composed of pre- and intraoperative factors and compared with a model consisting of only preoperative features. We validated the model in an external cohort of patients at another hospital between 2020 and 2021. Results: A total of 15752 patients were included in the development cohort, and 109 patients had perioperative stroke. In external validation cohorts, stroke occurred in 11 of 449 patients. The area under the receiver operating characteristics curves (AUC) for integrated models using pre- and intraoperative parameters was significantly higher than that of model using only preoperative factors, as shown in figure(0.822, 95% confidence interval, 0.760-0.883, p <0.001). The AUC of integrated model in external validation cohorts showed the trend in line with that of development cohorts. Conclusions: We demonstrated that using both pre- and intraoperative features may improve the accuracy of prediction for perioperative stroke.

Preoperative hyperglycemia is associated with elevated risk of perioperative ischemic stroke in type 2 diabetic patients undergoing non-cardiovascular surgery: A retrospective cohort study.

Diabetes mellitus (DM) has been reported to be associated with perioperative stroke, but the effects of preoperative hyperglycemia on the risk of perioperative stroke in diabetic patients undergoing non-cardiovascular surgery remain unclear. This study investigated the association between preoperative hyperglycemia and the risk of perioperative ischemic stroke in type 2 diabetic patients undergoing non-cardiovascular surgery. This retrospective cohort study screened 27,002 patients with type 2 DM undergoing non-cardiovascular surgery with general anesthesia between January 2008 and August 2019 at The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital. The exposure of interest was preoperative hyperglycemia, defined as a fasting plasma glucose (FPG) ≥ 7 mmol/L. The outcome of interest was a new diagnosis of perioperative ischemic stroke within 30 days after surgery. Residual confounding was minimized by controlling for observable patient and intraoperative factors. Logistic regression was conducted in the total and propensity score matched cohorts. In addition, we stratified patients into six subgroups to investigate whether the association between preoperative hyperglycemia and perioperative ischemic stroke differs in these subgroups. The overall incidence of perioperative ischemic stroke was 0.53% (n = 144) in the current cohort. The odds of perioperative ischemic stroke were significantly increased for patients with preoperative hyperglycemia after adjusting for patient- related variables (OR: 1.95; 95% CI: 1.39-2.75; p < 0.001), surgery-related variables (OR: 2.1; 95% CI: 1.51-2.94; p < 0.001), and all confounding variables (OR: 1.78; 95% CI: 1.26-2.53; p < 0.001). The risk of perioperative stroke was significantly increased in patients with preoperative hyperglycemia (OR: 2.51; 95% CI: 1.66-3.9; p < 0.001) in the propensity score matched cohort. Preoperative hyperglycemia was associated with the outcome for all the subgroups except for patients undergoing neurosurgery. Preoperative hyperglycemia is associated with an elevated risk of perioperative stroke in patients with type 2 DM undergoing non-cardiovascular surgery. The effect could be eliminated for patients undergoing neurosurgery, during which specific risk factors should be considered.

Risk Factors of Transient Neurological Deficits and Perioperative Stroke after Revascularization in Patients with Moyamoya Disease.

Objective: To analyze the risk factors of transient neurological deficits (TND) and perioperative stroke in patients with MMD after extracranial–intracranial revascularization. Methods: A retrospective analysis of the clinical data of 183 patients with MMD undergoing 203 EC–IC bypass operation procedures from January 2018 to August 2020. According to whether TND and stroke occurred within 14 days after operation, univariate analysis and multivariate logistic regression were used. Results: TND occurred in 26 cases (12.8%) of revascularization. The results of the univariate analysis showed that history of diabetes, multiple episodes of preoperative symptoms, lesions involving the posterior circulation, and high postoperative blood pressure are the risk factors of TND. Further multivariate logistic regression analysis showed that multiple episodes of preoperative symptoms (p = 0.016) and lesions involving the posterior circulation (p = 0.014) are the independent risk factors for TND. Perioperative stroke occurred in 12 cases (5.9%). The results of the univariate analysis showed that older age, history of hypertension, preoperative cerebral infarction as the main symptom, lesions involving the posterior circulation, and high perioperative blood pressure are the risk factors of perioperative stroke. The results of multivariate logistic regression analysis showed that preoperative cerebral infarction as the main symptom (p = 0.015) is an independent risk factor for perioperative stroke. The occurrence of perioperative complications was not related to the improvement of follow-up mRS (Modified Rankin Scale) score and long-term cerebral rehemorrhage. Conclusions: Clinically, patients with MMD have multiple episodes of preoperative symptoms, lesions involving the posterior circulation, and preoperative cerebral infarction and should be attached when undergoing revascularization.

