Risk Factors For Postoperative Stroke Research Articles

Clinical Features and Risk Factors of Postoperative Stroke in Adult Moyamoya Disease.

The clinical features of and risk factors for postoperative stroke after surgical revascularization in adult moyamoya disease (MMD) have not been fully elucidated. To this end, the baseline clinical features were hereby described, and the risk factors for postoperative stroke were determined. Data of 4078 MMD inpatients were collected retrospectively across all secondary- and higher-level hospitals of Hubei Province from January 2019 to December 2020. In accordance with inclusion and exclusion criteria, 559 adult MMD inpatients were finally enrolled. The associated characteristics and potential risk factors were analyzed, and the Kaplan-Meier risk of stroke was also calculated. The patients consisted of 286 females and 273 males, with a mean age of 49.1 ± 10.0 years, all of whom had at least 1 year of follow-up (median 25.1 months). There were 356 cases of preoperative ischemic symptoms and 203 cases of preoperative hemorrhage symptoms. Indirect, direct, and combined revascularization were conducted on 97, 105 and 357 patients, respectively. Among these patients, 17 had postoperative hemorrhagic stroke (PHS), and 43 had postoperative ischemic stroke (PIS). A comparison between PHS/PIS group and control group (patients without postoperative stroke events) showed that preoperative hemorrhage was significantly associated with PHS (p = 0.003), while hypertension (p = 0.003), diabetes mellitus (p = 0.003) and modified Rankin scale (mRS) (p = 0.034) at admission were associated with a higher rate of PIS. Furthermore, preoperative hemorrhagic stroke was identified as a risk factor for PHS (odds ratio [OR], 4.229 [95% CI, 1.244-14.376]; p = 0.021), while hypertension (odds ratio [OR], 0.424 [95% CI, 0.210-0.855]; p = 0.017), diabetes mellitus (odds ratio [OR], 0.368 [95% CI, 0.163-0.827]; p = 0.016) and admission mRS (odds ratio [OR], 2.301 [95% CI, 1.157-4.575]; p = 0.017) were found to be risk factors for PIS. The age distribution of adult MMD patients with revascularization was predominantly concentrated within the range from 46 to 55 years. Preoperative hemorrhage events were considered the risk factor for PHS. Hypertension, diabetes and admission mRS were correlated with PIS, and were also the risk factors for PIS. These results indicated the possible contribution of enhancing systematic disease management to the prevention of postoperative cerebrovascular accidents.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

Risk Factors for Stroke Development After Thoracic Aortic Surgery

Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development. A retrospective analysis. Tertiary, high-volume cardiac surgery center. Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021. None. A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p=0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p=0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p=0.021). This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.

Incidence, risk factors and outcomes of early post-operative stroke in a university-based, tertiary care hospital: A 7-year retrospective case-control study.

Most post-operative stroke cases occur within 24 hours. This retrospective case-control study aimed to investigate the incidence, risk factors, and outcomes of early post-operative stroke that occurred within 24 hours after surgery in a university-based tertiary care hospital. Medical records were collected and reviewed between 2015 and 2021. Early post-operative stroke cases were compared with age-matched controls in a 1:3 ratio, and data regarding patient characteristics, intra-operative events, and post-operative outcomes were analyzed. Multiple logistic regression was performed to identify the risk factors for post-operative stroke. The incidence of early (≤24 hours) post-operative stroke was 0.015% (43 out of 284,105 cases). The multivariable analysis revealed that American Society of Anesthesiologists (ASA) physical status ≥3 (adjusted odds ratio [OR]: 3.12; 95% confidence interval [CI]: 1.22-7.99, P = .017), operation time >120 minutes (adjusted OR: 10.69; 95% CI: 3.95-28.94, P < .001), and intra-operative hypotension and inotrope/vasopressor use (adjusted OR: 2.80; 95% CI: 1.08-7.24, P = .034) were risk factors for early post-operative stroke. Compared to the controls, stroke patients had higher rates of planned and unplanned intensive care unit (ICU) admission, length of stay, ventilator use, and death. Despite its low incidence (0.015%), stroke is associated with poor clinical outcomes and increased mortality. Stratification of potential risks and establishment of risk optimization may help reduce stroke incidence.

