Selnes, Gottesman, ....McKhann. NEJM 2012; 366: 250-7 Review article
Bullet points STROKE
1. 1.6 % rate overall, but rate may increase 10x if radiographic/clinically silent CVA's included
2. Mechanism of micro/macroemboli with cross clamping needs to be modified to include hypotension and inflammatory response. Caplan et al , proposed the combination of hypotension and microemboli leads to more injury because microemboli aren't washed out as readily.
3. risk factors for neurologic morbidity: age, DM, HTN, history of stroke Others: PREOPERATIVE FACTORS (and odds ratio) : athero of ascending aorta (2.0), h/o of TIA/CVA (2.1); h/o of subcortical disease (4.1), carotid stenosis (5.3); PVD (2); DM (1.2 or 2.8);HTN (1.8 or 1.3); high pulse pressure (1.1);prior cardiac surgery (1.4); smoking history (1.6). OPERATIVE FACTORS: Hypotension (8.4); manipulation of aorta (1.8); bypass time > 2 hours (1.4). POSTOP FACTORS: AD (.8 to 2.6). (article gives references for each risk factor).
4. PREVENTION: Use of individualized factors, and use of preop or postop ASA which are both controversial. Use of eipaortic ultrasound to guide decision to cross clamp. Use of carotid screening preop. Avoiding combined carotid/coronary procedures. All of these ideas have limited data. Operative monitoring with TCD or near infraredspectroscopy has been used.
COGNITIVE DECLINE
Factors include:
1. preop cognitive abilities/disabilities
2,
Bullet points STROKE
1. 1.6 % rate overall, but rate may increase 10x if radiographic/clinically silent CVA's included
2. Mechanism of micro/macroemboli with cross clamping needs to be modified to include hypotension and inflammatory response. Caplan et al , proposed the combination of hypotension and microemboli leads to more injury because microemboli aren't washed out as readily.
3. risk factors for neurologic morbidity: age, DM, HTN, history of stroke Others: PREOPERATIVE FACTORS (and odds ratio) : athero of ascending aorta (2.0), h/o of TIA/CVA (2.1); h/o of subcortical disease (4.1), carotid stenosis (5.3); PVD (2); DM (1.2 or 2.8);HTN (1.8 or 1.3); high pulse pressure (1.1);prior cardiac surgery (1.4); smoking history (1.6). OPERATIVE FACTORS: Hypotension (8.4); manipulation of aorta (1.8); bypass time > 2 hours (1.4). POSTOP FACTORS: AD (.8 to 2.6). (article gives references for each risk factor).
4. PREVENTION: Use of individualized factors, and use of preop or postop ASA which are both controversial. Use of eipaortic ultrasound to guide decision to cross clamp. Use of carotid screening preop. Avoiding combined carotid/coronary procedures. All of these ideas have limited data. Operative monitoring with TCD or near infraredspectroscopy has been used.
COGNITIVE DECLINE
Factors include:
1. preop cognitive abilities/disabilities
2,
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