Risk of Perioperative Stroke in Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis.

Patent foramen ovale (PFO) is a common congenital cardiac abnormality. Risk of stroke increases perioperatively, but the association of PFO with perioperative stroke risk remains unclear. We conducted a systematic review to inform the risk of perioperative stroke in patients with PFO undergoing surgery. Embase, MEDLINE, and Cochrane databases were searched from inception to January 2020. We described methods used for establishing PFO and perioperative stroke diagnosis. We conducted meta-analyses to obtain pooled estimates for risk of stroke in patients with and without PFO in different surgical populations. Ten articles with a total of 20,858,011 patients met the eligibility criteria. Prevalence of PFO ranged from 0.06% to 1.4% based on International Classification of Diseases (ICD)-code diagnosis and from 10.4% to 40.4% based on echocardiography diagnosis. Perioperative stroke was observed in 0% to 25% of patients with PFO, and 0% to 16.7% without PFO. Studies that used echocardiography to diagnose PFO found no association between PFO and perioperative stroke. Studies that used ICD codes found strong association but were highly heterogeneous. PFO was not associated with a risk of perioperative stroke in cardiac and transplantation surgeries. While the adjusted odds ratios for stroke were substantial for orthopaedic, general, genitourinary, neurologic, and thoracic surgeries (with PFO status established based on ICD codes), data heterogeneity and quality of data create significant uncertainty. In conclusion, PFO is likely a risk factor for perioperative stroke in selected types of surgeries. However, this is based on very low-quality evidence. Rigorous prospective studies are needed to further investigate this relationship.

Perioperative stroke in patients undergoing spinal surgery: a retrospective cohort study

BackgroundThe incidence of perioperative stroke following spinal surgery, including ischemic and hemorrhagic stroke, has not been fully investigated in the Chinese population. Whether specific spinal or emergency/elective procedures are associated with perioperative stroke remains controversial. This study aimed to investigate the incidence of perioperative stroke, health economic burden, clinical outcomes, and associated risk factors.MethodA retrospective cohort study using an electronic hospital information system database was conducted from Jan 1, 2015, to Jan 1, 2021, in a tertiary hospital in China. Patients aged ≥18 years who had undergone spinal surgery were included in the study. We recorded patient demographics, comorbidities, and health economics data. Clinical outcomes included perioperative stroke during hospitalization and associated risk factors. The patients’ operative data, anesthetic data, and clinical manifestations were recorded.ResultA total of 17,408 patients who had undergone spinal surgery were included in this study. Twelve patients had perioperative stroke, including seven ischemic stroke (58.3%) and five hemorrhagic stroke (41.7%). The incidence of perioperative stroke was 0.07% (12/17,408). In total, 12 stroke patients underwent spinal fusion. Patients with perioperative stroke were associated with longer hospital stay (38.33 days vs. 9.78 days, p < 0.001) and higher hospital expenses (RMB 175,642 vs. RMB 81,114, p < 0.001). On discharge, 50% of perioperative patients had severe outcomes. The average onset time of perioperative stroke was 1.3 days after surgery. Stroke history (OR 146.046, 95% CI: 28.102–759.006, p < 0.001) and hyperlipidemia (OR 4.490, 95% CI: 1.182–17.060, p = 0.027) were associated with perioperative stroke.ConclusionThe incidence of perioperative stroke of spinal surgery in a tertiary hospital in China was 0.07%, with a high proportion of hemorrhagic stroke. Perioperative stroke patients experienced a heavy financial burden and severe outcomes. A previous stroke history and hyperlipidemia were associated with perioperative stroke.

