Abstract
The major mechanism of stroke in cardiac surgery is embolization. The risk is higher in intracardiac than in extracardiac surgery. The incidence of stoke associated with CABG is about 5%. The cerebral protective properties of isoflurane and thiopentone, acid-base management, and monitoring of cerebral perfusion during cardiopulmonary bypass are discussed. Prophylactic carotid endarterectomy for patients with asymptomatic carotid disease before cardiac surgery is not necessary. Symptomatic carotid disease increases the risk of stroke, and the management of patients who have both symptomatic coronary and carotid artery diseases is discussed. Cardiogenic embolism is probably responsible for many perioperative strokes. Patients with atrial fibrillation, valvular disease, and prosthetic heart valves are at high risk of cardiogenic embolism. Strokes associated with cardioversion, pacemaker insertion, coronary arteriography and angioplasty are explored.
Résumé
La plus importante cause d’apoplexie lors de la chirurgie cardiaque demeure l’embolisation. Le risque est plus grand lorsque la chirurgie est intracardiaque plutôt qu’extracardiaque. L’incidence d’apoplexie associée au pontage aortocoronarien est à peu prés 5%. Les propriétés protectrices du cerveau, de l’isoflurane et du thiopentone, la conduite de l’équilibre acido-basique et la surveillance de la perfusion cérébrale durant la circulation exlracorporelle sont discutées. L’andartérectomie carotidienne prophylactique pour les patients atteints de maladie carotidienne asymptomatique avant la chirurgie cardiaque n’est pas nécessaire. Les maladies carotidiennes svmptomatiques augmentent le risque d’apoplexie, el la conduite à faire chez les patients qui out une symptomatologie coronarienne et carotidienne est discutée. L’embolisalion cardiogénique est probablement responsable de plusieurs épisodes d’apoplexie périopératoire. Les patients atteints de fibrillation auriculaire, de maladies valvulaires, el ayant des valves cardiaques prosthetiques sont à risque élevé d’embolisation cardiogénique. Les apoplexies associées à la cardioversion, l’insertion de pace maker, l’artériographie coronarienne et l’angioplastie sont explorées.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Sotaniemi KA. Cerebral outcome after extracorporeal circulation. Comparison between prospective and retrospective evaluations. Arch Neurol 1983; 40: 75–7.
Silverstein A, Krieger HP. Neurologic complications of cardiac surgery. Arch Neurol 1960; 5: 601–5.
Gilman S. Cerebral disorders after open-heart operations. N Engl J Med 1965; 272: 489–94.
Brierley JB. Brain damage complicating open-heart surgery: a neuropathological study of 46 patients. Proc R SocMed 1967; 60: 858–9.
Javid H, Tufo HM, Najafi H et al. Neurological abnormalities following open-heart surgery. J Thorac Cardiovasc Surg 1969; 58: 502–9.
Lytle BW, Cosgrove DM, Taylor PC et al. Primary isolated aortic valve replacement. J Thorac Cardiovasc Surg 1989; 97: 675–94.
Sotaniemi KA. Brain damage and neurological outcome after open-heart surgery. J Neurol Neurosurg Psychiatry 1980; 43: 127–35.
Lee MC, Geiger J, Nicoloff D et al. Cerebrovascular complications associated with coronary artery bypass (CAB) procedures. Stroke 1979; 10: 107.
Gonzalez-Scarano F, Hurtig H. Neurologic complications of coronary artery bypass grafting: case-control study. Neurology 1981; 31: 1032–5.
Martin WRW, Hashimoto SA. Stroke in coronary bypass surgery. Can J Neurol Sci 1982; 9: 21–6.
Bojar RM, Najafi H, Delaria GA et al. Neurological complications of coronary revascularization. Ann Thorac Surg 1983; 36: 427–32.
Coffey CE, Massey W, Roberts KB et al. Natural history of cerebral complications of coronary artery bypass graft surgery. Neurology 1983; 33: 1416–21.
Shaw PJ, Bates D, Cartlidge NEF et al. Early neurological complications of coronary artery bypass surgery. BMJ 1985; 291: 1384–7.
Breuer AC, Furlan AJ, Hanson MR et al. Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients. Stroke 1983; 14: 682–7.
Schober R, Herman MM. Neuropathology of cardiac transplantation: survey of 31 cases. Lancet 1973; 962–7.
Montero CG, Nartinez AJ. Neuropathology of heart transplantation: 23 cases. Neurology 1986; 36: 1149–54.
Fink ME, Drusin R, Lamb J et al. Cerebrovascular complications of cardiac transplantation. Stroke 1987; 18: 294.
Sila CA. Spectrum of neurologic events following cardiac transplantation. Stroke 1989; 24: 19–23.
