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Puac-Polanco P, Subasinghe S, Omid-Fard N, Zhang L, Oliveira EPD, Tsehmaister-Abitbul V, Chakraborty S, Torres C, Fahed R, Dowlatshahi D, Aviv RI. Influence of Stroke-Onset Location on the Efficacy of Endovascular Thrombectomy: Comparison of Outcomes between In-Hospital versus Community-Onset Strokes. AJNR Am J Neuroradiol 2024:ajnr.A8362. [PMID: 38816016 DOI: 10.3174/ajnr.a8362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND PURPOSE Previous studies have suggested that patients experiencing an in-hospital stroke may face delays in treatment and worse outcomes compared with patients with community-onset strokes. However, most studies occurred when IV thrombolysis was the primary treatment. This study aimed to examine the outcomes of patients experiencing an in-hospital stroke in the endovascular thrombectomy era. MATERIALS AND METHODS This was a single-center retrospective cohort study of patients older than 18 years of age with acute ischemic stroke treated with endovascular thrombectomy within 12 hours of stroke onset from January 1, 2015, to April 30, 2021. Patients were classified into 2 groups: in-hospital strokes and community-onset strokes. We compared the time metrics of stroke care delivery, the rate of successful reperfusion, and functional outcome as scored using the mRS score at 90 days (favorable outcome was defined as mRS 0-2). Differences in proportions were assessed using the Fisher exact and χ2 tests as appropriate. For continuous variables, differences in medians between groups were evaluated using Mann-Whitney U tests. RESULTS A total of 676 consecutive patients were included, with 69 (10%) comprising the in-hospital stroke group. Patients experiencing in-hospital stroke were more likely to have diabetes (36% versus 18%, P = .02) and less likely to receive thrombolysis (25% versus 68%, P < .001) than those in the community-onset stroke group, but they were otherwise similar. Patients with in-hospital stroke had significantly faster overall time metrics, most notably from stroke recognition to imaging (median, 70 [interquartile range, 38-141] minutes versus 121 [74-228] minutes, P < .001). Successful recanalization was achieved in >75% in both groups (P = .39), with a median NIHSS score at discharge of <4 (P = .18). The 90-day mRS was similar in both groups, with a trend toward higher in-hospital mortality in the in-hospital stroke group (P = .06). CONCLUSIONS Patients with in-hospital stroke had shorter workflow delays to initiation of endovascular thrombectomy compared with their community counterparts but with a similar rate of successful recanalization and clinical outcomes. Most important, 90-day mortality and mRS scores were equivalent between in-hospital stroke and community-onset stroke groups.
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Affiliation(s)
- Paulo Puac-Polanco
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shanelle Subasinghe
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
| | - Nima Omid-Fard
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
| | - Liying Zhang
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
| | - Eduardo Portela de Oliveira
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Vered Tsehmaister-Abitbul
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
| | - Santanu Chakraborty
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Carlos Torres
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robert Fahed
- Division of Neurology (R.F., D.D.), Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Interventional Radiology (R.F.), Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology (R.F., D.D.), Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Richard I Aviv
- From the Department of Radiology, Radiation Oncology and Medical Physics (P.P.-P., S.S, N.O.-F., L.Z., E.P.d.O., V.T.-A., S.C., C.T., R.I.A.), University of Ottawa, Ottawa, Ontario, Canada
- Neuroscience Program (P.P.-P., E.P.d.O., S.C., C.T., R.F., D.D., R.I.A.), The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Butnariu AD, Miron I, David B, Visarion DM, Pruna VI, Pruna VM. Postoperative Stroke Following Anterior Cervical Spine Surgery: A Case Report. Cureus 2024; 16:e63846. [PMID: 39099982 PMCID: PMC11297389 DOI: 10.7759/cureus.63846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/06/2024] Open
Abstract
Vascular complications succeeding anterior cervical spine surgery are rare, but their consequences represent a major burden for the patient. Cerebral infarction following anterior cervical discectomy and fusion (ACDF) is uncommon. However, screening for risk factors before surgery should become mandatory. We present the case of a patient with no significant medical history who underwent ACDF for a C5/C6 herniated disc with myelopathy. Although the surgery was uneventful, after the surgery, partial right palpebral ptosis and miosis were noted, suggestive of Horner syndrome. On the fifth postoperative day, the patient experienced left hemiplegia and drowsiness. An emergency CT scan and cerebral MRI revealed ischemia in the right middle cerebral artery territory. The patient was transferred to a neurology center for mechanical thrombectomy, which revealed a complete occlusion of the right internal carotid artery. The procedure had to be halted due to blood extravasation at the internal carotid artery bifurcation to prevent further complications. An angio-CT examination of the cervical arteries exposed a soft atheromatous plaque on the right internal carotid artery, immediately after the bifurcation. Despite the patient having no significant medical history, blood tests indicated dyslipidemia. At the two-month follow-up, the patient remained hemiplegic, with mild dysphasia. Performing carotid and vertebral Doppler ultrasound before cervical spine surgery might be useful, whenever possible, to assess high-risk factors for ischemic events and avoid such debilitating complications.
