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Neurologic injury in cardiac surgical patients with a history of stroke
J M Redmond1, P S Greene, M A Goldsborough
1Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
Insights
Patients with a prior stroke face significantly higher risks of neurological complications, including new strokes and worsening deficits, after heart surgery involving cardiopulmonary bypass. This highlights the brain's vulnerability during such procedures.
Area of Science:
- Neurology
- Cardiovascular Surgery
- Neurosurgery
Background:
- The risk of neurological complications after cardiac operations in patients with a history of stroke remains debated.
- Established risk factors for neurological complications did not significantly differ between study and control groups.
Purpose of the Study:
- To prospectively analyze the risk of neurologic complications in patients with previous stroke undergoing cardiac operations requiring cardiopulmonary bypass.
- To identify specific neurological sequelae and outcomes in this patient population.
Main Methods:
- A prospective analysis of 1,000 consecutive patients undergoing cardiac operations with cardiopulmonary bypass.
- A study group of 71 patients with a documented previous stroke was compared to a control group of 142 patients without a history of stroke.
- Patients were monitored for awakening time, extubation, reintubation, postoperative confusion, and focal neurological deficits.
Main Results:
- Patients with prior stroke experienced significantly longer awakening (12.6 vs. 3.5 hours) and extubation times (29.5 vs. 9.1 hours).
- The incidence of reintubation (9.9% vs. 1.4%), postoperative confusion (36.6% vs. 4.9%), and focal neurological deficits (43.7% vs. 1.4%) was substantially higher in the study group.
- New strokes occurred in 8.5% of study patients, and previous deficits reappeared or worsened in 35.3% of cases. The 30-day mortality rate was also higher (7% vs. 0.7%).
Conclusions:
- Patients with a history of stroke are at a significantly increased risk for neurological sequelae after cardiopulmonary bypass.
- The previously injured brain is particularly vulnerable, leading to reappearance or exacerbation of focal deficits.
- These findings underscore the need for careful patient selection and management strategies to mitigate risks in this high-risk group.
Background:
Controversy still exists as to whether patients with previous stroke are at increased risk for neurologic complications after heart operations.
Methods:
We performed a prospective analysis of 1,000 consecutive patients undergoing cardiac operations requiring cardiopulmonary bypass, without hypothermic circulatory arrest. Of the 1,000 patients, 71 had previously documented stroke (study group); 2 control patients with no history of stroke were selected for each of these patients (control group, n = 142). There were no significant differences between the study and control patients with respect to established risk factors for neurologic complications.
Results:
Compared with controls, study patients took longer to awaken (12.6 +/- 10.9 versus 3.5 +/- 2.1 hours; p < 0.0001) and longer to extubate (29.5 +/- 29.3 versus 9.1 +/- 5.2 hours; p < 0.001), and had a greater incidence of reintubation (7 of 71, 9.9% versus 2 of 142, 1.4%; p < 0.01) and postoperative confusion (26 of 71, 36.6% versus 7 of 142, 4.9%; p < 0.001). There was a higher incidence of focal neurologic deficit among study patients (31 of 71, 43.7% versus 2 of 142, 1.4%; p < 0.001). These deficits included new stroke (6 of 71, 8.5%) as well as the reappearance of previous deficits (19 of 71, 26.8%) or worsening of previous deficits (6 of 71, 8.5%), without new abnormalities on head computed tomography or magnetic resonance imaging. Study patients with neurologic deficit had longer cardiopulmonary bypass times than did study patients without deficit (146 +/- 48.5 versus 110 +/- 43.3 minutes; p < 0.001). The 30-day mortality rate was greater in study patients than in controls (5 of 71, 7% versus 1 of 142, 0.7%; p < 0.02), with four deaths among the 6 study patients with a new stroke (66.7%).
Conclusion:
This analysis identifies a group of patients at high risk for neurologic sequelae and confirms the vulnerability of the previously injured brain to cardiopulmonary bypass, as evidenced by reappearance or exacerbation of focal deficits in such patients.