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Side differences in cerebrovascular accidents after cardiac surgery: a statistical analysis of neurologic symptoms and possible implications for anatomic mechanisms of aortic particle embolization.
Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
2005 (English)In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, Vol. 129, no 3, 591-598 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Aortic manipulation and particle embolization have been identified to cause cerebrovascular accidents in cardiac surgery. Recent data suggest that left-hemispheric cerebrovascular accident (right-sided symptoms) is more common, and this has been interpreted as being caused by aortic cannula stream jets. Our aim was to evaluate symptoms of cerebrovascular accident and side differences from a retrospective statistical analysis. METHODS: During a 2-year period, 2641 consecutive cardiac surgery cases were analyzed. Patients positive for cerebrovascular accident were extracted from a database designed to monitor clinical symptoms. A protocol was used to confirm symptom data with the correct diagnosis in patient records. Patients were subdivided into 3 groups: control, immediate cerebrovascular accident, and delayed cerebrovascular accident. RESULTS: Among pooled patients, immediate and delayed cerebrovascular accidents were 3.0% and 0.9%, respectively. The expected predisposing factors behind immediate cerebrovascular accidents were significant, although the type of operation affected this search. Aortic quality was a strong predictor ( P < .001). The rate of delayed cerebrovascular accident was unaffected by surgery group. Left-sided symptoms of immediate cerebrovascular accident were approximately twice as frequent ( P = .016) as on the contralateral side. This phenomenon was observed for pooled patients and for isolated coronary bypass procedures (n = 1882; P = .025). CONCLUSIONS: Immediate cerebrovascular accident and aortic calcifications are linked. The predominance of left-sided symptoms may suggest that aortic manipulation and anatomic mechanisms in the aortic arch are more likely to cause cerebrovascular accidents than effects from cannula stream jets.

Place, publisher, year, edition, pages
2005. Vol. 129, no 3, 591-598 p.
Keyword [en]
Aged, Aortic Diseases/*epidemiology, Arteriosclerosis/*epidemiology, Cardiopulmonary Bypass, Coronary Artery Bypass, Female, Humans, Male, Middle Aged, Retrospective Studies, Stroke/*epidemiology/physiopathology, Time Factors
URN: urn:nbn:se:umu:diva-6035DOI: 10.1016/j.jtcvs.2004.07.020PubMedID: 15746743OAI: diva2:145703
Available from: 2007-12-05 Created: 2007-12-05 Last updated: 2009-11-09Bibliographically approved
In thesis
1. Cerebrovascular accidents associated with aortic manipulation during cardiac surgery
Open this publication in new window or tab >>Cerebrovascular accidents associated with aortic manipulation during cardiac surgery
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Despite the successful development in cardiac surgery, cerebrovascular accidents (CVA) remain a devastating complication. Aortic atherosclerosis has been identified as a major risk factor for CVA. The present thesis addresses this question in relation to aortic manipulation during cardiac surgery, being divided into a clinical (I-II) and an experimental part (III-V).

Material and methods: Consecutive cardiac surgery cases (n=2641) were analyzed. Patients with CVA were extracted from a database designed to monitor clinical symptoms. Patient records were used to confirm clinical data and diagnosis. Subdivision was made into three groups: control subjects, immediate, and delayed CVA, being analyzed for neurological symptoms (I). Patients with CVA who also had been investigated with computer tomography (CT) (n=77) were further evaluated in terms of hemispheric and vascular distribution of lesions. The CT-findings were compared with CVA symptoms (II). An aortic perfusion model was developed using cadaver aorta onto which multiple cross-clamp manipulations were applied (III). Washout samples of perfusate were analyzed by computerized image processing and with subdivision into different particle spectra. The model was further developed with the introduction of intraluminal manipulation from cannula and intra-aortic filter (IV). A technique for macro-anatomic mapping of plaque distribution of cadaver thoracic aorta was developed (V). Variation in plaque density was analyzed in different anatomical segments, monitored by digital image analysis. Hazards associated with surgical manipulation were studied by superimposing cannulation and cross-clamp sites onto the aortic maps in a blinded fashion.

Results: The incidence of immediate and delayed CVA was 3.0% and 0.9%, respectively. Aortic quality was a strongly associated with immediate but not delayed CVA. Left-sided symptoms of immediate CVA were significantly more frequent than of the contra-lateral side. Positive signs on CT were seen in 66% of the CVA patients. Right-hemispheric lesions were more frequent compared with the contra-lateral side and the middle-cerebral artery territory dominated. Aortic cross-clamping produced a substantial output of particulate matter. Manipulation by intra-aortic filter produced a significant washout of embolic particles that escaped the filter, although some particles were captured. Cannulation was an additional source of embolic material. In terms of plaque distribution was the anterior wall of the ascending part and arch of the aorta more affected than its posterior side. However, observing a plaque in the anterior wall of this aortic segment predicted to 83% a concomitant plaque in the posterior wall. Increased age correlated positively with plaque density. The theoretical chance of interfering with a plaque during cannulation and/or clamp positioning was 45.8%.

Conclusions: Both CT scans and clinical symptoms confirmed that CVA after cardiac surgery had a right-hemispheric predominance. The perfusion model resulted in a profound output of material during cross-clamp maneuvers. The intra-aortic filter successfully collected particles but also generated embolic debris on its own. Aortic cannulation was an additional source of embolic debris. Plaques were frequently found in the cadaveric aorta, and there was a high risk of plaque interference during surgical manipulation. As expected, plaque density was age-dependent.

Place, publisher, year, edition, pages
Umeå: Kirurgisk och perioperativ vetenskap, 2005. 42 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 0346-6612
Surgery, aortic atherosclerosis, aortic cannulation, aortic cross-clamp, cardiac surgery, cerebral protection, cerebrovascular accidents, epiaortic ultrasound, intra-aortic filter, Kirurgi
National Category
Research subject
Thoracic and Cardivascular Suregery
urn:nbn:se:umu:diva-628 (URN)91-7305-954-4 (ISBN)
Public defence
2005-12-02, Sal B, Tandläkarhögskolan, 9 tr, Norrlands universitetssjukhus, 901 85 Umeå, 13:00 (English)
Available from: 2005-11-16 Created: 2005-11-16 Last updated: 2009-11-09Bibliographically approved

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