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Affiliation(s)
- Andreea D Butnariu
- Neurosurgery Department, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, ROU
| | - Ioana Miron
- Neurosurgery Department, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Neurosurgery Department, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, ROU
| | - Bogdan David
- Neurosurgery Department, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, ROU
| | - Dan M Visarion
- Neurosurgery Department, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Neurosurgery Department, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, ROU
| | - Violeta I Pruna
- Ophthalmology Department, CF2 Clinical Hospital, Bucharest, ROU
| | - Viorel M Pruna
- Neurosurgery Department, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Neurosurgery Department, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, ROU
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Bay B, Gloyer NO, Remmel M, Schell M, Zelenak K, Seiffert M, Brunner FJ, Clemmensen P, Reichenspurner H, Blankenberg S, Thomalla G, Fiehler J, Conradi L, Waldeyer C, Flottmann F. Mechanical thrombectomy in ischemic stroke after cardiovascular procedures: a propensity-matched cohort analysis. J Neurointerv Surg 2023; 15:e129-e135. [PMID: 35985838 DOI: 10.1136/jnis-2022-019152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Stroke after a cardiovascular procedure (CVP) is a devastating complication adversely affecting outcome. Mechanical thrombectomy (MT) has not been investigated systematically in this population. OBJECTIVE To carry out a retrospective study in patients undergoing MT for early stroke after CVP, aiming to further characterize this cohort of patients, and to evaluate the efficacy, safety, procedural characteristics, and outcome of MT. METHODS A single-center stroke registry of patients who received MT was analyzed. Baseline and procedural parameters, mortality, functional outcome, recanalization rates, and complications were evaluated. Propensity score matching was carried out, identifying a control cohort with non-periprocedural large vessel occlusion (LVO). RESULTS Overall 913 patients were included (mean age 73.0 (±13.0) years, 52.5% female, median National Institutes of Health Stroke Scale score 15 (10-19)). Eleven patients with a LVO after a recent (<30 days postoperatively) CVP were identified (n=3 transcatheter aortic valve and n=1 surgical aortic valve replacements (SAVR), n=3 coronary bypass grafting (CABG) surgeries, n=2 SAVR+CABG, and n=2 aortic surgeries). After matching, 8 patients in the CVP group were compared with 16 patients in the matched cohort. Comparable rates of reperfusion were achieved. Time from symptom onset to groin puncture (171.5 min (136.3, 178.3) vs 284.0 min (215.0, 490.5); p=0.039), as well as recanalization (195.0 min (146.0, 201.0) vs 419.0 min (274.0, 613.0); p=0.028) was faster in the CVP group. However, this was not reflected by an improved outcome (modified Rankin Scale score after 90 days: 5.5 (3.3, 6.0) vs 5.0 (4.0, 6.0), mortality after 90 days 50.0% vs 37.5%). Complications did not differ between the groups. CONCLUSIONS Use of MT for LVO stroke in patients after a recent CVP is a safe and efficient treatment in comparison with patients with a non-periprocedural LVO undergoing MT.
