(Circulation. 1999;100:642-647.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Risk Factors for Early or Delayed Stroke After Cardiac Surgery
From the Department of Anesthesiology (C.W.H., V.G.D.-R.); the Cardiovascular Division, Department of Internal Medicine (V.G.D.-R.); and the Department of Biostatistics (K.B.S.), Washington University School of Medicine and Barnes-Jewish Hospital, St Louis, Mo.
Correspondence to Charles W. Hogue, Jr, MD, Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Ave, Box 8054, St Louis, MO 63110. E-mail hoguec{at}notes.wustl.edu
Background—Stroke after cardiac surgery is a devastating complication that leads to excess mortality and health resource utilization. The purpose of this study was to identify risk factors for perioperative stroke, including strokes detected early after cardiac surgery or postoperatively.
Methods and Results—Data were obtained from 2972 patients
undergoing coronary artery bypass graft and/or valve surgery.
Patients 
65 years old and those with a history of
symptomatic neurological disease underwent preoperative
carotid artery ultrasound scanning. Intraoperative epiaortic ultrasound
to assess for ascending aorta atherosclerosis was
performed in all patients. New strokes were considered as a single end
point and were categorized with respect to whether they were detected
immediately after surgery (early stroke) or after an initial,
uneventful neurological recovery from surgery (delayed stroke). Strokes
occurred in 48 patients (1.6%); 31 (65%) were delayed strokes. By
multivariate analysis, prior neurological
event, aortic atherosclerosis, and duration of
cardiopulmonary bypass were independently associated with early
stroke, whereas predictors of delayed stroke were prior neurological
event, diabetes, aortic atherosclerosis, and the
combined end points of low cardiac output and atrial fibrillation.
Female sex was associated with a 6.9-fold increased risk of early
stroke and a 1.7-fold increased risk of delayed stroke. In-hospital
mortality of patients with early (41%) and delayed (13%) strokes was
higher than that of other patients (3%, P=0.0001).
Conclusions—Most strokes after cardiac surgery occurred after initial uneventful recovery from surgery. Women were at higher risk to suffer early and delayed perioperative strokes. Atrial fibrillation had no impact on postoperative stroke rate unless it was accompanied by low cardiac output syndrome.
Key Words: stroke • surgery • atherosclerosis
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M. Elahi, L. Hadjinikolaou, and M. Galinanes Incidence and Clinical Consequences of Atrial Fibrillation Within 1 Year of First-Time Isolated Coronary Bypass Surgery Circulation, September 9, 2003; 108(90101): II-207 - 212. [Abstract] [Full Text] [PDF]
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D. C. Charlesworth, D. S. Likosky, C. A. S. Marrin, C. T. Maloney, H. B. Quinton, J. R. Morton, B. J. Leavitt, R. A. Clough, and G. T. O'Connor Development and validation of a prediction model for strokes after coronary artery bypass grafting Ann. Thorac. Surg., August 1, 2003; 76(2): 436 - 443. [Abstract] [Full Text] [PDF]
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M. Nakajima, K. Tsuchiya, K. Kanemaru, H. Yamazaki, H. Koizumi, S. Nakano, H. Inoue, Y. Naito, and E. Mizutani Subdural hemorrhagic injury after open heart surgery Ann. Thorac. Surg., August 1, 2003; 76(2): 614 - 615. [Abstract] [Full Text] [PDF]
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T. Goto, T. Baba, K. Matsuyama, K. Honma, M. Ura, and T. Koshiji Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients Ann. Thorac. Surg., June 1, 2003; 75(6): 1912 - 1918. [Abstract] [Full Text] [PDF]
