From preoperative evaluation to stroke center: Management of postoperative acute ischemic stroke

Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review

There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.

Incidence and risk factors associated with postoperative stroke in the elderly patients undergoing hip fracture surgery

OBJECTIVES

Stroke is one of the rare but devastating complications after hip fracture in the elderly. By far, there is still scarce data on postoperative stroke in elderly patients with hip fractures.

METHODS

This was a retrospective study of prospectively collected data. Between October 2014 to December 2018, patients aged above 65 years who underwent operative treatment for hip fractures were included. Inpatient medical surveillance and scheduled telephone follow-up at 1, 3, 6, and 12 months after operation was conducted to identify who developed an incident stroke. Variables of interests were extracted from patients' inpatient medical records. Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factors associated with stroke.

RESULTS

During the study period, a total of 3743 patients were included, among whom 56 were found to have a stroke after operation, representing an incidence of 1.5% (95% CI, 1.1 to 1.9%). The multivariate analyses showed that advanced age (1-year increment; OR, 1.32; 95% CI, 1.08 to 1.48), history of previous stroke (OR, 4.79; 95% CI, 1.86 to 6.56), ASA III and above (OR, 2.62; 95% CI, 1.27 to 3.68), long-term use of aspirin (OR, 3.63; 95% CI, 1.41 to 4.78), and elevated RDW level (each increment of 1%, OR, 1.21; 95% CI, 1.02 to 1.36) were independently associated with postoperative stroke.

CONCLUSIONS

Although most are not modifiable, these risk factors help in counseling patients regarding the risk of postoperative stroke, individual risk stratification, and targeted optimization of medical conditions and should be firmly kept in treating surgeon's mind.

Striate Artery Infarct After Bilateral Carotid Artery Ligation (BCAL) in a Dog: A Multimodal MRI Study

Bilateral carotid artery ligation has been reported as a lifesaving procedure to control severe hemorrhage. However, reports are sparse and little information is available regarding the potential risks associated with this procedure. We report an ischemic brain infarct as a complication after vascular surgery. A 3-year old, male intact border collie was presented for acute onset of forebrain signs 5 days after bilateral carotid artery ligation. Multimodal brain MRI including morphologic sequences, MR angiography, diffusion- and perfusion-weighted images were performed. MRI revealed a well-defined intra-axial lesion of the left caudate nucleus, with increased T2 and decreased T1 signal intensity and moderate heterogeneous peripheral contrast enhancement. The cerebral blood flow was reduced relative to the contralateral caudate nucleus. Images were consistent with a subacute lacunar ischemic infarct of the left striate artery. Additionally, multiple arterio-arterial anastomosis arising from the vertebral arteries were visible in the angiography sequences. Ischemic infarct due to thromboembolism should be considered as a possible complication associated with bilateral carotid artery ligation. Collateral blood supply can develop as early as 5 days after surgery.

[Perioperative stroke in heart valve surgery: pathogenesis, clinical findings, diagnosis, prevention, treatment]

AIM

To study risk factors, characteristics of clinical symptoms and diagnosis, and possibilities of prevention of perioperative stroke and other clinical types of cerebral dysfunction in main types of heart valve surgery.

MATERIAL AND METHODS

The study included 83 patients, aged 63 (54; 70) years, undergoing heart valve surgery with cardiopulmonary bypass.

RESULTS

Postoperative cerebral dysfunction was diagnosed in 37.3% of cases, including perioperative stroke in 3.6% of cases. In cases of aortic stenosis, the frequency of perioperative stroke was 9.5%. The cardioembolic subtype of perioperative ischemic stroke in cardiac valve surgery was most likely. The risk factors of the symptomatic delirium of the early postoperative period are: age over 75 years, preoperative frontal dysfunction, duration of artificial respiratory care more than 20 hours after the surgery.

CONCLUSION

The results suggest the efficacy of preventive use of cytoflavin for reducing the frequency and severity of perioperative stroke and symptomatic delirium of the early postoperative period in heart valve surgery with cardiopulmonary bypass.

Incidence of and Risk Factors for Inpatient Stroke After Hip Fractures in the Elderly

Although uncommon, stroke can be a catastrophic inpatient complication for patients with hip fractures. The current study determines the incidence of inpatient stroke after hip fractures in elderly patients, identifies risk factors associated with such strokes, and determines the association of stroke with short-term inpatient outcomes. A retrospective review of all patients aged 65 years or older with isolated hip fractures in the 2011 and 2012 National Trauma Data Bank was conducted. A total of 37,584 patients met inclusion criteria. Of these patients, 162 (0.4%) experienced a stroke during their hospitalization for the hip fracture. In multivariate analysis, a history of prior stroke (odds ratio [OR], 13.24), coronary artery disease (OR, 2.05), systolic blood pressure 180 mm Hg or higher (OR, 1.66), and bleeding disorders (OR, 1.65) were associated with inpatient stroke. Inpatient stroke was associated with increased mortality (OR, 7.17) and inpatient serious adverse events (OR, 6.52). These findings highlight the need for vigilant care of high-risk patients, such as those with a history of prior stoke, and for an understanding that patients who experience an inpatient stroke after a hip fracture are at significantly increased risk of mortality and inpatient serious adverse events. [Orthopedics. 2018; 41(1):e27-e32.].

Mechanical Thrombectomy in Perioperative Strokes: A Case-Control Study

BACKGROUND AND PURPOSE

Perioperative strokes (POS) are rare but serious complications for which mechanical thrombectomy could be beneficial. We aimed to compare the technical results and patients outcomes in a population of POS versus non-POS (nPOS) treated by mechanical thrombectomy.

METHODS

From 2010 to 2017, 25 patients with POS (ie, acute ischemic stroke occurring during or within 30 days after a procedure) who underwent mechanical thrombectomy (POS group) were enrolled and paired with 50 consecutive patients with nPOS (control group), based on the occlusion's site, National Institute of Health Stroke Scale, and age.

RESULTS

Respectively, mean age was 68.3±16.6 versus 67.2±16.6 years (P=0.70), and median National Institute of Health Stroke Scale score at admission was 20 (interquartile range, 15-25) versus 19 (interquartile range, 17-25; P=0.79). Good clinical outcome (modified Rankin Scale score of 0-2 at 3 months) was achieved by 33.3% (POS) versus 56.5% (nPOS) of patients (P=0.055). Successful reperfusion (modified Thrombolysis In Cerebral Infarction score of ≥2b) was obtained in 76% (POS) versus 86% (nPOS) of cases (P=0.22). Mortality at 3 months was 33.3% in the POS group versus 4.2% (nPOS) (P=0.002). The rate of major procedural complications was 4% (POS) versus 6% (nPOS); none were lethal. Average time from symptoms' onset to reperfusion was 4.9 hours (±2.0) in POS versus 5.2 hours (±2.6).

CONCLUSIONS

Successful reperfusion seems accessible in POS within a reasonable amount of time and with a good level of safety. However, favorable outcome was achieved with a lower rate than in nPOS, owing to a higher mortality rate.