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Affiliation(s)
- Benjamin Bay
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils-Ole Gloyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marko Remmel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Moritz Seiffert
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian J Brunner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Peter Clemmensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Faculty of Health Sciences, Department of Regional Health Research, University of Southern Denmark and Nykoebing Falster Hospital, Odense, Denmark
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Waldeyer
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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Mechanical thrombectomy for perioperative ischemic stroke following elective inpatient surgery in the United States. J Clin Neurosci 2022; 101:100-105. [PMID: 35576771 DOI: 10.1016/j.jocn.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 11/20/2022]
Abstract
Perioperative ischemic stroke significantly increases morbidity and mortality in patients undergoing elective surgery. Mechanical thrombectomy can improve ischemic stroke outcomes, but frequency and trend of its utilization for treatment of perioperative ischemic stroke is not studied. We identified adults who underwent elective inpatient surgery from 2008 to 2018 and suffered from a perioperative ischemic stroke from the Premier Healthcare Database. The difference in mechanical thrombectomy usage before and after the updated recommendation inacute stroke guidelines was assessed in a univariate analysis using a chi-squared test. A segmented regression model was created to assess the change in rate over time.Of 6,349,668 patients with elective inpatient surgery, 12,507 (0.2%) had perioperative ischemic stroke. Mean age (and standard deviation) was 69.5 (11.7) years, and 48.8% were female. Mechanical thrombectomy was used in 1.7% patients and its use increased from 0.0% in 3rd quarter, 2008 to 4.4% in 4th quarter, 2018. Significant increase in the use of mechanical thrombectomy was seen after 3rd quarter, 2015 when its use was incorporated in acute stroke treatment guideline (1.14% before 3rd quarter, 2015 versus 3.07% after; p < 0.0001). Amongst patients with perioperative ischemic stroke, patients who received mechanical thrombectomy were more likely to have their surgery performed at a teaching institute (67.3% versus 53.9%). Although a significant increase in rates of utilization of mechanical thrombectomy was observed, rates of utilization remain low, especially in non-teaching hospitals. This highlights improvements in the management of perioperative ischemic strokes and further opportunities to improve outcomes.
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Cummings S, Kasner SE, Mullen M, Olsen A, McGarvey M, Weimer J, Jackson B, Desai N, Acker M, Messé SR. Delays in the Identification and Assessment of in-Hospital Stroke Patients. J Stroke Cerebrovasc Dis 2022; 31:106327. [PMID: 35123276 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/07/2022] [Accepted: 01/15/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES In-hospital stroke is associated with poor outcomes. Reasons for delays, use of interventions, and presence of large vessel occlusion are not well characterized. MATERIALS AND METHODS A retrospective single center cohort of 97 patients with in-hospital stroke was analyzed to identify factors associated with delays from last known normal to symptom identification and to stroke team alerting. Stroke interventions and presence of large vessel occlusion were also assessed. RESULTS Strokes were predominantly on surgery services (70%), ischemic (82%), and severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from last known normal to symptom identification (median 5.1 hours, IQR 1.0-19.7 hours), symptom identification to stroke team alerting (median 2.1 hours, IQR 0.5-9.9 hours), and total time from last known normal to alerting (median 11.4 [IQR 2.7-34.2] hours). In univariable analysis, being on a surgical service, in an ICU, intubated, and higher NIHSS were associated with delays. In multivariable analysis only intubation was independently associated with time from last known normal to symptom identification (coefficient 20 hours, IQR 0.2 - 39.8, p=0.047). Interventions were given to 17/80 (21%) ischemic stroke patients; 3 (4%) received IV tPA and 14 (18%) underwent thrombectomy. Vascular imaging occurred in 57/80 (71%) ischemic stroke patients and 21/57 (37%) had large vessel occlusion. CONCLUSIONS Hospitalized patients with stroke experience long delays from symptom identification to stroke team alerting. Intubation was strongly associated with delay to symptom identification. Although stroke severity was high and large vessel occlusion common, many patients did not receive acute interventions.
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Affiliation(s)
- Stephanie Cummings
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Mullen
- Department of Neurology, Temple University Hospital, Philadelphia, PA, United States
| | - Andrew Olsen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael McGarvey
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - James Weimer
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Ben Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States.
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8
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Mullen MT, Messé SR. Stroke Related to Surgery and Other Procedures. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00034-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Surgery and anesthesia carry risks of ischemic, hemorrhagic, hypoxic, and metabolic complications, all of which can result in neurologic symptoms and deficits. Patients with underlying cardiovascular and cerebrovascular risk factors are particularly vulnerable. In this article the authors review the neurologic complications of surgery and anesthesia, with a focus on the role of the neurologic consultant in preoperative evaluation and risk stratification and diagnosis and management of postoperative complications.
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Affiliation(s)
- Daniel Talmasov
- Department of Neurology, New York University School of Medicine, 222 East 41st Street, 14th Floor, New York, NY 10017, USA
| | - Joshua P Klein
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Room 4018, 60 Fenwood Road, Boston 02115, MA, USA.