Intracranial Atherosclerosis and Postoperative Stroke Following Coronary Artery Bypass Surgery: A Literature Review

Stroke is a devastating complication of cardiac surgery. Extracranial carotid atherosclerosis (ECAS) is a risk factor for postoperative stroke, but there is limited insight into the effect of intracranial atherosclerosis (ICAS). It is believed that this is the first literature review investigating ICAS and postoperative stroke in a cardiac surgery patient cohort. This review aimed to explore the prevalence and predictors of intracranial ICAS, association with postoperative stroke, and treatment options in patients with ICAS undergoing cardiac surgery.

Prospective analysis of cerebrovascular events in patients following coronary artery bypass surgery

Background: Cerebrovascular events are the most common cause of disability in adults and can be classified into two categories: ischemic stroke and hemorrhagic stroke. Risk factors for stroke include age, gender, race, family history of stroke, hypertension, smoking, heart disease, valvular heart disease, arrhythmias, diabetes, obesity, and dyslipidemia. Low cardiac output syndrome, myocardial infarction, and atrial fibrillation can also contribute to stroke. This study aims to investigate the incidence of stroke post-cardiac surgery and the risk factors contributing to it. Methods: A prospective observational study with a sample size of 516 patients was conducted. Patients over the age of 40 who were undergoing CABG (both off and on pump) were included. Patients were subjected to on-pump or off-pump coronary artery bypass surgery as per requirement, but preferably off-pump. Results: Out of 516 patients, 13 developed strokes, of which 8 (61.5%) had hypertension and 10 (76.9%) had diabetes, 4 (30.8%) were smokers, 6 (46.2%) had normal LDL values, 7 (53.8%) had high LDL levels, none had normal HDL values, 1 (7.7%) had normal LV function, 4 (30.8%) had mild LV dysfunction, 4 (30.8%) had moderate LV dysfunction, and 4 (30.8%) had severe LV dysfunction. 11 (84.6%) had COPD. 7 (53.8%) had no prior MI, 5 (38.5%) had a recent MI, and 1 (7.7%) had a prior MI that was more than ten years old. 8 (61.5%) had normal renal functions, while 5 (38.5%) had disturbed renal functions. Conclusions: In this study, the incidence of CVE after CABG is 2.52%. All the patients who developed stroke had multiple risk factors. High LDL, low LVEF, deranged renal functions, PVD, arrhythmia pre-op, anti-coagulation pre-op, on pump surgery, Cardioplegia usage, CCF pre-op, urgent surgery, LCOS post-operatively are risk factors for post-operative stroke.

Carotid endarterectomy is safe for octogenarians

Carotid endarterectomy (CEA) has demonstrated superior results in stroke risk reduction for patients with symptomatic and asymptomatic high-grade carotid stenosis. However, this benefit has long been questioned for the elderly and high-risk populations. In the present study, we aimed to provide high-volume, single-institution data with long-term follow-up examining the risk factors for postoperative stroke and stroke-free survival stratified by age for asymptomatic and symptomatic patients undergoing CEA. A single-institution retrospective review of 840 consecutive patients who had undergone CEA from 2011 to 2018 was performed, inclusive of both symptomatic and asymptomatic operative indications. The primary end point was perioperative stroke within 30days of surgery. The secondary end points were late stroke, death, and myocardial infarction. Patients aged >80years were compared with those aged<80years to examine freedom from stroke and death. Statistically significant differences were defined as those with P< .05. A total of 840 patients were evaluated with a median follow-up of 416± 1244days. Of the 840 patients, 499 (59%) were men, and 604 (72%) were White. The mean age was 72± 9years, with 202 (24%) aged ≥80years. CEA was performed for symptomatic disease in 305 patients (36%), of whom 143 (47%) had had strokes and 162 (53%) had had transient ischemic attacks. The overall 30-day postoperative stroke rate was 1.0% (eight patients; 0.6% for asymptomatic and 1.6% for symptomatic; P= .147). Compared with younger patients, octogenarians had had a similar stroke rate after CEA (1.5% vs 0.8%; P= .407). Hispanic race was an independent risk factor for postoperative stroke. White race and preoperative statin use both appeared to be protective. Kaplan-Meier survival curves demonstrated decreased a 5-year stroke-free survival in patients aged ≥80years (P= .031). However, overall, the estimated 5-year survival was similar to the U.S. general population across both age groups. CEA for octogenarians is safe and effective for both symptomatic and asymptomatic populations with excellent 30-day outcomes and long-term survival mirroring that of the general population.