Eptifibatide bridging therapy for staged carotid artery stenting and cardiac surgery: Safety and feasibility.

Prophylactic carotid artery stenting (CAS) is an effective strategy to reduce perioperative stroke in patients with severe carotid stenosis who require cardiothoracic surgery (CTS). Staging both procedures (CAS-CTS) during a single hospitalization presents conflicting demands for antiplatelet therapy and the optimal pharmacologic strategy between procedures is not established. The purpose of this study is to present our initial experience with a "bridging" protocol for staged CAS-CTS. A retrospective review of staged CAS-CTS procedures at a single referral center was performed. All patients had multivessel coronary and/or valvular disease and severe carotid stenosis (>70%). Patients not previously on aspirin were also started on aspirin prior to surgery, followed by eptifibatide during CAS (intraprocedural bolus followed by post-procedural infusion which was continued until the morning of surgery). Pre- and perioperative (30days) neurologic morbidity and mortality was the primary endpoint. 11 CAS procedures were performed in 10 patients using the protocol. The median duration of eptifibatide bridge therapy was 36h (range 24-288 h). There was one minor bleeding complication (1/11, 9.1%) and no major bleeding complications during the bridging and post-operative period. There was one post-operative, non-neurologic death and zero perioperative ischemic strokes. For patients undergoing staged CAS-CTS, Eptifibatide bridging therapy is a viable temporary antiplatelet strategy with a favorable safety profile. This strategy enables a flexible range of time-intervals between procedures.

Treatment-Associated Stroke in Patients Undergoing Endovascular Therapy in the ARUBA Trial.

Since the publication of ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), outcomes in treated and untreated patients with unruptured arteriovenous malformation have been thoroughly compared. However, no prior analysis of ARUBA patients has sought to identify risk factors for perioperative stroke. Improved understanding of risks within the ARUBA cohort will help clinicians apply the study’s findings in a broader context. The National Institute of Neurological Disorders and Stroke database was queried for all data relating to ARUBA patients, including demographics, interventions undertaken, and timing of stroke. Retrospective cohort analysis was performed with the primary outcome of perioperative stroke in patients who underwent endovascular intervention, and stroke risk was modeled with multivariate analysis. A total of 64 ARUBA patients were included in the analysis. One hundred and fifty-ninth interventions were performed, and 26 (16%) procedures resulted in stroke within 48 hours of treatment. Posterior cerebral artery supply (adjusted odds ratio, 4.42 [95% CI, 1.23–15.9], P=0.02) and Spetzler-Martin grades 2 and 3 arteriovenous malformation (adjusted odds ratio, 7.76 [95% CI, 1.20–50.3], P=0.03; 9.64 [95% CI, 1.36–68.4], P=0.04, respectively) were associated with increased perioperative stroke risk in patients who underwent endovascular intervention. Patients treated in the United States or Germany had a significantly lower stroke risk than patients treated in other countries (adjusted odds ratio, 0.18 [95% CI, 0.04–0.82], P=0.02). Knowing patient and lesion characteristics that increase risk during endovascular treatment can better guide clinicians managing unruptured brain arteriovenous malformation. Our analysis suggests risk of perioperative stroke is dependent on Spetzler-Martin grade and posterior-circulation arterial supply. Differences in regional treatment paradigms may also affect stroke risk.

Perioperative Malignant Infarct in a Patient undergoing Mandibular Reconstruction with Free Fibular Flap Surgery for Oral Cancer: A Case Report

Oral cancer is among the top three cancers in India. Surgery is the recommended treatment option for early-stage and locally advanced resectable cases. The incidence of perioperative stroke in patients undergoing neck dissection for head and neck cancer is only 0.2%. In the following article, we report the first case of perioperative malignant infarct in a patient undergoing mandibular reconstruction with free fibula flap surgery for oral cancer. An eighty-year-old male diagnosed with locally advanced carcinoma of the oral cavity underwent mandibular reconstruction with free fibula flap surgery. In the perioperative period, he developed malignant infarction involving the right middle and posterior cerebral artery in the immediate postoperative period, however, it was diagnosed after 36 hours of surgery. He was managed conservatively and discharged with a favorable outcome. This case highlights the importance of clinical examination in such a case, along with the difficulties faced in examining the patient in the perioperative period.