Slogoff A, Girgis KZ, Keats AS. Etiologic factors in neuropsychiatric complications associated with cardio-pulmonary bypass. Anesth Analg 1982; 61: 903–11.
Gallagher EC, Pearson DT. Ultrasonic identification of sources of gaseous microemboli during open heart surgery. Thorax 1973; 28: 295–305.
Oka Y, Moriwaki KM, Hong Y et al. Detection of air emboli in the left heart by M-mode transesophageal echocardiography following cardiopulmonary bypass. Anesthesiology 1985; 63: 109–13.
Lawrence GH, McKay HA, Sherensky RT. Effective measures in the prevention of intraoperative aeroembolus. J Thorac Cardiovasc Surg 1971; 62: 731–5.
Padula RT, Eisenstat TE, Bronstein MH, Camishion RC. Intracardiac air following cardiotomy. Location, causative factors, and a method for removal. J Thorac Cardiovasc Surg 1971; 62: 736–42.
Oka Y, Inoue T, Hong Y et al. Retained intracardiac air. Transesophageal echocardiography for definition of incidence and monitoring removal by improved techniques. J Thorac Cardiovasc Surg 1986; 91: 329–38.
Robicsek F, Duncan GD. Retrograde air embolization in coronary operations. J Thorac Cardiovasc Surg 1987; 94: 110–4.
Bagdonas AA, Stuckey JH, Dennis C et al. The role of position in the development of cerebral air embolism following air injection at the base of the aorta. Surg Forum 1960; 10: 653–6.
Mills NL, Ochsner JL. Massive air embolism during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1980; 80: 708–17.
Wells DG, Podolakin W, Mohr M et al. Nitrous oxide and cerebrospinal fluid markers of ischaemia following cardiopulmonary bypass. Anaesth Intensive Care 1987; 15: 431–5.
Gardner TJ, Horneffer PJ, Manolio TA et al. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985; 40: 574–81.
McKibbin DW, Bulkley BH, Green WR et al. Fatal cerebral atheromatous embolization after cardiopulmonary bypass. J Thorac Cardiovasc Surg 1976; 71: 741–5.
Hartman RB, Harrison EE, Pupello DF et al. Characteristics of left ventricular thrombus resulting in perioperative embolism. A complication of coronary artery bypass grafting. J Thorac Cardiovasc Surg 1983; 86: 706–9.
Coselli JS, Crawford ES. Aortic valve replacement in the patient with extensive calcification of the ascending aorta (the porcelain aorta). J Thorac Cardiovasc Surg 1986; 91: 184–7.
Evans EA, Wellington JS. Emboli associated with cardio-pulmonary bypass. J Thorac Cardiovasc Surg 1964; 48: 323–30.
Reed CC, Romagnoli A, Taylor DE, Clark DK. Paniculate matter in bubble oxygenators. J Thorac Cardiovasc Surg 1974; 68: 971–4.
Guidoin RG, Awad JA, Laperehe Y et al. Nature of deposits in atubular membrane oxygenator after prolonged extracorporeal circulation. A scanning electron microscope study. J Thorac Cardiovasc Surg 1975; 69: 479–91.
Kessler J, Patterson RH. The production of microemboli by various blood oxygenators. Ann Thorac Surg 1970; 9:221–8.
Padayachee TS, Parsons S, Theobold R et al. The effect of arterial filtration on reduction of gaseous microemboli in the middle cerebral artery during cardiopulmonary bypass. Ann Thorac Surg 1988; 45: 647–9.
Blauth CI, Smith PL, Arnold JV et al. Influence of oxygenator type on the prevalence and extent of microembolic retinal ischemia during cardiopulmonary bypass. Assessment by digital image analysis. J Thorac Cardiovasc Surg 1990; 99: 61–9.
Young JA, Kisker CT, Doty DB. Adequate anticoagulation during cardiopulmonary bypass determined by activated clotting time and the appearance of fibrin monomer. Ann Thorac Surg 1978; 26: 231–40.
Dutton RC, Edmunds LH, Hutchinson JC, Roe BB. Platelet aggregate emboli produced in patients during cardio-pulmonary bypass with membrane and bubble oxygenators and blood filters. J Thorac Cardiovasc Surg 1974; 67: 258–65.
Loop FD, Szabo J, Rowlinson RD, Urbanek K. Events related to microembolism during extracorporeal perfusion in man: effectiveness of in-line filtration recorded by ultrasound. Ann Thorac Surg 1976; 21: 412–20.
Semb BKH, Pedersen T, Hatteland K et al. Doppler ultrasound estimation of bubble removal by various arterial line filters during extracorporeal circulation. Scand J Thorac Cardiovasc Surg 1982; 16: 55–62.
Solis RT, Noon GP, Beall AC, DeBakey ME. Paniculate microembolism during cardiac operation. Ann Thorac Surg 1974; 17: 332–44.