Outcomes and role of shunting during carotid endarterectomy for symptomatic patients.

Shunt placement during carotid endarterectomy (CEA) has often been advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. In the present study, we assessed the effect of shunt placement during CEA on postoperative stroke risk in symptomatic patients. We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data available. Symptomatic patients were identified as those with a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack, amaurosis fugax, or temporary monocular blindness. The DS patients were further analyzed according to the severity of their stroke using the modified Rankin scale scores. To better assess the effect of shunt placement on the stroke rate, we compared cases of CEA with the patch angioplasty technique stratified by the use of an intraoperative shunt. Patients who had undergone carotid eversion or primary closure were excluded. The baseline demographics and perioperative outcomes were compared using the χ2 and Mann-Whitney U tests. Multivariate analysis was performed to identify the independent risk factors for postoperative stroke and cranial nerve injury. We identified 4652 cases of CEA with patch angioplasty in symptomatic patients, including 1889 with (40.6%) and 2763 without (59.4%) shunt placement. The distribution of age, race, and sex was similar for both procedures. Compared with patients without a shunt, those with a shunt had significantly higher rates of emergency surgery (9.1% vs 7.0%; P= .010), nonelective surgery (40.3% vs 37.2%; P= .035), general anesthesia (97.0% vs 86.3%; P< .001), and bleeding disorders (27.2% vs 22.7%; P< .001). The 30-day incidence of postoperative stroke was similar between the patients with (3.2%) and without (2.6%) shunt placement (P= .219). Additionally, a subgroup analysis failed to show any benefit from shunt placement on the incidence of postoperative stroke, regardless of the preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with an increased rate of cranial nerve injury (4.1% vs 2.4%; P= .001). Multivariate analysis revealed that nonelective surgery (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.36-2.91; P< .001) and DS (vs transient ischemic attack, amaurosis fugax, or temporary monocular blindness; OR, 1.64; 95% CI, 1.12-2.41; P= .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30days but remained an independent risk factor for cranial nerve injury (adjusted OR, 1.87; 95% CI, 1.32-2.64; P< .001). For symptomatic patients undergoing CEA with patch angioplasty, shunt placement was associated with an increased risk of cranial nerve injury without a reduction in postoperative stroke risk.

Risk factors and outcomes of postoperative stroke in surgical treatment for giant intracranial aneurysms

BackgroundGiant intracranial aneurysms (GIAs) are challenges for surgical treatment. Risk factors of postoperative stroke remain unclear. This study aims to investigate the predictors of postoperative stroke in GIAs and the impact of stroke on outcomes.MethodsWe performed a retrospective medical record review of patients with GIAs who received microsurgery at our institution between 2011 and 2018. Multivariate logistic regression analyses were carried out to identify risk factors for postoperative stroke. The clinical and angiographic outcomes were compared between patients with and without stroke.ResultsA total of 97 patients were included in this study. Surgical modalities included direct aneurysm neck clipping in 85 patients (87.7%), trapping with the bypass in 8 (8.2%), proximal artery ligation in 1 (1%), and bypass alone in 3 (3.1%). Postoperative stroke was found in 26 patients (26.8%). Independent factors that affect postoperative stroke were recurrent aneurysm (OR, 10.982; 95% CI, 1.976–61.045; P = 0.006) and size ≥ 3.5 cm (OR, 3.420; 95% CI, 1.133–10.327; P = 0.029). Combined perioperative mortality and morbidity was 26.8%. Follow-up was achieved from 89 patients (91.8%), with a mean follow-up period of 39 months (range 19 to 94 months). Good outcomes were observed in 75 patients (84.3%) and poor outcomes were observed in 14 patients (15.7%).ConclusionsPostoperative stroke was significantly associated with clinical outcome. Favorable outcomes can be achieved in most patients with GIAs after appropriate microsurgical modality. Recurrent aneurysm and size ≥ 3.5 cm are risk factors of postoperative stroke.

