Inflammatory responses and CNS injury: implications, prophylaxis, and treatment

EXCERPT: Early detection of perioperative stroke is essential if there is to be any opportunity to improve outcome. If there is suspicion of cerebral embolic stroke, scanning with computerized tomography can rule out acute hemorrhage and demonstrate diagnostic changes in a majority of patients within 5 hours of onset of symptoms. Strategies for reperfusion of ischemic tissue may include intraarterial thrombolysis in select patients with acute ischemic stroke even after recent cardiac operation. In one series, 13 patients with acute ischemic stroke within 12 days of cardiac operation underwent intraarterial thrombolysis within 6 hours of stroke symptom onset. Recanalization was complete in 1 patient and partial in 5, and 7 patients had low flow. Neurologic improvement occurred in 5 patients (38%). One patient needed a chest tube for hemothorax; 2 others received transfusions for low hemoglobin. No operative intervention for bleeding was necessary. In addition to thrombolysis, mechanical clot removal may be attempted. Thromboaspiration requires favorable anatomy and a fresh nonadhesive clot. It reduces the time for recanalization, has no hemorrhagic risk, and may prevent distal clot migration. Thromboaspiration may be attempted as an adjunct or alternative to intraarterial fibrinolysis for basilar artery recanalization. If massive cerebral gas embolism is suspected and hyperbaric facilities are available, confirmation can be obtained by early single-photon emission tomography (SPET) and hyperbaric oxygen therapy instituted. This process was successfully undertaken in a case of paradoxical air embolism in a patient undergoing percutaneous nephrolithotripsy in the prone position and presenting with blindness and neurological deficits 8 hours later. Treatment with hyperbaric oxygen therapy was successful in this case.