A Novel Approach to Prevent Perioperative Stroke in Patients Undergoing Debranching Thoracic Endovascular Aortic Repair with a Mini-Cardiopulmonary Bypass Support

Perioperative stroke is a major complication after debranching thoracic endovascular aortic repair (TEVAR), with a reported incidence of 7.0-26.9%. Subsequent functional recovery is difficult in most cases. This study was performed to evaluate the efficacy of mini-cardiopulmonary bypass (mini-CPB) support in debranching TEVAR to prevent perioperative stroke. From December 2010 to July 2017, 32 patients with a shaggy aorta or intimal irregularity in the aortic arch identified on preoperative computed tomography underwent debranching TEVAR. Nineteen patients underwent debranching TEVAR without mini-CPB, and 13 patients underwent debranching TEVAR with a mini-CPB support. Mini-CPB support had been used in November 2014 to treat perioperative stroke, which had occurred in 8 (42%) patients at that time. The form of the debranching arch vessels was not changed; bypass from the right axillary artery to the left axillary artery was performed for one debranching, and bypass from the right axillary artery to the left common carotid artery and left axillary artery was performed for two debranchings. After establishment of mini-CPB support through this debranching graft and right femoral vein cannulation, all endovascular manipulations were initiated. The left subclavian artery was occluded with a plug at the end of the procedure. The proximal landing zones of the endoprosthesis were as follows: zone 0 in 9 patients, zone 1 in 5 patients, and zone 2 in 5 patients in the no-CPB era and zone 1 in 3 patients and zone 2 in 10 patients in the CPB era. The mean mini-CPB support period was 51minutes. Postoperative respiratory support and hospitalization were not prolonged with mini-CPB support. The incidence of perioperative stroke was 42% in the no-CPB era and 8% in the CPB era. No operative mortality was observed in the CPB era, although 5 (26%) patients died in the no-CPB era. The cause of operative mortality in the no-CPB era was perioperative stroke in 4 patients and acute myocardial infarction in 1 patient. No significant difference in the cumulative survival rate was found between patients with and without mini-CPB support. Our mini-CPB system may have the potential to prevent perioperative stroke during debranching TEVAR for treatment of aortic arch pathologies.

Abstract TMP60: Trends in Neurophysiologic Intraoperative Monitoring and Occurrence of Stroke at the Time of Hospitalization for Carotid Endarterectomy

Background: intraoperative neurophysiological monitoring (IoNM) is a valuable technique for determining the need for selective intraoperative shunting and prevention of perioperative stroke in patients undergoing carotid endarterectomy (CEA). Methods: We aimed to describe the trends of intraoperative monitoring utilization using the US-representative 2006-2015 National Inpatient Sample database. We sought to identify associations of patient’s demographics with outcomes with an adjusted multivariable logistic regression model. Results: Between 2006-2014, there were a total of 11003 endarterectomies included in our analysis, most commonly performed in men 6764 (61.5%), and women 4239 (38.5%) mostly older than 65 years old. Intraoperative monitoring was used in 266 cases (2.45%) equally across genders, 168 (2.5%) man, 98 (2.3%) women. Nearly 80.8% undergoing CEA and IoNM were white, 8.7% black, 5.7% Hispanic with no differences of IoNM use across race. No difference between primary payer, location/teaching status or size of the hospital were observed. The use of IoNM during CEA was more frequent in the Midwest region: 32.9% (89), Northeast: 28% (74), South: 21.4% (57), and West: 17.6% (46), p=0.0000. The rate of utilization of IoNM increased across the years, 2006/08 (0.06%), 2009/11 (2.1%) and 2012/14 (4.6%). p=0.0000. Unadjusted rates of in-hospital death were not associated with IoNM. Mean length of stay(LOS) of ECA with IoNM was 8 days (95% CI, 7.36-8.76) and IoNM without ECA was 7.25 (95% CI, 7.10-7.38). Adjusted Mortality did not differ in time. During 2009-2011: aOR 0.60 (95% CI, 0.36-0.98) and 2012-2014: aOR 0.50, (95% CI, 0.29-0.86) were associated with lower odds of using Intraoperative monitoring. The Charlson Comorbidity Index aOR 1.2 (95% CI, 1.09-1.33) and Length of stay aOR 1.06 (95% CI, 1.04-1.08) Conclusions: The percent of endarterectomies performed with IoNM has increased over the years; however, this trend does not seem to impact LOS and in-hospital mortality. This might be explained by the overall low rate of utilization, with documentation of its use in only 5.2% of CEA performed in 2014. Despite being a highly specific test in predicting neurological outcomes, the impact on perioperative stroke prevention is perhaps undervalued.