Preoperative and intraoperative risk factors of postoperative stroke in total aortic arch replacement and stent elephant trunk implantation

SummaryBackgroundAcute type A aortic dissection (AAAD) is a disease with high mortality, for which total aortic arch replacement (TAAR) combined with stent elephant implantation (SETI) is a reliable surgical treatment; however, it is associated with a high incidence of postoperative stroke. This retrospective study aimed to find preoperative and postoperative risk factors for postoperative stroke in patients with TAAR combined with SETI, and to provide predictive models and single-factor threshold suggestions.MethodsFrom October 2019 to March 2021, 229 AAAD patients who underwent TAAR and SETI were selected. Patients were divided into stroke group (n = 23) and non-stroke group (n = 206), and preoperative/intraoperative factors were evaluated by independent-samples T-test/ Mann-Whitney U test/Chi-Square test and odds ratio (OR) analysis. The Logistic regression equation and decision tree were used to construct the prediction model of the probability of postoperative stroke. Bayesian-learning model and 2-order derivation were used to calculate the inflection points of the continuous variables.FindingsPlatelet count (PLT), International normalised ratio (INR) value, presence of diabetic history, and cardiopulmonary bypass (CPB) time were independent predictors of postoperative stroke (P-value < 0.05), and the above four factors were used to construct the Logistic regression equation. As for the decision-tree model, a radical model with higher accuracy in stroke predicting was chosen. Three inflection points for the effect of continuous variables (PLT count = 60 × 10^9/L; INR value = 1.82; CPB time = 300 min) on postoperative stroke were found by 2-order derivation.InterpretationPLT count, INR value, presence of diabetic history, and CPB time were significant preoperative and intraoperative risk factors for postoperative stroke, and the identification and modeling of these factors can help us to take more active brain protection measures in high-risk patients.FundingYS was funded by the 10.13039/501100001809National Natural Science Foundation of China (Grant ID 81671942).

Factors Affecting the Outcome of Symptomatic Carotid Stenosis Surgical Treatment in a Single-center Series

Retrospective, single-center review between January 2010 and June 2020. We included 134 patients (93 male) with symptomatic ipsilateral carotid stenosis and ischemic brain lesions assessed by diffusion-weighted magnetic resonance brain imaging (DW-MRI) with RAPID processing underwent carotid endarterectomy (CEA). Patients who underwent CEA within 48 hours of symptoms suffered a significantly higher rate of postoperative stroke (emergent = 11%) compared with CEA between 2 and 14 days (urgent = 1.5%) and CEA after 14 days (elective = 0%). Ischemic brain lesion volume of less than 10 mL based on DW-MRI was an independent risk factor for postoperative stroke. Optimal timing for CEA is between 2 and 14 days after symptoms. Ischemic brain lesion volume of more than 10 mL is a reliable threshold value to predict adverse postoperative neurological results in patients with symptomatic carotid artery stenosis.

Relationship Between the Degree of Carotid Stenosis and the Risk of Stroke in Patients Undergoing Cardiac Surgery.