Solis RT, Kennedy PS, Beall AC Jret al. Cardiopulmonary bypass. Microembolization and platelet aggregation. Circulation 1975; 52: 103–8.
Aberg T, Kihlgren M. Cerebral protection during open-heart surgery. Thorax 1977; 32: 525–33.
Carlson RG, Lande AJ, Landis B et al. The Lande-Edwards membrane oxygenator during heart surgery. Oxygenation, microemboli counts, and Bender-Gestalt visual motor test scores. J Thorac Cardiovasc Surg 1973; 66: 894–905.
Garvey JW, Wilner A, Wolpowiiz A et al. The effect of arterial filtration during open heart surgery. Circulation 1983; 68 (Suppl II): 125–8.
Newberg LA, Michenfelder JD. Cerebral protection by isoflurane during hypoxemia or ischemia. Anesthesiology 1983; 59: 29–35.
Todd MM, Drummond JC. A comparison of the cerebrovascular and metabolic effects of halothane and isoflurane in the cat. Anesthesiology 1984: 60: 276–82.
Baughman VL, Hoffman WE, Miletich DJ et al. Neurologic outcome in rats following incomplete cerebral ischemia during halothane, isoflurane, or N2O. Anesthesiology 1988; 69: 192–8.
Newberg LA, Milde JH, Michenfelder JD. The cerebral metabolic effects of isoflurane at and above concentrations that suppress cortical electrical activity. Anesthesiology 1983; 59: 23–8.
Nehis DG, Todd MM, Spetzler RF et al. A comparison of the cerebral protective effects of isoflurane and barbiturates during temporary focal ischemia in primates. Anesthesiology 1987; 66: 453–64.
Young WL, Prohovnik I, Correll JW et al. Cerebral blood flow and metabolism in patients undergoing anesthesia for carotid endarterectomy. A comparison of isoflurane, halothane, and fentanyl. Anesth Analg 1989; 68: 712–7.
Newberg LA, Milde JH, Michenfelder JD. Systemic and cerebral effects of isoflurane-induced hypotension in dogs. Anesthesiology 1984; 60: 541–6.
Newman B, Gelb AW, Lam AM. The effect of isofluraneinduced hypotension on cerebral blood flow and cerebral metabolic rate for oxygen in humans. Anesthesiology 1986; 64: 307–10.
Artru AA. Cerebral metabolism and EEG during combination of hypocapnia and isoflurane-induced hypotension in dogs. Anesthesiology 1986; 65: 602–8.
Mutch WAC, Malo LA, Ringaert KHA. Phenylephrine increases regional cerebral blood flow following hemorrhage during isoflurane-oxygen anesthesia. Anesthesiology 1989; 70: 276–9.
Ruta TS, Mutch WAC. Regional cerebral blood flow following hemorrhage during isoflurane anesthesia in the rabbit: comparison of techniques to support blood pressure. Anesthesiology 1989; 70: 978–83.
Messick JM Jr, Casement B, Sharbrough FW et al. Correlation of regional cerebral blood flow (rCBF) with EEG changes during isoflurane anesthesia for carotid endarterectomy: critical rCBF. Anesthesiology 1987; 66: 344–9.
Michenfelder JD, Sundt TM, Fode N, Sharbrough FW. Isoflurane when compared to enflurane and halothane decreases the frequency of cerebral ischemia during carotid endarterectomy. Anesthesiology 1987; 67: 336–40.
Woodcock TE, Murkin JM, Farrar JK et al. Pharmacologic EEG suppression during cardiopulmonary bypass: cerebral hemodynamic and metabolic effects of thiopental or isoflurane during hypothermia and normothermia. Anesthesiology 1987; 67: 218–24.
Slogoff S, Keats AS. Randomized trial of primary anesthetic agents on outcome of coronary artery bypass operations. Anesthesiology 1989; 70: 179–99.
Tuman KJ, McCarthy RJ, Spiess BD et al. Does choice of anesthetic agent significantly affect outcome after coronary artery surgery? Anesthesiology 1989; 70: 189–98.
Inoue K, Reichelt W, El-Banayosy A et al. Does isoflurane lead to a higher incidence of myocardial infarction and perioperative dea th than enflurane in coronary artery surgery? A clinical study of 1178 patients. Anesth Analg 1990; 71: 469–74.
Steen PA, Newberg L, Milde JH, Michenfelder JD. Hypothermia and barbiturates: individual and combined effects on canine cerebral oxygen consumption. Anesthesiology 1983; 58: 527–32.
Michenfelder JD. The interdependency of cerebral functional and metabolic effects following massive doses of thiopental in the dog. Anesthesiology 1974; 41: 231–6.
