TY - JOUR
T1 - Large-vessel occlusion stroke after cardiothoracic surgery
T2 - Expanding time windows offer new salvage opportunities
AU - Sheriff, Faheem
AU - Hirsch, Joshua
AU - Shelton, Kenneth
AU - D'Alessandro, David
AU - Stapleton, Chris
AU - Koch, Matthew
AU - Rabinov, James
AU - Jassar, Arminder
AU - Patel, Aman
AU - Leslie-Mazwi, Thabele
N1 - Publisher Copyright:
© 2018 The American Association for Thoracic Surgery
PY - 2019/7
Y1 - 2019/7
N2 - Objectives: Ischemic stroke due to large-vessel occlusion (LVO) is a complication after cardiothoracic surgery (CTS). Recently published endovascular stroke trials have major implications for treating LVO strokes; we evaluated our experience in patients undergoing CTS. Methods: Our prospective institutional CTS database was reviewed between July 2013 and April 2018 for ischemic strokes. Patients with LVO were identified and their course and outcomes analyzed. Results: A total of 5947 patients were reviewed; 148 (2.48%) had a cerebrovascular complication; 92.5% were ischemic. Of these 10.9% had an LVO. Prolonged aortic crossclamp was associated with LVO (odds ratio, 1.012 for every minute of prolonged aortic crossclamp time; confidence interval, 1.001-1.023) and remained significant in patients with ejection fraction >45%; prolonged cardiac bypass time was only associated with LVO in patients with ejection fraction >45% (odds ratio, 1.012 for every minute of prolonged cardiac bypass time; confidence interval, 1.003-1.021). Patients fell into 2 categories: detection of neurologic deficit in the stable postoperative patient or detection of deficit on emergence from anesthesia. Seven patients met criteria for emergent revascularization, with median National Institutes of Health Stroke Scale score 15, and shorter times from last seen well to deficit detection compared with patients not meeting criteria (P = .032). Median National Institutes of Health Stroke Scale day 7 score improved to 5. There was a trend toward better modified Rankin Scale scores at 3 months in patients who underwent thrombectomy. Conclusions: LVO complicates a small proportion of patients after CTS and may be more likely with prolonged aortic crossclamp and cardiac bypass times. Both early and late window endovascular stroke treatment has the potential to positively modify the complication profile of CTS. Greater awareness of this treatment option is needed.
AB - Objectives: Ischemic stroke due to large-vessel occlusion (LVO) is a complication after cardiothoracic surgery (CTS). Recently published endovascular stroke trials have major implications for treating LVO strokes; we evaluated our experience in patients undergoing CTS. Methods: Our prospective institutional CTS database was reviewed between July 2013 and April 2018 for ischemic strokes. Patients with LVO were identified and their course and outcomes analyzed. Results: A total of 5947 patients were reviewed; 148 (2.48%) had a cerebrovascular complication; 92.5% were ischemic. Of these 10.9% had an LVO. Prolonged aortic crossclamp was associated with LVO (odds ratio, 1.012 for every minute of prolonged aortic crossclamp time; confidence interval, 1.001-1.023) and remained significant in patients with ejection fraction >45%; prolonged cardiac bypass time was only associated with LVO in patients with ejection fraction >45% (odds ratio, 1.012 for every minute of prolonged cardiac bypass time; confidence interval, 1.003-1.021). Patients fell into 2 categories: detection of neurologic deficit in the stable postoperative patient or detection of deficit on emergence from anesthesia. Seven patients met criteria for emergent revascularization, with median National Institutes of Health Stroke Scale score 15, and shorter times from last seen well to deficit detection compared with patients not meeting criteria (P = .032). Median National Institutes of Health Stroke Scale day 7 score improved to 5. There was a trend toward better modified Rankin Scale scores at 3 months in patients who underwent thrombectomy. Conclusions: LVO complicates a small proportion of patients after CTS and may be more likely with prolonged aortic crossclamp and cardiac bypass times. Both early and late window endovascular stroke treatment has the potential to positively modify the complication profile of CTS. Greater awareness of this treatment option is needed.
KW - cardiothoracic surgery
KW - endovascular therapy
KW - ischemic stroke
KW - large-vessel occlusion
UR - http://www.scopus.com/inward/record.url?scp=85060291352&partnerID=8YFLogxK
U2 - 10.1016/j.jtcvs.2018.11.106
DO - 10.1016/j.jtcvs.2018.11.106
M3 - Article
C2 - 30685180
AN - SCOPUS:85060291352
SN - 0022-5223
VL - 158
SP - 186-196.e2
JO - Journal of Thoracic and Cardiovascular Surgery
JF - Journal of Thoracic and Cardiovascular Surgery
IS - 1
ER -