The impact of carotid stenosis (CS) in patients undergoing cardiac surgery remains controversial. The aim of this study was to evaluate the association between carotid stenosis and stroke and/or transient ischemic attack (TIA) in patients undergoing cardiac surgery on cardiopulmonary bypass. This was a retrospective cohort study including patients undergoing cardiac surgery on cardiopulmonary bypass from January 2006 to March 2018 at the Québec Heart and Lung Institute. Data of patients' preoperative demographic characteristics, operative and postoperative variables were taken from a computerised database and patients' charts. Univariate and multivariate analyses were performed. A total of 20,241 patients were included in the study. Among those who had received preoperative carotid ultrasound, 516 (2.6% of the total population) had unilateral or bilateral CS ≥ 50%. Categorised levels of CS severity were identified as independent risk factors for postoperative stroke and/or TIA. There was an almost 3-fold increased risk of postoperative neurologic events in 80%-99% CS vs less severe 50%-79% CS (odds ratio 2.91, 95% confidence interval 1.30-6.54), suggesting that the degree of severity of CS is potentially a strong independent predictor of postoperative neurologic events. CS is an independent risk factor of postoperative stroke and/or TIA. This study suggests for the first time that the risk of stroke increases with the degree of severity of CS, with the greatest risk being for CS of 80%-99%. The strength of this relationship and potential causality effect should be further explored in a prospective study focusing on this population most at risk.

Abstract TMP90: Perioperative And Delayed Stroke After Surgical Revascularization In Pediatric Moyamoya Arteriopathy

Introduction: Surgical revascularization is the mainstay of management in severe moyamoya arteriopathy (MMA). While perioperative stroke has been characterized, little is known about delayed postoperative stroke. Methods: We retrospectively identified patients diagnosed with MMA between 28 days and 18 years of age seen at our center between 1/2003 and 6/2021 using ICD codes. Those who underwent surgical revascularization either at our or another center were analyzed. Descriptive analysis of patients experiencing perioperative (defined as ≤7 days after surgery) versus delayed postoperative stroke (stroke occurring &gt;7 days after surgery) was conducted. Results: 53 unique patients underwent 68 revascularization surgeries of 95 hemispheres. Median age at time of surgery was 8.3 years. Median time from surgery to final follow-up was 6.6 years. Postoperative stroke occurred in 11 (16%) cases, including 7 (10%) in the perioperative period and 4 (6%) &gt;7 days after surgery. Patients with delayed stroke had a median age of 5.1 years at surgery, and median time to stroke was 87 days. While MMA associated with Trisomy 21 represented only 15% of cases in our sample, these cases accounted for 36% of postoperative strokes. Delayed stroke occurred more frequently in patients with unilateral revascularization. These patients developed infarcts contralateral to the revascularized hemisphere. Conclusions: Delayed stroke following surgical revascularization in patients with MMA occurred less frequently than perioperative stroke in our cohort. Trisomy 21 may be a risk factor for postoperative stroke. Further study is needed to characterize and predict which patients are at risk for delayed stroke.

Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique.

OBJECTIVESThis study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique.METHODSTwo-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each’s cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke.RESULTSOverall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20–8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28–19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09–360.84; P = 0.044) as predictors for postoperative stroke.CONCLUSIONSStroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.

Aortic and arch branch vessel cannulation in acute type A aortic dissection repair.

ObjectiveTo evaluate central aortic cannulation and arch branch vessel (ABV) cannulation in acute type A aortic dissection repair.MethodsFrom 2015 to April 2020, 298 patients underwent open repair of an acute type A aortic dissection. Patients undergoing femoral cannulation for cardiopulmonary bypass (n = 34) were excluded. Patients were then divided based on initial cannulation for cardiopulmonary bypass into central aortic cannulation (n = 72) and ABV cannulation (n = 192) groups. ABV sites included cannulation of the axillary, innominate, right/left common carotid, and intrathoracic right subclavian arteries.ResultsThe aortic cannulation group was younger (59 vs 62 years; P = .02), more likely to be men (76% vs 60%; P = .02), and had more peripheral vascular disease (60% vs 37%; P = .0009). ABV dissection was similar between central and ABV cannulation groups (53% vs 60%; P = .51). The aortic cannulation group underwent less aggressive arch replacement, had shorter cardiopulmonary bypass times (200 vs 222 minutes; P = .01), less utilization of antegrade cerebral perfusion (93% vs 98%; P = .04), and received less blood transfusion (0 vs 1 U; P = .001). Postoperative outcomes were similar between aortic and ABV cannulation groups, including stroke (5.6% vs 5.2%; P = 1.0) and operative mortality (4.2% vs 6.3%; P = .77). In addition, postoperative strokes were similar in location (right-brain, left-brain, or bilateral), etiology (embolic vs hemorrhagic), and presence of permanent deficits. Aortic cannulation was not a risk factor for postoperative stroke (odds ratio, 0.94; P = .91) or operative mortality (odds ratio, 0.70; P = .64). Short-term survival was similar between central and ABV cannulation groups.ConclusionsBoth aortic and ABV cannulation were safe and effective cannulation strategies in acute type A aortic dissection repair.