Astrup J, Sorensen PM, Sorensen HR. Inhibition of cerebral oxygen and glucose consumption in the dog by hypothermia, pentobarbital, and lidocaine. Anesthesiology 1981; 55: 263–8.
Branston JH, Hope T, Symon L. Barbiturates in focal ischemia of primate cortex: effects on blood flow distribution, evoked potential and extracellular potassium. Stroke 1979; 10: 647–53.
Selman WR, Spetzler RF, Roessmann UR et al. Barbiturate-induced coma therapy for focal cerebral ischemia. Effect after temporary and permanent MCA occlusion. J Neurosurg 1981; 55: 220–6.
Nussmeier NA, Arlund C, Slogoff S. Neuropsychiatric complications after cardiopulmonary bypass: cerebral protection by a barbiturate. Anesthesiology 1986; 64: 165–70.
McMurrey JD, Bernard WF, Taren JA, Bering EA. Studies on hypothermia in monkeys: the effect of hypothermia on the prolongation of permissible time of total occlusion of the afferent circulation of the brain. Surg Gynecol Obstet 1956; 102: 75–86.
Lajferty JJ, Keykhah MM, Shapiro HM et al. Cerebral hypometabolism obtained with deep pentobarbital anesthesia and hypothermia (30°C). Anesthesiology 1978; 49: 159–64.
Gordon RJ, Ravin M, Daicoff GR, Rawitscher RE. Effects of hemodilution on hypotension during cardiopulmonary bypass. Anesth Analg 1975; 54: 482–8.
Williams JJ, Marshall BE. A fresh look at an old question. Anesthesiology 1982: 56: 1–2.
Reeves RB, Rahn H. Patterns in vertebrate acid-base regulation.In. Wood SC, Lenfant C. (Eds.). Evolution of Respiratory Processes: A Comparative Approach. New York: Marcel Dekker, Inc. 1979; 225–52.
McConnel DH, White FN, Nelson RL et al. Importance of alkalosis in maintenance of “ideal” blood pH during hyopothermia. Surg Forum 1975; 26: 263–5.
Ohmura A, Wong KC, Westenskow DR, Shaw CL. Effects of hypocarbia and normocarbia on cardiovascular dynamics and regional circulation in the hypothermic dog. Anesthesiology 1979; 50: 293–8.
Henriksen L, Hjelms E, Lindeburgh T. Brain hyperperfusion during cardiac operations. J Thorac Cardiovasc Surg 1983; 86: 202–8.
Govier AV, Reves JG, McKay RD et al. Factors and their influence on regional cerebral blood flow during nonpulsatile cardiopulmonary bypass. Ann Thorac Surg 1984; 38: 592–600.
Prough DS, Stump DA, Roy RC et al. Response of cerebral blood flow to changes in carbon dioxide tension during hypothermic cardiopulmonary bypass. Anesthesiology 1986; 64: 576–81.
Hägerdal M, Harp JR, Siesjo BK. Influence of changes in arterial PCO2 on cerebral blood flow and cerebral energy state during hypothermia in the rat. Acta Anaesth Scand 1975; 57 (Suppl): 25–33.
Murkin JM, Farrar JK, Tweed WA et al. Cerebral autoregulation and flow/metabolism coupling during cardiopulmonary bypass: the influence of PaCO2. Anesth Analg 1987; 66: 825–32.
Habal SM, Weiss MB, Spotnitz HM et al. Effects of pulsatile and nonpulsatile coronary perfusion on performance of the canine left ventricle. J Thorac Cardiovasc Surg 1976; 72: 742–5.
German JC, Chalmers GS, Hirai J et al. Comparison of nonpulsatile and pulsatile extracorporeal circulation in renal tissue perfusion. Chest 1972; 61: 65–9.
Taylor KM, Bain WH, Maxted KJ et al. Comparative studies of pulsatile and nonpulsatile tlow during CPB. I. Pulsatile system employed and its hematologic effects. J Thorac Cardiovasc Surg 1978; 75: 569–73.
Taylor KM, Wright GS, Reid JM et al. Comparative studies of pulsatile and nonpulsatile flow during CPB. II. The effects on adrenal secretion of cortisol. J Thorac Cardiovasc Surg 1978; 75: 574–8.
Taylor KM, Wright GS, Bain WH et al. Comparative studies of pulsatile and nonpulsatile How during CPB. III. Response of anterior pituitary gland to thyrotropinreleasing. J Thorac Cadiovasc Surg 1978; 75: 579–84.
Kritikou PE, Branthwaite MA. Significance of changes in cerebral electrical activity at onset of cardiopulmonary bypass. Thorax 1977; 32: 534–8.
Mavroudis C. To pulse or not to pulse. Ann Thorac Surg 1978; 25: 259–71.
Edmunds LH. Pulseless cardiopulmonary bypass. J Thorac Cardiovasc Surg 1982; 84: 800–4.
