Cardiac surgery in patients with cerebrovascular disease

Authors: Fujita T, Kobayashi J.

Cerebral event is the 2nd leading cause of mortality and morbidity after cardiac surgery. Therefore, management of cerebrovascular disease is essential to improve the outcome. We reviewed the literatures and cases in our institute to present the current strategy for these patients. Firstly, for the patients in high risk of stroke, if patients undergo coronary artery bypass grafting (CABG), off-pump CABG (OPCAB) with aorta non-touch technique is recommended. We experienced no intraoperative stroke in our recent consecutive 1,000 cases. If patients require cardiopulmonary bypass, keeping blood pressure high during bypass may prevent local hypoperfusion in brain. Second, for the patients having carotid artery disease, the team approach with neurologists is essential to determine to precede either of cardiac surgery or carotid endoarterectomy. Because preceding carotid endoarterectomy gives the best result to prevent stroke, these patients had better have carotid endoarterectomy first, unless there is indication of urgent cardiac surgery. Third, for the patients with active endocarditis, early indication of surgery is recently recommended, unless patients have intracranial hemorrhage. Recent magnetic resonance imaging (MRI) examination revealed more than 60% of patients have stroke regardless of size, therefore, team approach with neurologists is important to decide the timing of the surgery. Team approach and correct selection of procedural technique are important to prevent cerebrovascular events during cardiac surgery.

Effects of Body Position on Intracranial Pressure and Cerebral Perfusion in Patients With Large Hemispheric Stroke

Authors: Stefan Schwarz, MD; Dimitrios Georgiadis, MD; Alfred Aschoff, MD; Stefan Schwab, MD

Background and Purpose— The purpose of this study was to prospectively evaluate the effects of body position in patients with large supratentorial stroke.

Methods— We performed 43 monitoring sessions in 18 patients with acute complete or subtotal middle cerebral artery (MCA) territory stroke. Intracranial pressure (ICP) was monitored with a parenchymal probe. Mean arterial blood pressure, ICP, and MCA peak mean flow velocity (VmMCA) were continuously recorded. Patients with acute ICP crises were excluded. After baseline values at a 0° supine position were attained, the backrest was elevated in 2 steps of 5 minutes each to 15° and 30° and then returned to 0°.

Results— Baseline mean arterial pressure was 90.0±1.6 mm Hg and fell to 82.7±1.7 mm Hg at 15° and 76.1±1.6 mm Hg at 30° backrest elevation (P<0.0001). ICP decreased from 13.0±0.9 to 12.0±0.9 mm Hg at 15° and 11.4±0.9 mm Hg at 30° backrest elevation (P<0.0001). As a result, cerebral perfusion pressure decreased from a baseline value of 77.0±1.8 to 70.0±1.8 mm Hg at 15° and 64.7±1.7 mm Hg at 30° backrest elevation (P<0.0001). VmMCA was already higher on the affected side during baseline measurements. VmMCA decreased from 72.8±11.3 cm/s at 0° to 67.2±9.7 cm/s at 15° and 61.2±8.9 cm/s at 30° on the affected and from 49.9±3.7 cm/s at 0° to 47.7±3.6 cm/s at 15° and 46.2±2.2 cm/s at 30° on the contralateral side (P<0.0001).

Conclusions— In patients with large hemispheric stroke without an acute ICP crisis, cerebral perfusion pressure was maximal in the horizontal position although ICP was usually at its highest point. If adequate cerebral perfusion pressure is considered more desirable than the absolute level of ICP, the horizontal position is optimal for these patients.

Increased Intracerebral Pressure Following Stroke

Authors: Thorsten Steiner, MD*, Ralf Weber, MD, Derk Krieger, MD

Increased intracerebral pressure with lethal herniation still accounts for high mortality rates in patients with massive strokes. Patients that are likely to develop increased intracranial pressure can often be identified within the first few hours after stroke onset. Although medical management seems to fail in most of these patients, early hemicraniectomy and induced moderate hypothermia (32;C to 33;C) represent two novel therapeutic approaches to improve neurologic outcomes and decrease mortality rates.

Home Blood Pressure Level, Blood Pressure Variability, Smoking, and Stroke Risk in Japanese Men: The Ohasama Study

Authors: Hashimoto T, Kikuya M, Ohkubo T, Satoh M, Metoki H, Inoue R, Asayama K, Kanno A, Obara T, Hirose T, Hara A, Hoshi H, Totsune K, Satoh H, Sato H, Imai Y.

BackgroundHypertension and smoking independently contribute to the risk of stroke. Our objective was to investigate home blood pressure (HBP) levels, day-by-day BP variability, and smoking in the prediction of stroke in Japanese men.MethodsIn this study, 902 men (mean age, 58.6 years) without a past history of stroke were evaluated. HBP was measured once every morning for 4 weeks. Day-by-day BP variability was defined as within-subject standard deviations (SD) of HBP. Smoking history was obtained from a standardized questionnaire. Hazard ratios (HRs) for stroke were examined by Cox regression model, with adjustment for possible confounders.ResultsDuring 13.1 years (median) of follow-up, 89 cerebral infarctions, 28 intracranial hemorrhages, and six other strokes occurred. Systolic HBP levels (HR = 1.59 per 14.6 mm Hg increase, P < 0.0001) and variability (HR = 1.26 per 3.1 mm Hg increase, P = 0.03) of +1 between-subject SD were significantly associated with cerebral infarction. The relationship between HBP and cerebral infarction differed with smoking status (interaction P = 0.021 and 0.017 for systolic level and variability, respectively). In analyses stratified according to smoking, systolic level (HR = 1.78, P < 0.0001) and variability (HR = 1.38, P = 0.006) were significantly associated with cerebral infarction in ever smokers (N = 511), but not in never smokers (N = 391; P ≥ 0.6 for both). No significant association was found between smoking and the risk of intracranial hemorrhage.ConclusionsIn ever smokers, both HBP levels and variability are significantly associated with the risk of cerebral infarction. Our findings further validate the benefit of smoking cessation in preventing cardiovascular disease (CVD), especially cerebral infarction.American Journal of Hypertension 2012; doi:10.1038/ajh.2012.62.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atheros

Authors: Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF; American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups.

PURPOSE: Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.
METHODS: Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.
RESULTS: Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Guidelines for the Early Management of Patients With Ischemic Stroke

Authors: Harold P. Adams Jr, MD, Chair; Robert J. Adams, MD; Thomas Brott, MD; Gregory J. del Zoppo, MD; Anthony Furlan, MD; Larry B. Goldstein, MD; Robert L. Grubb, MD; Randall Higashida, MD; Chelsea Kidwell, MD; Thomas G. Kwiatkowski, MD; John R. Marler, MD; George J. Hademenos, PhD.

In 1994, a panel appointed by the Stroke Council of the American Heart Association authored guidelines for the management of patients with acute ischemic stroke.1 After the approval of the use of intravenous recombinant tissue plasminogen activator (rtPA) for treatment of acute ischemic stroke by the Food and Drug Administration, the guidelines were supplemented by a series of recommendations 2 years later.2 Several promising interventions for the treatment of acute ischemic stroke have subsequently been tested in clinical trials, and other components of acute management have been evaluated since the previous guidelines were published. These new data have prompted the present revision of the prior guideline statement.

The goal of these guidelines is to provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications.


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