Factors Affecting the Outcome of Symptomatic Carotid Stenosis Surgical Treatment in a Single Center Series

The aim of this study is to evaluate the role of preoperative ischemic brain lesion (IBL) volume, assessed by Diffusion-weighted magnetic resonance brain imaging (DW-MRI) with RAPID® processing, and surgery timing in predicting post-operative neurological outcomes in symptomatic carotid stenosis (SCS) patients treated with carotid endarterectomy (CEA). All patients with SCS who underwent CEA between January 2010 and June 2020 were considered. IBLs ipsilateral to the stenosis were identified in the preoperative magnetic resonance brain (MRI). The volume was quantified in mL and correlated with 30-day rates of stroke and stroke/death by χ2 and receiver operating characteristic (ROC) curve. One hundred thirty-four patients were surgically treated for SCS during the entire study period. CEA procedures were defined as emergent, urgent, or elective if performed within 48 hr, between 48 hr and 14 days, or after 14 days from symptoms onset, respectively. Cumulative new ipsilateral stroke rate was 4,5%, with a statistically higher neurological complications in emergent patients compared to urgent and elective patients (10,6%, 1,47% and 0% respectively, P 0,039). ROC curve analysis showed a volume of 10 mL was predictive of postoperative stroke with 100% sensitivity and 80% specificity. An IBL volume >10 mL was an independent risk factor for postoperative stroke. In fact, the perioperative neurological complication rate was significantly different in high-IBL volume patients (>10 mL) compared with low-IBL volume patients (<10 mL) (P 0,003) CONCLUSIONS: The present study suggests that the optimal timing for CEA is between 48 hr and 14 days. Furthermore, the present study suggests that the presence of the IBL, by itself, is not definitively related with an unsatisfactory neurological outcome. However, an IBL higher than 10 mL should be as a reliable threshold value adverse neurological result in SCS patients.

New-Onset Atrial Fibrillation After Cardiac Surgery is a Significant Risk Factor for Long-Term Stroke: An Eight-Year Prospective Cohort Study

This study sought to determine the incidence and significance of new-onset atrial fibrillation as a risk factor for long-term stroke and mortality after cardiac surgery. A prospective cohort study. Two large tertiary public hospitals. The study comprised 3008 patients who underwent coronary artery bypass grafting and/or valve surgery from 2008 to 2012. None. New-onset atrial fibrillation was analyzed as a risk factor for postoperative stroke using a multivariate logistic regression model after adjustment for potential confounders. A Cox regression model with time-dependent variables was used to analyze relationships between new-onset atrial fibrillation and postoperative survival. New-onset atrial fibrillation was detected in 573 (19.0%) patients. Stroke occurred in 234 (7.8%) patients during the mean postoperative follow-up period of six ± two years. The incidence of postoperative stroke in patients with new-onset atrial fibrillation (9.9%) and patients with both preoperative and postoperative atrial fibrillation (13.8%) was higher than in patients with no atrial fibrillation (6.8%) (p=0.002). New-onset atrial fibrillation (odds ratio, 1.53; 95% confidence interval [CI], 1.08-2.18; p=0.017) was identified as an independent risk factor for postoperative stroke. A total of 518 (17.2%) mortalities occurred within the mean postoperative follow-up period of eight ± two years. New-onset atrial fibrillation was associated with shorter survival (hazard ratio, 1.49; 95% CI, 1.22-1.81; p < 0.001) compared with patients with no atrial fibrillation. New-onset atrial fibrillation is a significant risk factor for long-term stroke and mortality after cardiac surgery. Close monitoring and treatment of this condition may be necessary to reduce the risk of postoperative stroke and mortality.

Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke.

The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures. Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010-1 August 2020. Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR. The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.

Postoperative stroke and neurological outcomes in the early phase after revascularization surgeries for moyamoya disease: an age-stratified comparative analysis.

Stroke and neurological outcomes in the early phase following revascularization for moyamoya disease (MMD) may depend on the patient's age. In this study, an age-stratified comparative analysis was performed to clarify this issue. We reviewed 105 MMD patients who underwent 179 revascularization surgeries. The demographic characteristics were collected in four age groups (≤ 5 and 6-17years for pediatric patients and 18-49 and ≥ 50years for adults). Additionally, we assessed the incidence of subsequent stroke and deterioration of modified Rankin Scale (mRS) score. Then, we evaluated predictors of postoperative stroke and mRS deterioration using logistic regression. The mean patient age was 26.2 ± 18.5years. No significant difference in the incidence of postoperative stroke was observed between age groups; however, the incidence tended to be increased among patients aged ≤ 5years (17.9%) and patients aged ≥ 50years (16.7%). Deterioration of mRS scores was significantly associated with ages ≤ 5years (17.9%) and ≥ 50years (11.1%). Logistic regression showed that posterior cerebral artery involvement (odds ratio [OR], 4.6) and postoperative transient neurological events (TNEs) (OR, 5.93) were risk factors for postoperative stroke. Age ≤ 5years (OR, 9.73), postoperative TNEs (OR, 7.38), and postoperative stroke (OR, 49) were identified as predictors of unfavorable neurological outcomes. The novel feature of this comparative analysis by age group is that membership in the early-childhood MMD patient group (under 5years old) was an independent risk factor for unfavorable short-term neurological outcomes and was mainly associated with the incidence of postoperative severe cerebral infarction.

Preoperative Imaging Risk Findings for Postoperative New Stroke in Patients With Acute Type A Aortic Dissection.

Background: Stroke is a common postoperative complication in patients with acute type A aortic dissection (ATAAD). We aimed to explore the preoperative imaging risk findings for postoperative new stroke in patients with ATAAD.Methods: From January 2015 to December 2018, 174 patients with ATAAD who underwent preoperative aortic computed tomography angiography (CTA) and cerebral diffusion-weighted imaging (DWI) as well as postoperative brain CT were included, and divided into DWI (+) and DWI (–) groups. Pre- and intraoperative variables were collected, and logistic regression analysis was used to determine the independent risk predictors of postoperative new stroke.Results: The incidence of postoperative new stroke was 18.4% (32/174) in patients with ATAAD. Postoperative stroke was detected in 13 (31.0%) patients in the DWI (+) group and in 19 (14.4%) patients in the DWI (–) group with significant difference (P = 0.016). In the DWI (+) group, the lesions of the cerebral infarction located in the unilateral cerebral hemisphere and distributed more than three lobes (P = 0.007) were an independent risk factor for postoperative new stroke. Hypotension (P = 0.002), retrograde ascending aorta dissection with thrombosis of the false lumen (P = 0.010), aortic arch entry (P = 0.035), and coronary artery involvement (P = 0.001) were independent risk factors for postoperative stroke in the DWI (–) cohort.Conclusions: Patients with ATAAD with cerebral infarction are more likely to develop postoperative new stroke; thus, a preoperative DWI examination may be necessary. DWI lesions distributed more than 3 lobes in the unilateral hemisphere suggest a high possibility of postoperative stroke. For patients with ATAAD with normal brain, particular attention should be given to the CTA findings of false lumen thrombosis, aortic arch entry, and coronary artery involvement to avoid postoperative stroke.