Philbin DM, Hickey PR, Buckley M. Should we pulse? J Thorac Cardiovasc Surg 1982; 84: 805–6.
Juneja I, Flynn RE, Berger RL. The arterial and venous pressures and the electroencephalogram during open heart surgery. Acta Neurol Scand 1972; 48: 163–8.
Stockard JJ, Bickford RG, Schauble JF. Pressure-dependent cerebral ischemia during cardiopulmonary bypass. Neurology 1973; 23: 521–9.
Stockard JJ, Bickford RG, Myers RR et al. Hypotension-induced changes in cerebral function during cardiac surgery. Stroke 1974; 5: 730–46.
Branthwaite MA. Detection of neurological damage during open-heart surgery. Thorax 1973; 28: 464–72.
Ellis RJ, Wisniewski A, Potts R et al. Reduction of flow rate and arterial pressure at moderate hypothermia does not result in cerebral dysfunction. J Thorac Cardiovasc Surg 1980; 79: 173–80.
Ames A III, Wright RL, Kowada M et al. Cerebral ischemia: II. The no-reflow phenomenon. Am J Pathol 1968; 52: 437–53.
Cantu RC, Ames A III, Digiacinto G, Dixon J. Hypotension: a major factor limiting recovery from cerebral ischemia. J Surg Res 1969; 9: 525–9.
Hekmatpanah J. Cerebral circulation and perfusion in experimental increased intracranial pressure. J Neurosurg 1970; 32: 21–9.
Hekmatpanah J. Cerebral blood flow dynamics in hypotension and cardiac arrest. Neurology 1973; 23: 174–80.
Witoszka MM, Tamura H, Indeglia R et al. Electroencephalographic changes and cerebral complications in open-heart surgery. J Thorac Cardiovasc Surg 1973; 66: 855–64.
Salerno TA, Lince DP, White DN et al. Monitoring of electroencephalogram during open-heart surgery. A prospective analysis of 118 cases. J Thorac Cardiovasc Surg 1978; 76: 97–100.
Schwartz MS, Colvin MP, Prior PF et al. The cerebral function monitor. Its value in predicting the neurological outcome in patients undergoing cardiopulmonary bypass. Anaesthesia 1973: 28: 611–8.
Nevin M, Colchester ACF, Adams S, Pepper JR. Prediction of neurological damage after cardiopulmonary bypass surgery. Use of the cerebral function analysing monitor. Anaesthesia 1989; 44: 725–9.
El-Fiki M, Fish KJ. Is the EEG a useful monitor during cardiac surgery? A case report. Anesthesiology 1987; 67: 575–8.
Jones BR, Scheller MS. Perfusion pressure and electroencephalographic changes during cardiopulmonary bypass. J Clin Monit 1989; 5: 288.
Levy WJ. Quantitative analysis of EEG changes during hypothermia. Anesthesiology 1984; 60: 291–7.
Sebel PS, Bovill JG, Wauquier A, Rog P. Effects of high-dose fentanyl anesthesia on the electroencephalogram. Anesthesiology 1981; 55: 203–11.
Bovill JG, Sebel PS, Wauquier A, Rog P. Electroencephalographic effects of sufentanil anaesthesia in man. Br J Anaesth 1982; 54: 45–52.
Levy WJ, Shapiro HM, Meathe E. The identification of rhythmic EEG artifacts by power-spectrum analysis. Anesthesiology 1980; 53: 505–7.
Steele ER, Albin MS, Monts JL, Harman PK. Compressed spectral array EEG monitoring during coronary bypass surgery in a patient with vertebrobasilar artery insufficiency. Anesth Analg 1987; 66: 271–3.
Von Reutern G-M, Hetzel A, Birnbaum D, Schlosser V. Transcranial Doppler ultrasonography during cardiopulmonary bypass in patients with severe carotid stenosis or occlusion. Stroke 1988; 19: 674–80.
Pasquale GD, Andreoli A, Pinelli G et al. Cerebral ischemia and asymptomatic coronary artery disease: a prospective study of 83 patients. Stroke 1986; 17: 1098–101.
Jones EL, Craver JM, Micholik RA et al. Combined carotid and coronary operations: when are they necessary? J Thorac Cardiovasc Surg 1984; 87: 7–16.
Herizer NR, Lees CD. Fatal myocardial infarction following carotid endarterectomy: three hundred thirty-five patients followed 6–11 years after operation. Ann Surg 1981; 194:212–8.
Thompson JE, Austin DJ, Potman RD. Carotid endarterectomy for cerebrovascular insufficiency: longterm results in 592 patients followed up to thirteen years. Ann Surg 1970; 172:663–79.
DeWeese JA, Rob CG, Satran R et al. Results of carotid endarterectomies for transient ischemic attacks — five years later. Ann Surg 1973; 178: 258–64.