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10
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Mechanical Thrombectomy Improves Outcome for Large Vessel Occlusion Stroke after Cardiac Surgery. J Stroke Cerebrovasc Dis 2021; 30:105851. [PMID: 34020323 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105851] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/04/2021] [Accepted: 04/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Stroke is a feared complication of cardiac surgery. Modern clot-retrieval techniques provide effective treatment for large vessel occlusion (LVO) strokes. The purpose of this study was to 1) report the incidence of LVO stroke after cardiac surgery at a large academic center, and 2) describe outcomes of postoperative LVO strokes. METHODS All patients experiencing stroke within 30 days after undergoing cardiac surgery at a single center in 2014-2018 were reviewed. LVOs were identified through review of imaging and medical records, and their characteristics and clinical courses were examined. RESULTS Over the study period, 7,112 cardiac surgeries, including endovascular procedures, were performed. Acute ischemic stroke within 30 days after surgery was noted in 163 patients (2.3%). Among those with a stroke, 51/163 (31.3%) had a CTA or MRA, and 15/163 (9.2%) presented with LVO stroke. For all stroke patients, the median time from surgery to stroke was 2 days (interquartile range, IQR, 0-6 days), and for patients with LVO, the median time from surgery to stroke was 4 days (IQR 0-6 days). The overall rate of postoperative LVO was 0.2% (95% CI 0.1-0.4%), though only 6/15 received thrombectomy. LVO patients receiving thrombectomy were significantly more likely to return to independent living compared to those managed medically (n = 4/6, 66.6% for mechanical thrombectomy vs. n = 0/9, 0% for medical management, P = .01). Of the 9 patients who did not get thrombectomy, 6 may currently be candidates for thrombectomy given new expanded treatment windows. CONCLUSIONS The rate of LVO after cardiac surgery is low, though substantially elevated above the general population, and the majority do not receive thrombectomy currently. Patients receiving thrombectomy had improved neurologic outcomes compared to patients managed medically. Optimized postoperative care may increase the rate of LVO recognition, and cardiac surgery patients and their caregivers should be aware of this effective therapy.
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Takemoto K, Sakuraya M, Nakamura M, Maekawa H, Yamanaka K, Atagi K. Early detection of large-vessel occlusion stroke after cardiac surgery using CT angiography leading to early recanalization with endovascular thrombectomy. Clin Case Rep 2021; 9:e04246. [PMID: 34026199 PMCID: PMC8133088 DOI: 10.1002/ccr3.4246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/21/2020] [Accepted: 04/07/2021] [Indexed: 11/26/2022] Open
Abstract
CT angiography may be useful for early diagnosis of ischemic stroke after cardiac surgery. When patients diagnosed with large-vessel occlusion, endovascular thrombectomy may be a therapeutic option and may improve their neurological complications.
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Affiliation(s)
- Kiyoshi Takemoto
- Division of Critical Care MedicineNara Prefecture General Medical CenterNaraJapan
| | - Masaaki Sakuraya
- Division of Critical Care MedicineNara Prefecture General Medical CenterNaraJapan
- Department of Emergency and Intensive Care MedicineJA Hiroshima General HospitalHiroshimaJapan
| | - Michitaka Nakamura
- Division of Critical Care MedicineNara Prefecture General Medical CenterNaraJapan
| | - Hidetsugu Maekawa
- Department of NeurosurgeryNara Prefecture General Medical CenterNaraJapan
| | - Kazuo Yamanaka
- Department of Cardiovascular SurgeryNara Prefecture General Medical CenterNaraJapan
| | - Kazuaki Atagi
- Division of Critical Care MedicineNara Prefecture General Medical CenterNaraJapan
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Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
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Anetakis KM, Dolia JN, Desai SM, Balzer JR, Crammond DJ, Thirumala PD, Castellano JF, Gross BA, Jadhav AP. Last Electrically Well: Intraoperative Neurophysiological Monitoring for Identification and Triage of Large Vessel Occlusions. J Stroke Cerebrovasc Dis 2020; 29:105158. [PMID: 32912500 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/12/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Intra-operative stroke (IOS) is associated with poor clinical outcome as detection is often delayed and time of symptom onset or patient's last known well (LKW) is uncertain. Intra-operative neurophysiological monitoring (IONM) is uniquely capable of detecting onset of neurological dysfunction in anesthetized patients, thereby precisely defining time last electrically well (LEW). This novel parameter may aid in the detection of large vessel occlusion (LVO) and prompt treatment with endovascular thrombectomy (EVT). METHODS We performed a retrospective analysis of a prospectively maintained AIS and LVO database from May 2018-August 2019. Inclusion criteria required any surgical procedure under general anesthesia (GA) utilizing EEG (electroencephalography) and/or SSEP (somatosensory evoked potentials) monitoring with development of intraoperative focal persistent changes using predefined alarm criteria and who were considered for EVT. RESULT Five cases were identified. LKW to closure time ranged from 66 to 321 minutes, while LEW to closure time ranged from 43 to 174 min. All LVOs were in the anterior circulation. Angiography was not pursued in two cases due to large established infarct (both patients expired in the hospital). EVT was pursued in two cases with successful recanalization and spontaneous recanalization was noted in one patient (mRS 0-3 at 90 days was achieved in all 3 cases). CONCLUSIONS This study demonstrates that significant IONM changes can accurately identify patients with an acute LVO in the operative setting. Given the challenges of recognizing peri-operative stroke, LEW may be an appropriate surrogate to quickly identify and treat IOS.