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H. R. Mallidi, J. Sever, M. Tamariz, S. Singh, N. Hanayama, G. T. Christakis, G. Bhatnagar, C. A. Cutrara, B. S. Goldman, and S. E. Fremes The short-term and long-term effects of warm or tepid cardioplegia J. Thorac. Cardiovasc. Surg., March 1, 2003; 125(3): 711 - 720. [Abstract] [Full Text] [PDF]
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J. Bucerius, J. F. Gummert, M. A. Borger, T. Walther, N. Doll, J. F. Onnasch, S. Metz, V. Falk, and F. W. Mohr Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients Ann. Thorac. Surg., February 1, 2003; 75(2): 472 - 478. [Abstract] [Full Text] [PDF]
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A. Parolari, S. Colli, L. Mussoni, S. Eligini, M. Naliato, X. Wang, S. Gandini, E. Tremoli, P. Biglioli, and F. Alamanni Coagulation and fibrinolytic markers in a two-month follow-up of coronary bypass surgery J. Thorac. Cardiovasc. Surg., February 1, 2003; 125(2): 336 - 343. [Abstract] [Full Text] [PDF]
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L. K. Ti, G. B. Mackensen, H. P. Grocott, D. T. Laskowitz, B. G. Phillips-Bute, C. A. Milano, A. K. Hilton, M. F. Newman, and J. P. Mathew Apolipoprotein E4 increases aortic atheroma burden in cardiac surgical patients J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 211 - 213. [Full Text] [PDF]
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K. G. Engstrom The embolic potential of liquid fat in pericardial suction blood, and its elimination Perfusion, January 1, 2003; 18(1_suppl): 69 - 74. [Abstract] [PDF]
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A A Albert, C J Beller, B Arnrich, J A Walter, U P Rosendahl, A Hetzel, H Priss, and J Ennker Is there any impact of the shape of aortic end-hole cannula on stroke occurrence? Clinical evaluation of straight and bent-tip aortic cannulae Perfusion, December 1, 2002; 17(6): 451 - 456. [Abstract] [PDF]
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W. Y. Thong, A. G. Strickler, S. Li, E. E. Stewart, C. L. Collier, W. K. Vaughn, and N. A. Nussmeier Hyperthermia in the Forty-Eight Hours After Cardiopulmonary Bypass Anesth. Analg., December 1, 2002; 95(6): 1489 - 1495. [Abstract] [Full Text] [PDF]
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P. Bergman, L. Hadjinikolaou, and J. van der Linden Aortic atheroma is related to number of particulates captured by intra-aortic filtration in CABG Eur. J. Cardiothorac. Surg., October 1, 2002; 22(4): 539 - 544. [Abstract] [Full Text] [PDF]
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S. C. Stamou, K. A. Jablonski, A. J. Pfister, P. C. Hill, M. K.C. Dullum, A. S. Bafi, S. W. Boyce, K. R. Petro, and P. J. Corso Stroke after conventional versus minimally invasive coronary artery bypass Ann. Thorac. Surg., August 1, 2002; 74(2): 394 - 399. [Abstract] [Full Text] [PDF]
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M. Appelblad and G. Engstrom Fat contamination of pericardial suction blood and its influence on in vitro capillary-pore flow properties in patients undergoing routine coronary artery bypass grafting J. Thorac. Cardiovasc. Surg., August 1, 2002; 124(2): 377 - 386. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, G. Teodori, G. Di Giammarco, S. Cirmeni, M. Contini, A. L. Iaco, and M. Pano Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization Ann. Thorac. Surg., May 1, 2002; 73(5): 1387 - 1393. [Abstract] [Full Text] [PDF]
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 A. T. Tang, M. Devbhandari, and S. K Ohri Complete Myocardial Revascularization in Severe Arteriopathy Asian Cardiovasc Thorac Ann, December 1, 2001; 9(4): 315 - 317. [Abstract] [Full Text] [PDF]
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N. Moazami, N. G. Smedira, P. M. McCarthy, I. Katzan, C. A. Sila, B. W. Lytle, and D. M. Cosgrove III Safety and efficacy of intraarterial thrombolysis for perioperative stroke after cardiac operation Ann. Thorac. Surg., December 1, 2001; 72(6): 1933 - 1938. [Abstract] [Full Text] [PDF]