Mackey WC, O’Donnell TF Jr, Callow AD. Cardiac risk in patients undergoing carotid endarterectomy: impact on perioperative and long-term mortality. J Vase Surg 1990; 11: 226–34.
Shaw PJ, Bates D, Cartlidge NEF et al. Neurologic and neuropsychological morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery. Stroke 1987; 18: 700–7.
Reed GL III, Singer DE, Picard EH, DeSanctis RW. Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits. N Engl J Med 1988; 319: 1246–50.
Kartchner MM, McRae LP. Non-invasive evaluation and management of the ‘asymptomatic’ carotid bruit. Surgery 1977; 82: 840–7.
Barnes RW, Liebman PR, Marszalek PB et al. The natural history of asymptomatic carotid disease in patients undergoing cardiovascular surgery. Surgery 1981; 90: 1075–83.
Gutierrez IZ, Barone DL, Makula PA, Currier C. The risk of perioperative stroke in patients with asymptomatic carotid bruits undergoing peripheral vascular surgery. Am Surg 1987; 53: 487–9.
Ivey TD, Strandness DE, Williams DB et al. Management of patients with carotid bruit undergoing cardiopulmonary bypass. J Thorac Cardiovasc Surg 1984; 87: 183–9.
Furlan AJ, Craciun AR. Risk of stroke during coronary artery bypass graft surgery in patients with internal carotid artery disease documented by angiography. Stroke 1985; 16: 797–9.
Gibbs JM, Wise RJS, Leenders KL, Jones T. Evaluation of cerebral perfusion reserve in patients with carotid artery occlusion. Lancet 1984; 1: 182–6.
Basino FG, Reves JG, Prough DS, Stump DA. Cerebral blood flow during cardiopulmonary bypass in a patient with occlusive cerebrovascular disease. Journal of Cardiothoracic Anesthesia 1989; 3: 87–90.
Barnes RW. Asymptomatic carotid disease in patients undergoing major cardiovascular operations: can prophylactic endarterectomy be justified? Ann Thorac Surg 1986; 42 (Suppl): 36–40.
Brener BJ, Brief DK, Alpert J et al. The risk of stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery: a follow-up study. J Vase Surg 1987; 5: 269–79.
Mehigan JT, Bush WS, Pipkin RD, Fogarty TJ. A planned approach to coexistent cerebrovascular disease in coronary artery bypass candidates. Arch Surg 1977; 112: 1403–9.
Gravlee GP, Cordell AR, Graham JE et al. Coronary revascularization in patients with bilateral internal carotid occlusions. J Thorac Cardiovasc Surg 1985; 90: 921–5.
Ennix CL Jr, Lawrie GM, Morris GC Jret al. Improved results of carotid endarterectomy in patients with symptomatic coronary disease: an analysis of 1546 consecutive carotid operations. Stroke 1979; 10: 122–5.
Morris GC Jr, Ennix CL Jr, Lawrie GM et al. Management of co-existent carotid and coronary artery occlusive atherosclerosis. Cleveland Clin Quarterly 1978; 45: 125–7.
Rice PL, Pifarre R, Sullivan HJ et al. Experience with simultaneous myocardial revascularization and carotid endarterectomy. J Thorac Cardiovasc Surg 1980; 79: 922–5.
Craver JM, Murphy DA, Jones EL et al. Concomitant carotid and coronary artery reconstruction. Ann Surg 1982; 195: 712–20.
Urschel HC Jr. Management of concomitent coronary and carotid artery obstructive disease. Cleve Clin J Med 1978; 45: 128–9.
Graor RA, Hetzer NR. Management of coexistent carotid artery and coronary artery disease. Stroke 1988; 19: 1441–4.
Cambria RP, Ivarsson BL, Akins CW et al. Simultaneous carotid and coronary disease: safety of the combined approach. J Vase Surg 1989; 9: 56–64.
Perler BA, Burdiek JF, Minken SL, Williams GM. Should we perform carotid endarterectomy synchronously with cardiac surgical procedures? J Vase Surg 1988; 8: 402–9.
Hertzer NR, Loop FD, Beven EG et al. Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization. J Vase Surg 1989; 9: 455–63.
Sherman DG, Dyken ML, Fisher M et al. Cerebral embolism. Chest 1986; 89 (Suppl): 82–98.
Yasaka M, Yamaguchi T, Miyashita T et al. Predisposing factors of recurrent embolization in cardiogenic cerebral embolism. Stroke 1990; 21: 1000–7.
Levine HJ, Pauker SG, Saizman EW. Antithrombotic therapy in valvular heart disease. Chest 1986; 89 (Suppl): 36–45.
Stein PD, Collins JC Jr, Kanlrowitz A. Antilhrombotic therapy in mechanical and biological prosthetic heart valves and saphenous vein bypass grafts. Chest 1986; 89 (Suppl): 46–53.