A functional evaluation of cerebral perfusion for coronary artery bypass grafting patients.

We evaluate the utility of providing a pulsatile blood flow by applying off-pump coronary artery bypass grafting (CABG) or intra-aortic balloon pumping (IABP) with conventional CABG to prevent perioperative stroke in patients with cerebral hypoperfusion on single-photon emission-computed tomography (SPECT). A total of 286 patients underwent isolated CABG with a cerebral magnetic resonance angiography (MRA) evaluation between 2006 and 2015. Seventy-five had significant stenosis and/or occlusion of craniocervical vessels; the other 211 had no significant stenosis. Cerebral SPECT was performed for 49 (SPECT group) of the 75 patients. The SPECT group was further divided into a normal perfusion (NP) (n = 37); and a hypoperfusion (HP) (n = 12). In the present study we compared the NP group and the 211 patients with no significant stenosis (as a control group) to the HP group. No strokes occurred in the HP group, and 1 stroke occurred at the time of operation in the control group. Postoperative stroke within 30days occurred in 3 patients in the control group; the difference was not statistically significant. The long-term stroke-free rates of the HP and Control group did not differ to a statistically significant extent. The functional evaluation of cerebral perfusion by SPECT is important when patients have significant stenotic lesions on cerebral MRA. Maintaining an adequate pulsatile flow by off-pump CABG or IABP with conventional CABG will help prevent perioperative stroke, even if cerebral hypoperfusion is detected by SPECT.

Impact of Perioperative Management for Intracranial Arterial Stenosis on Postoperative Stroke Incidence in Coronary Artery Bypass Surgery: A Propensity Matching and Multivariate Analyses

Background: Intracranial arterial steno-occlusive lesion (IAS) is the most common cause of stroke. We hypothesized that adequate perioperative management for IAS is useful to prevent stroke in coronary artery bypass grafting (CABG). Methods: IAS was evaluated using magnetic resonance imaging/angiography (MRI/A, n = 216) in patients without a history of stroke or carotid stenosis (≥50%) in CABG between May 2005 and June 2018 (n = 424). Off-pump CABG was performed in most patients. Different perioperative managements of systolic arterial pressure (SAP) were applied for patients with and without MRI/A. SAP was strictly maintained at ≥80 mmHg in patients with significant IAS (≥50%, n = 28) and ≥90 mmHg for severe IAS (≥70%, n = 44) while SAP less than 80 mmHg (usually ≥70 mmHg) was allowed for patients without MRI/A. Intra-aortic balloon pumping was used for patients with multiple severe IAS and/or occlusion. Clinical outcomes were compared between patients with and without MRI/A. Propensity matching was performed (n = 181 each). Results: Complete revascularization was achieved in all patients. Nine patients (2.12%) had postoperative strokes; the incidence of stroke was signifi-cantly less in patients with preoperative MRI/A (n = 1, p = 0.016). There was no significant difference in the incidence of in-hospital mortality between patients with and without preoperative MRI/A (0.5% and 1.0%, respectively; p = 0.529). Multivariate analysis revealed that no preoperative MRI/A was the only significant predictors of postoperative stroke (p = 0.045). The incidence of stroke was not higher in patients with IAS who underwent MRI/A (p = 0.332). Conclusions: Preoperative evaluation of IAS using MRI/A and following our perioperative management significantly reduced perioperative stroke in patients undergoing CABG.