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V. G. Davila-Roman and C. W. Hogue Jr Invited commentary Ann. Thorac. Surg., December 1, 2001; 72(6): 1938 - 1939. [Full Text] [PDF]
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J. D. Salazar, R. J. Wityk, M. A. Grega, L. M. Borowicz, J. R. Doty, J. A. Petrofski, and W. A. Baumgartner Stroke after cardiac surgery: short- and long-term outcomes Ann. Thorac. Surg., October 1, 2001; 72(4): 1195 - 1201. [Abstract] [Full Text] [PDF]
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G. B. Luciani, T. Menon, B. Vecchi, S. Auriemma, and A. Mazzucco Modified Ultrafiltration Reduces Morbidity After Adult Cardiac Operations: A Prospective, Randomized Clinical Trial Circulation, September 18, 2001; 104 (2009): I-253 - I-259. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, M. Contini, G. Di Giammarco, M. Pano, G. Vitolla, A. Bivona, R. Carella, and S. D'Alessandro Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome Ann. Thorac. Surg., August 1, 2001; 72(2): 456 - 462. [Abstract] [Full Text] [PDF]
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S. C. Stamou, P. C. Hill, G. Dangas, A. J. Pfister, S. W. Boyce, M. K.C. Dullum, A. S. Bafi, P. J. Corso, and B. Silver Stroke After Coronary Artery Bypass : Incidence, Predictors, and Clinical Outcome Editorial Comment: Incidence, Predictors, and Clinical Outcome Stroke, July 1, 2001; 32(7): 1508 - 1513. [Abstract] [Full Text] [PDF]
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R. Svedjeholm, E. Hakanson, Z. Szabo, and F. Vanky Neurological injury after surgery for ischemic heart disease: risk factors, outcome and role of metabolic interventions Eur. J. Cardiothorac. Surg., May 1, 2001; 19(5): 611 - 618. [Abstract] [Full Text] [PDF]
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C. W. Hogue Jr, B. Barzilai, K. S. Pieper, L. P. Coombs, E. R. DeLong, N. T. Kouchoukos, and V. G. Davila-Roman Sex Differences in Neurological Outcomes and Mortality After Cardiac Surgery : A Society of Thoracic Surgery National Database Report Circulation, May 1, 2001; 103(17): 2133 - 2137. [Abstract] [Full Text] [PDF]
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L. B. Goldstein, R. Adams, K. Becker, C. D. Furberg, P. B. Gorelick, G. Hademenos, M. Hill, G. Howard, V. J. Howard, B. Jacobs, et al. Primary Prevention of Ischemic Stroke : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Circulation, January 2, 2001; 103(1): 163 - 182. [Full Text] [PDF]
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S. Wan and A. P. C. Yim Is Off-Pump Cardiac Surgery Better for the Brain? Chest, January 1, 2001; 119(1): 1 - 1. [Full Text] [PDF]
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L. B. Goldstein, R. Adams, K. Becker, C. D. Furberg, P. B. Gorelick, G. Hademenos, M. Hill, G. Howard, V. J. Howard, B. Jacobs, et al. Primary Prevention of Ischemic Stroke : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Stroke, January 1, 2001; 32(1): 280 - 299. [Full Text] [PDF]
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K. Fan, K. L. Lee, C. S.W. Chiu, J. W.T. Lee, G.-W. He, D. Cheung, M. P. Sun, and C.-P. Lau Effects of Biatrial Pacing in Prevention of Postoperative Atrial Fibrillation After Coronary Artery Bypass Surgery Circulation, August 15, 2000; 102(7): 755 - 760. [Abstract] [Full Text] [PDF]
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 G. R. McAnulty, H. J. Robertshaw, and G. M. Hall Anaesthetic management of patients with diabetes mellitus Br. J. Anaesth., July 1, 2000; 85(1): 80 - 90. [Full Text] [PDF]
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M RICCI, H L KARAMANOUKIAN, J BERGSLAND, and T A SALERNO Good outcomes from cardiac surgery in the over 70s Heart, January 1, 2000; 83(1): 103e - 103. [Full Text]
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