Dunn M, Alexander J, de Silva R, Hildner F. Antithrombotic therapy in atrial fibrillation. Chest 1986; 89 (Suppl): 68–74.
Taylor GJ, Malik SA, Colliver JA et al. Usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting. Am J Cardiol 1987; 60: 905–7.
Wolf PA, Dawber TR, Thomas HE, Kannel WB. Epidemiological assessment of chronic atrial fibrillation and risk of stroke: the Framingham Study. Neurology 1978; 28: 973–7.
Pelersen P, Hansen JM. Stroke in thyrotoxicosis with atrial fibrillation. Stroke 1988; 19: 15–8.
Petersen P, Godtfredsen J. Embolic complications in paroxysmal atrial fibrillation. Stroke 1986; 17: 622–6.
Petersen P. Thromboembolic complications in airial fibrillation. Stroke 1990; 21: 4–13.
Petersen P, Madsen EB, Brun B et al. Silent cerebral infarction in chronic atrial fibrillation. Stroke 1987; 18: 1098–100.
Kempster PA, Gerraty RP, Gates PC. Asymptomatic cerebral infarction in patients with chronic atrial fibrillation. Stroke1988; 19: 955–7.
Halperin JL, Hart RG. Atrial fibrillation and stroke. New ideas, persisting dilemmas. Stroke 1988; 19: 937–41.
Flegel KM, Hanley J. Risk factors for stroke and other embolic events in patients with nonrheumatic atrial fibrillation. Stroke 1989; 20: 1000–4.
Levine HJ. Which atrial fibrillation patients should be on chronic anticoagulation? J Cardiovasc Med 1981; 6: 483–7.
Savage DD, Garrison RJ, Devereux RB et al. Mitral valve prolapse in the general population. I. Epidemological features: the Framingham Study. Am Heart J 1983; 106: 571–5.
Feltes TF, Wilcox WD. Mitral valve prolapse in adolescents.In: Julian DG, Wenger NK (Ed.). Cardiac Problems of the Adolescent and Young Adult. London: Butterworths, 1985.
Levy D, Savage D. Prevalence and clinical features of mitral valve prolapse. Am Heart J 1987; 113: 1281–90.
Boughner DR, Barnes HJM. The enigma of the risk of stroke in mitral valve prolapse. Stroke 1985; 16: 175–7.
Sandok BA, Giuliani ER. Cerebral ischemic events in patients with mitral valve prolapse. Stroke 1982; 13: 448–50.
Bergeron GA, Shah PM. Echocardiography unwarranted in patients with cerebral ischemic events. N Engl J Med 1981; 304:489.
Smith DL, McKnight TE. TIAs, completed strokes and mitral valve prolapse. South Med J 1981; 74: 1454–6.
Come PC, Riley MF, Bivas NK. Roles of echocardiography and arrhythmia monitoring in the evaluation of patients with suspected systemic embolism. Ann Neurol 1983; 13: 527–31.
Nishide Ma, Irino T, Gotoh M et al. Cardiac abnormalities in ischemic cerebrovascular disease studied by two-dimentional echocardiography. Stroke 1983; 14: 541–5.
Reetn JA, Hachinski VC, Boughner DR, Barnett HJM. Value of cardiac monitoring and echocardiography inTIA and stroke patients. Stroke 1985; 16: 950–6.
Good DC, Frank S, Verhulst S, Sharma B. Cardiac abnormalities in stroke patients with negative arteriograms. Stroke 1986; 17: 6–11.
Kelley RE, Pina I, Lee S-C. Cerebral ischemia and mitral valve prolapse: case-control study of associated factors. Stroke 1988; 19: 443–6.
Wolf PA, Sila CA. Cerebral ischemia with mitral valve prolapse. Am Heart J 1987; 113: 1308–15.
Edmunds LH. Thrombotic and bleeding complications of prosthetic heart valves. Ann Thorac Surg 1987; 44: 430–45.
Lieberman A, Hass WK, Pinto A et al. Intracranial hemorrhage and infarction in anticoagulated patients with prosthetic heart valves. Stroke 1978; 9: 18–24.
Edmunds LH Jr. Thromboembolic complications of current cardiac valvular prostheses. Ann Thorac Sur 1982; 34: 96–106.
Shattel LFB. The prevention of prosthetic valve thromboembolism. Uses and limitations of anti-platelet drugs. Int J Cardiol 1983; 3: 87–91.
Braunwald E. Valvular Heart Disease.In: Braundwald E(Ed.). Heart Disease. Philadelphia: W.B. Saunders, 1984; 1063.
Coon WW, Willis PW. Hemorrhagic complications of anticoagulant therapy. Arch Intern Med 1974; 133: 386–92.