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Affiliation(s)
- Katherine M Anetakis
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Jay N Dolia
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Shashvat M Desai
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Jeffrey R Balzer
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Donald J Crammond
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Parthasarathy D Thirumala
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - James F Castellano
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Bradley A Gross
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Ashutosh P Jadhav
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA.
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Demaerschalk BM, Scharf EL, Cloft H, Barrett KM, Sands KA, Miller DA, Meschia JF. Contemporary Management of Acute Ischemic Stroke Across the Continuum: From TeleStroke to Intra-Arterial Management. Mayo Clin Proc 2020; 95:1512-1529. [PMID: 32622453 DOI: 10.1016/j.mayocp.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
Abstract
In this comprehensive contemporary review of acute ischemic stroke management, what is new and different will be highlighted beginning with prehospital stroke systems of care, emergency medical systems, and mobile stroke units, followed by hospital stroke teams, emergency evaluation, telemedicine, and brain and vascular imaging, and finishing with emergency treatments including thrombolysis and mechanical thrombectomy.
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Affiliation(s)
| | - Eugene L Scharf
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Harry Cloft
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN
| | - Kevin M Barrett
- Departments of Neurology and Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Kara A Sands
- Department of Neurology Mayo Clinic, Phoenix/Scottsdale, AZ
| | - David A Miller
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Jacksonville, FL
| | - James F Meschia
- Departments of Neurology and Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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15
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Bulwa Z, Del Brutto VJ, Loggini A, Ammar FE, Martinez RC, Christoforidis G, Brorson JR, Ardelt AA, Goldenberg FD. Mechanical Thrombectomy for Patients with In-Hospital Ischemic Stroke: A Case-Control Study. J Stroke Cerebrovasc Dis 2020; 29:104692. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 01/12/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022] Open
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16
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Sano T, Kobayashi K, Ichikawa T, Hakozaki K, Tanemura H, Ishigaki T, Miya F. In-hospital Ischemic Stroke Treated by Mechanical Thrombectomy. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:133-140. [PMID: 37520171 PMCID: PMC10374366 DOI: 10.5797/jnet.oa.2019-0048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Objective We investigated in-hospital stroke (IHS) treated by mechanical thrombectomy in comparison with out-of-hospital stroke (OHS) to clarify the points of concern in IHS at our institution. Methods Between September 2015 and June 2018, 19 patients with IHS who underwent mechanical thrombectomy (IHS group) were enrolled, and compared with 154 patients with OHS (OHS group) regarding patient characteristics, technical results, and outcome. In this study, we set the detection time in the IHS group as patient arrival time, termed "Door" in the OHS group. Results Cardiology and gastroenterology were the two main admitting departments, including four (21%) patients of IHS group. In all, 15 (79%) patients had atrial fibrillation; however, less than one-third of them was taking anticoagulant drugs at onset. There were only two cases of direct consultation to the stroke specialists, although IHS onset was mainly recognized by nurses. The median age in the IHS group was 81 (interquartile range (IQR), 76-86.5) versus 80 in the OHS group (IQR, 73-85; p = 0.43), and the median initial National Institutes of Health Stroke Scale score was 21 (IQR, 16-23) versus 21 (IQR, 14-26; p = 0.92), respectively. Sex, Alberta Stroke Program Early CT Score, etiology, and occlusion site did not differ between groups. The rate of use of intravenous tissue plasminogen activator (IV-tPA) was 26% in the IHS group versus 49% in the OHS group (p = 0.065). The median time of detection to imaging, detection to needle for IV-tPA, and detection to puncture were 32, 69, and 87 minutes, respectively, in the IHS group, being significantly longer than those in the OHS group (11, 30, and 50 minutes; p <0.01, p <0.01, and p <0.01, respectively). The median time of puncture to reperfusion was 39 minutes, being significantly shorter than that in the OHS group (82 minutes; p <0.01). Successful reperfusion defined as thrombolysis in cerebral infarction (TICI) 2b-3 was obtained in 94.7% of the IHS group versus 83.1% of the OHS group (p = 0.19). A favorable outcome (modified Rankin Scale score 0-2) at 90 days was achieved by 36.8% (IHS) versus 35.1% (OHS) of patients (p = 0.88). The rate of symptomatic procedural complications was 0% (IHS) versus 7.1% (OHS; p = 0.23). The rate of death at 90 days was 15.8% (IHS) versus 12.3% (OHS; p = 0.67). Conclusion The times of detection to imaging and of detection to puncture in the IHS group were longer than those in the OHS group; however, patients in the IHS group had shorter reperfusion. The outcome of the IHS group did not differ from that of OHS group. Our study suggests that the time course of treatment should be improved and rapid stroke pathways involved in consultation with the stroke specialists for IHS should be organized.