Concomitant aorto-right subclavian artery bypass with off-pump coronary artery bypass grafting: a case report

BackgroundAtherosclerotic stenosis of the brachiocephalic artery sometimes occurs in patients with coronary artery disease, and can cause stroke during the perioperative period of coronary artery bypass grafting.Case presentationWe describe the case of a 77-year old male with severe stenosis of the brachiocephalic artery and severe coronary artery disease. He successfully underwent aorto-right subclavian artery bypass that was performed concomitantly with off-pump coronary artery bypass.ConclusionConcomitant aorto-subclavian artery bypass with off-pump coronary artery bypass grafting is a therapeutic option that minimizes the risk of perioperative stroke in patients with brachiocephalic artery stenosis and coronary artery disease.

Neurological outcome and efficacy of intensive craniocervical screening for elective cardiac surgery.

To evaluate the efficacy of intensive craniocervical screening before elective cardiovascular surgery. A retrospective analysis of 1134 consecutive patients who underwent routine screening before cardiovascular surgery between November 2004 and December 2014 was conducted. The study was divided into 2 distinct cohorts of patients undergoing surgery: before (n = 500) and after (n = 634) the introduction of intensive screening in January 2009. In 2009, preoperative screening underwent a transition from the evaluation of carotid atherosclerosis alone to that of craniocervical atherosclerosis. Additionally, patients with moderate or greater stenosis on intensive screening underwent single-photon emission computed tomography with acetazolamide. Craniocervical atherosclerosis was classified as no or mild [0-49%: n = 836 (before/after: 370/466)], moderate [50-69%: n = 118 (56/62)] or severe [70-100%: n = 141 (36/105)]. One of 166 (0.6%) patients with moderate or greater stenosis undergoing single-photon emission computed tomography with acetazolamide after the introduction of intensive screening was diagnosed as having impaired cerebral autoregulation. The occurrences of perioperative stroke were 2.8% before the introduction of intensive screening and 0.9% after that (P = 0.033). Notably, intraoperative stroke significantly decreased from 1.4% to 0.2% (P = 0.034). Specifically, the occurrence of perioperative stroke in patients with no or mild stenosis decreased significantly after the introduction of intensive screening, from 2.7% to 0.4% (P = 0.007). The incidence of perioperative stroke decreased following the introduction of intensive screening. Intensive screening may be able to detect patients with a greater risk of perioperative stroke.

Perioperative stroke after cerebral aneurysm clipping: Risk factors and postoperative impact

Stroke is a devastating complication after intracranial aneurysm clipping. Understanding the risk factors that prognosticate perioperative stroke may help to identify patients that would benefit from neuroprotective therapy. This study assesses patient-specific independent predictors of perioperative stroke in relation to surgical aneurysm clipping. Additionally, this study evaluates the postoperative complications of stroke. We performed a retrospective chart review of 437 patients with ruptured and unruptured intracranial aneurysms, which underwent surgical clipping from 2006 to 2013. Multivariate logistical regression was utilized to assess the effect of age, race, gender, subarachnoid hemorrhage, Hunt and Hess (H/H) grade, aneurysm location, and intraoperative somatosensory evoked potentials (SSEPs) changes on the frequency of perioperative stroke. Thirty-five (8.0%) patients developed a stroke within 24h postoperatively. Patients with significant intraoperative SSEP changes were 7.33 (95% confidence interval [CI]: 3.51–15.31) times more likely to develop perioperative strokes. In patients who presented with H/H grade 5, the odds ratio for developing perioperative stroke was 9.21 (95% CI: 1.28–66.13) respectively. In the absence of aneurysm rupture, patients presenting with new-onset stroke were more likely to suffer postoperative complications, stay in the intensive care unit longer, and be discharged to in-patient rehabilitation compared to patients without new-onset stroke. This study suggests that severity of subarachnoid hemorrhage based on the patient’s clinical condition increases the risk of perioperative stroke in patients with surgical aneurysm clipping. SSEP changes and high-grade H/H scores can serve as independent predictors of perioperative stroke, with the latter having the greatest predictive value.