Kase CS, Robinson RK, Stein RW et al. Anticoagulant related intracerebral hemorrhage. Neurology 1985; 35: 943–8.
Katholi RE, Nolan SP, McGuire LB. Living with prosthetic heart valves: Subsequent noncardiac operations and the risk of thromboembolism or hemorrhage. Am Heart J 1976; 92: 162–7.
Katholi RE, Nolan SP, McGuire LB. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. A prospective study. Am Heart J 1978; 96: 163–5.
Bodnar AG, Hutter AM Jr. Anticoagulation in valvular heart disease preoperatively and postoperatively.In: Conti CR (Ed.) Cardiac Drug Therapy, Cardiovascular Clinics 1984; 4: 247–64. Philadelphia: FA Davis Co.
Tinker JH, Tarhan S. Discontinuing anticoagulant therapy in surgical patients with cardiac valve prostheses: observations in 180 operations. JAMA 1978; 239: 738–9.
Pruitt AA, Rubin RH, Karchmer AW, Duncan GW. Neurologic complications of bacterial endocarditis. Medicine 1978; 57: 329–43.
Hart RG, Kagan-Hallet K, Joerns SE. Mechanisms of intracranial hemorrhage in infective endocarditis. Stroke 1987; 18: 1048–56.
Davenport J, Hart RG. Prosthetic valve endocarditis 1976–1987. Antibiotics, anticoagulation, and stroke. Stroke 1990; 21: 993–9.
Heyen PT, Scholz DG, Edwards WP. Incidence and size of patent foramen ovale in the first ten decades of life. Mayo Clin Proc 1984; 59: 17–20.
Biller J, Adams HP, Johnson MR et al. Paradoxical cerebral embolism: eight cases. Neurology 1986; 36: 1356–60.
Harvey JR.Teague SM, Anderson JL et al. Clinically silent patent foramen ovale with evidence of cerebral embolism. Ann Intern Med 1986; 105: 695–7.
Lechat P, Mas JL, Lascault G et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318: 1148–52.
Colemnan SA, Wilson-MacDonald J. Fatal paradoxical thrombo-embolism during anaesthesia. Anaesthesia 1988; 43: 213–5.
Dalman R, Kohler TR. Cerebrovascular accident after Greenfield filter placement for paradoxical embolism. J Vasc Surg 1989; 9: 452–4.
Black S, Muzzi DA, Nishimura RA, Cucchiara RF. Preoperative and intraoperative echocardiography to detect right-to-left shunt in patients undergoing neurosurgical procedures in the sitting position. Anesthesiology 1990; 72: 436–8.
Shuiab A. Cerebral infarction and ventricular septal defect. Stroke 1989; 20: 957–8.
Keith D, Rose V, Collins G, Kidd BSL. Ventricular septal defect. Incidence, morbidity, mortality in various age groups. Br Heart J 1971; 33 (Supp): 81–7.
Bjerkelund CJ, Orning OM. The efficacy of anticoagulant therapy in preventing embolism related to D.C. electrical conversion of atrial fibrillation. Am J Cardiol 1969; 23: 208–16.
Fisher M, Kase CS, Stelle B, Mills RM Jr. Ischemic stroke after cardiac pacemaker implantation in sick sinus syndrome. Stroke 1988; 19: 712–5.
Adams DF, Fraser DB, Abrams HC. The complication of coronary arteriography. Circulation 1973; 48: 609–18.
Bourassa MG, Noble J. Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique. Circulation 1976; 53: 106–14.
Oliva A, Scherokman B. Two cases of occipital infarction following cardiac catheterization. Stroke 1988; 19: 773–5.
Dawson DM, Fischer EG. Neurologic complications of cardiac catheterization. Neurology 1977; 27: 496–7.
Sones FM Jr. Complications of coronary arteriography and left heart catheterization. Cleve Clin J Med 1978; 45:21–3.
Lockwood K, Capraro J, Hanson M, Conomy J. Neurologic complications of cardiac catheterization. Neurology 1983; 33 (Suppl 2): 143.
Kent KM, Bentiusglio LG, Block PC et al. Percutaneous transluminal coronary angioplasty. Report from the Registry of the National Heart, Lung, and Blood Institute. Am J Cardiol 1982; 49: 2011–20.
Dorros G, Cowley MJ, Simpson J et al. Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry. Circulation 1983; 67: 723–30.
Galbreath C, Salgado ED, Furlan AJ, Hollman J. Central nervous system complications of percutaneous transluminal coronary angioplasty. Stroke 1986; 17: 616–9.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Wong, D.H.W. Perioperative stroke part II: Cardiac surgery and cardiogenic embolic stroke. Can J Anaesth 38, 471–488 (1991). https://doi.org/10.1007/BF03007584
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03007584