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Affiliation(s)
- Takanori Sano
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Kazuto Kobayashi
- Department of Neurology, Ise Red Cross Hospital, Ise, Mie, Japan
| | | | - Koichi Hakozaki
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Hiroshi Tanemura
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Tomoki Ishigaki
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Fumitaka Miya
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
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Schweizer R, Jacquet-Lagrèze M, Fellahi JL. Cerebrovascular complications after cardiac surgery: It is time to track and treat large vessel occlusion. J Thorac Cardiovasc Surg 2019; 159:e263-e264. [PMID: 31812298 DOI: 10.1016/j.jtcvs.2019.10.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rémi Schweizer
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | | | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Université Claude Bernard Lyon 1, Lyon, France
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18
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Le Guennec L, Schmidt M, Clarençon F, Elhfnawy AM, Baronnet F, Kalamarides M, Lebreton G, Luyt CE. Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation. J Neurointerv Surg 2019; 12:486-488. [PMID: 31744852 DOI: 10.1136/neurintsurg-2019-015407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients to treat refractory cardiogenic shock has increased in recent years, and ischemic stroke is the most frequent VA-ECMO-induced cerebrovascular complication. No adult case of mechanical thrombectomy (MT) has been reported. METHODS Retrospective observational study of hospital medical records of patients who received circulatory support with VA-ECMO with acute ischemic stroke treated with MT, from 2006 to 2018. RESULTS Two adult patients on VA-ECMO with acute ischemic stroke treated with MT were found. Both cases were successfully treated. CONCLUSION These cases illustrate the feasibility of performing MT in adult patients on ECMO.
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Affiliation(s)
- Loic Le Guennec
- Intensive Care, Pitié-Salpêtrière Hospital, Paris, France .,Sorbonne Université, Paris, France
| | - Matthieu Schmidt
- Intensive Care, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, Paris, France
| | - Frédéric Clarençon
- Sorbonne Université, Paris, France.,Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Ahmed Mohamed Elhfnawy
- Sorbonne Université, Paris, France.,Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Flore Baronnet
- Sorbonne Université, Paris, France.,Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Michel Kalamarides
- Sorbonne Université, Paris, France.,Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, Paris, France.,Cardiac Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Intensive Care, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Université, Paris, France
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Postoperative stroke: The picture is out of focus. Eur J Anaesthesiol 2019; 35:896-898. [PMID: 30278034 DOI: 10.1097/eja.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Del Brutto VJ, Ardelt A, Loggini A, Bulwa Z, El-Ammar F, Martinez RC, Brorson J, Goldenberg F. Clinical Characteristics and Emergent Therapeutic Interventions in Patients Evaluated through the In-hospital Stroke Alert Protocol. J Stroke Cerebrovasc Dis 2019; 28:1362-1370. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022] Open
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Ali JM, Wolff I, Falconieri F, Aresu G, Coonar AS, Joshi Y, Peryt A. Mechanical thrombectomy for the treatment of acute ischaemic stroke following pulmonary lobectomy. Ann R Coll Surg Engl 2019; 101:e115-e118. [PMID: 30855160 PMCID: PMC6513363 DOI: 10.1308/rcsann.2019.0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2019] [Indexed: 11/22/2022] Open
Abstract
Acute ischaemic stroke is a devastating postoperative complication that significantly impacts upon a patient's quality of life. Endovascular retrieval of thromboembolic material from proximal cerebral arteries by mechanical thrombectomy is the new standard of care for patients presenting with a proximal artery occlusion. We report the case of a patient developing an acute ischaemic stroke following pulmonary lobectomy, who was transferred to the regional neurosciences unit, despite the absence of an established referral pathway, to undergo mechanical thrombectomy, with significant prognostic neurological benefit. We would advocate all cardiothoracic centres identify their regional neurosciences unit and initiate discussion to establish a referral pathway.