Red cell distribution width is a prognostic marker of perioperative stroke in patients undergoing cardiac valve surgery.

Numerous studies have shown that elevated red cell distribution width (RDW) is associated with poor outcomes in patients with cardiovascular diseases such as coronary artery disease, peripheral artery disease or stroke. The usefulness of the RDW as a predictor of perioperative stroke in patients with valve disease undergoing valve surgery is currently unknown. The aim of the study was to evaluate the prognostic value of RDW for stroke in the early postoperative period in patients undergoing valve replacement or repair surgery. A prospective study was conducted on a group of 500 consecutive patients with haemodynamically significant valvular heart disease who underwent elective valvular surgery. Preoperative complete blood count, data on risk factors, the course of operations and the postoperative period were assessed. The primary end-point at the 30-day follow-up was perioperative stroke or transient ischaemic attack. The secondary end-point was death from all causes in patients with perioperative stroke. Univariate analysis, followed by multivariate regression analysis, was performed. The perioperative stroke occurred in 14 patients. At multivariate analysis: RDW [odds ratio (OR) 1.640, 95% confidence interval (CI) 1.132-2.377; P = 0.009] and haemoglobin (OR 0.655, 95% CI 0.447-0.961; P = 0.03) remained independent predictors of the primary end-point. Receiver operator characteristics analysis determined a cut-off value of RDW for the prediction of the occurrence of the perioperative stroke/transient ischaemic attack at 14.1%. Creatinine (OR 1.015, 95% CI 1.004-1.026; P = 0.0079) and RDW (OR 1.493, 95% CI 1.171-1.815; P = 0.04) were associated with an increased risk of death in patients with perioperative stroke. Elevated RDW is associated with a higher risk of perioperative stroke/transient ischaemic attack and death in patients with perioperative stroke.

The impact of carotid or intracranial atherosclerosis on perioperative stroke in patients undergoing open aortic arch surgery

ObjectivesThis study aimed to clarify the impact of carotid or intracranial atherosclerosis on perioperative stroke in patients undergoing open aortic arch surgery. MethodsBetween 2008 and 2015, 200 consecutive patients underwent elective aortic arch surgery with selective antegrade cerebral perfusion and moderate hypothermic circulatory arrest. Nonselective screening for carotid or intracranial atherosclerosis was performed using carotid ultrasonography or magnetic resonance angiography. Carotid or intracranial atherosclerosis was classified as below moderate (0%-49% stenosis), moderate (50%-69%), or severe (70%-100%). In patients with moderate or severe stenosis, cerebral hemodynamics were evaluated using single-photon emission computed tomography with acetazolamide. ResultsNone of the 37 patients undergoing preoperative single-photon emission computed tomography with acetazolamide had impaired cerebral hemodynamics. In-hospital mortality rate was 3.5% (7/200). Postoperative neurologic morbidity included permanent stroke in 8 patients (4.0%) and transient neurologic deficits in 27 patients (14%). Permanent stroke occurred in 3 of 159 patients (1.9%) with below moderate stenosis and 5 of 41 patients (12.2%) with moderate or severe stenosis (P = .008). Seven of 8 patients (87.5%) with stroke experienced multiple atherothrombotic embolizations, and 1 patient experienced a stroke of unknown cause. In multivariate analysis, previous cerebrovascular accident (odds ratio, 5.0; 95% confidence interval, 2.07-12.42; P = .0004) and shaggy aorta (odds ratio, 4.2; 95% confidence interval, 1.58-10.98; P = .0045) were significant determinants of neurologic morbidity. ConclusionsEmbolism was the major cause of permanent stroke in our patient population. Preoperative craniocervical and aortic screening may aid in modifying the operative strategy to reduce the occurrence of stroke.