Neurologic injury in cardiac surgical patients with a history of stroke.
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%).


CONCLUSIONS
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.
Redmond
J M
JM
Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
Greene
P S
PS
Goldsborough
M A
MA
Cameron
D E
DE
Stuart
R S
RS
Sussman
M S
MS
Watkins
L
L
Laschinger
J C
JC
McKhann
G M
GM
Johnston
M V
MV
Baumgartner
W A
WA
D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D002315:Cardiopulmonary Bypass; D002561:Cerebrovascular Disorders / Q000209:etiology*; D003221:Confusion / Q000209:etiology; D001026:Coronary Artery Bypass; D005260:Female; D006351:Heart Valves / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012307:Risk Factors