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Affiliation(s)
- JM Ali
- Department of Thoracic Surgery, Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - I Wolff
- Department of Thoracic Surgery, Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - F Falconieri
- Department of Thoracic Surgery, Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - G Aresu
- Department of Thoracic Surgery, Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - AS Coonar
- Department of Thoracic Surgery, Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - Y Joshi
- Department of Radiology, Addenbrookes Hospital, Hills Road, Cambridge, UK
| | - A Peryt
- Department of Thoracic Surgery, Royal Papworth Hospital, Papworth Everard, Cambridge, UK
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22
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Coronary artery bypass graft surgery complications: A review for emergency clinicians. Am J Emerg Med 2018; 36:2289-2297. [PMID: 30217621 DOI: 10.1016/j.ajem.2018.09.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Coronary artery bypass graft (CABG) surgery remains a high-risk procedure, and many patients require emergency department (ED) management for complications after surgery. OBJECTIVE This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post-CABG surgery complications. DISCUSSION While there has been a recent decline in all cardiac revascularization procedures, there remains over 200,000 CABG surgeries performed in the United States annually, with up to 14% of these patients presenting to the ED within 30 days of discharge with post-operative complications. Risk factors for perioperative mortality and morbidity after CABG surgery can be divided into three categories: patient characteristics, clinician characteristics, and postoperative factors. Emergency physicians will be faced with several postoperative complications, including sternal wound infections, pneumonia, thromboembolic phenomena, graft failure, atrial fibrillation, pulmonary hypertension, pericardial effusion, strokes, renal injury, gastrointestinal insults, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary surgical team is needed, which improves patient outcomes. This review provides several guiding principles for management of acute complications. Understanding these complications and an approach to the management of hemodynamic instability is essential to optimizing patient care. CONCLUSIONS Postoperative complications of CABG surgery can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Early surgical consultation is imperative, as is optimizing the patient's hemodynamics, including preload, heart rate, cardiac rhythm, contractility, and afterload.
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Mönch S, Lehm M, Maegerlein C, Hedderich D, Berndt M, Boeckh-Behrens T, Wunderlich S, Kreiser K, Zimmer C, Friedrich B. Worse endovascular mechanical recanalization results for patients with in-hospital onset acute ischemic stroke. J Neurol 2018; 265:2525-2530. [DOI: 10.1007/s00415-018-9035-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 11/24/2022]
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Ko SB. Perioperative stroke: pathophysiology and management. Korean J Anesthesiol 2018; 71:3-11. [PMID: 29441169 PMCID: PMC5809704 DOI: 10.4097/kjae.2018.71.1.3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 11/19/2017] [Indexed: 01/01/2023] Open
Abstract
Although perioperative stroke is uncommon during low-risk non-vascular surgery, if it occurs, it can negatively impact recovery from the surgery and functional outcome. Based on the Society for Neuroscience in Anesthesiology and Critical Care Consensus Statement, perioperative stroke includes intraoperative stroke, as well as postoperative stroke developing within 30 days after surgery. Factors related to perioperative stroke include age, sex, a history of stroke or transient ischemic attack, cardiac surgery (aortic surgery, mitral valve surgery, or coronary artery bypass graft surgery), and neurosurgery (external carotid-internal carotid bypass surgery, carotid endarterectomy, or aneurysm clipping). Concomitant carotid and cardiac surgery may further increase the risk of perioperative stroke. Preventive strategies should be individualized based on patient factors, including cerebrovascular reserve capacity and the time interval since the previous stroke.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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