Perioperative strokes following combined coronary artery bypass grafting and carotid endarterectomy: A nationwide perspective.

BACKGROUND: To assess the risk of perioperative stroke on in-hospital morbidity and mortality following combined coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA). MATERIALS AND METHODS: Data from the National Inpatient Sample (NIS) database for all patients who underwent CABG with CEA were identified using ICD-9 codes. Combined procedures were identified as CEA and CABG procedures that happened on the same day. Various preoperative and perioperative risk factors and their association with in-hospital mortality and morbidity were studied. RESULTS: A total of 8457 patients underwent combined CABG and CEA from 1999 to 2011. The average age of the patient population was 69.98 years. A total of 6.17% (n = 521) of the patients developed perioperative strokes following combined CABG and CEA. An in-hospital mortality of 4.96% and morbidity of 66.35% was observed in the patient cohort. Patients with perioperative strokes showed a mortality of 19% and a morbidity of 89.34%. Other notable risk factors for in-hospital mortality and morbidity were heart failure, paralysis, renal failure, coagulopathy, weight loss and fluid and electrolyte disturbances, and postoperative myocardial infarction. CONCLUSION: A strong association was found to exist between perioperative stroke and in-hospital mortality and morbidity after combined CABG and CEA. CEA procedures are thought to mitigate the high stroke rate of 3-5% post-CABG, but our study found that combined procedures exhibit a similar stroke risk undercutting their effectiveness. Further investigative studies on combined CABG+CEA are needed to assess risk-stratification for better patient selection and examine other preventative strategies to minimize the risk of ischemic strokes.

Carotid artery stenosis as an independent risk factor for perioperative strokes following mitral valve surgical intervention.

OBJECTIVE: To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke following either mitral valve repair or replacement. METHODS: Using data from the National Inpatient Sample (NIS) database for analysis, all patients who underwent either mitral valve repair or replacement were identified using ICD-9 codes. RESULTS: A total of 79,583 patients who underwent either mitral valve replacement or repair were studied. 3.39% of the total cohort developed perioperative stroke. With a mean age of 62.78±0.23, there was a statistically significant amount of stroke cases in age ranges 65-74 and 75-84 (p<0.05). Risk stratification was done using Van Walraven (VWR) scoring and the cohort had a mean of 2.73±0.06. The following independent predictors were found to be significant: age, female gender, moderate and high VWR risk, both symptomatic and asymptomatic CS, atrial fibrillation, previous h/o smoking, and other cardiac valve procedures performed, and congestive heart failure (CHF). CONCLUSION: CS is a significant risk factor for perioperative strokes following mitral valve surgery. Further prospective clinical studies are needed that look into risk stratification of patients for better patient selection and the question of whether carotid revascularization procedures will be beneficial in reducing stroke rates.

Delirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis.

OBJECTIVE: To investigate the risk factors for postoperative delirium and the impact of delirium on mortality and morbidity following transcatheter aortic valve implantation (TAVI). DESIGN: Patients who underwent TAVI were identified using the International Classification of Diseases, 9th revision clinical modification codes from the National Inpatient Sample database. Statistical analysis of preoperative and perioperative risk factors was done to identify the independent risk factors for delirium after TAVI. SETTING: Multi-institutional. PARTICIPANTS: Patients who underwent TAVI from 2012 to 2013. INTERVENTIONS: TAVI. MEASUREMENTS AND MAIN RESULTS: Over the period of 2 years (2012-2013), 7,566 patients underwent TAVI. The incidence of delirium post-TAVI was 4.57% (345). Age >85 (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.05; p = 0.003), electrolyte abnormalities (OR 1.83; 95% CI 1.17-2.87; p = 0.008), prior neurologic illness (OR 1.67; 95% CI 1.10-3.15; p = 0.01), and weight loss in the hospital (OR 1.77; 95% CI 1.05-2.99; p = 0.03) were independent risk factors for postoperative delirium (POD). Unilateral or bilateral carotid stenosis did not predispose to the development of delirium. POD was an independent risk factor for procedural morbidity (OR 3.29; 95% CI 2.05-5.28; p < 0.001). POD did not increase the risk of in-house mortality after TAVI. CONCLUSION: Age of >85, electrolyte disturbance, pre-existing neurologic disease and weight loss were found to be independent risk factors for delirium. POD was associated significantly with morbidity. Owing to a significant increase in the morbidity, a thorough screening protocol and effective strategies to predict, prevent, and treat postoperative delirium would reduce the cost associated with TAVI.

Perioperative Strokes Following Surgical Correction of Mitral Valves: A Systematic Review and Meta-Analysis.

OBJECTIVE: The primary aim of this meta-analysis was to quantify the impact of perioperative strokes on stroke-related mortality after open mitral valve (MV) procedures were performed. METHODS: An electronic search of the PubMed, Embase, and the Web of Science databases was performed to retrieve articles published up to December 2015, relevant to patients undergoing MV procedures. Data were extracted from the final list of 25 studies to calculate a summary OR for 30-day stroke-related mortality. RESULTS: The stroke rate in the total sample population was 1.62% (73/4,498). The 30-day all-cause mortality rate was 3.51% (158/4,498). The percentage of total deaths caused by stroke was 6.87%. The summary OR of stroke-related mortality following MV procedures was estimated to be 7.22 (95% CI 4.13-12.63, p < 0.0001). A subgroup analysis was done for studies involving concomitant MV surgery and coronary artery bypass grafting. The summary estimate of the subgroup showed an OR of 8.508 (95% CI 1.552-46.622, p = 0.0136). CONCLUSION: Perioperative strokes following open MV procedures may be associated with more than 7 times greater odds of 30-day stroke-related mortality. They appear to be more commonly occurring than what is reported by current literature, making further studies investigating possible mechanisms and preventive measures a priority.

Perioperative strokes after coronary artery bypass grafting with staged carotid endarterectomy: A nationwide perspective.

STUDY OBJECTIVE: To examine the risk of perioperative stroke on in-hospital morbidity and mortality in staged coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) procedures. DESIGN: The National Inpatient Sample (NIS) database was used to extract data on all patients who underwent staged CABG CEA procedures. They were identified using the ICD-9 (International Classification of Diseases, Ninth Revision-Clinical Modification) diagnosis and procedure codes. SETTING: Multi-institutional. PATIENTS: Patients who underwent staged CABG and CEA from 1999 to 2011. INTERVENTIONS: Staged CABG and CEA procedures. MEASUREMENTS: Various pre-operative, and perioperative risk factors and their association with in-hospital mortality and morbidity were studied. MAIN RESULTS: The study cohort was grouped into 2761 patients who underwent staged CEA and CABG. The average age of the patient population was 69years. An in-hospital mortality of 4.96% (137) was observed. Staged procedures showed a morbidity rate of 69.21%. Patients with perioperative strokes had a mortality rate of 16.73% following staged procedures. Other notable risk factors for mortality and morbidity were post-operative myocardial infarction (MI) and congestive heart failure (CHF). CONCLUSION: Analysis of 2761 patients over a period of 12years (1999-2011) indicate perioperative stroke to be a strong post-operative predicator of in-hospital mortality and morbidity for staged procedures. Other significant factors such as advancing age, female gender and comorbidities like CHF, left ventricular dysfunction (LVD) and post-operative MI should also be considered when determining patient risk. Further investigative studies on staged CABG and CEA procedures are needed for better patient selection and for implementing preventative strategies such as neuroprotective medication and neuromonitoring to minimize the risk of ischemic strokes.

Carotid artery disease and periprocedural stroke risk after transcatheter aortic valve implantation.

OBJECTIVE/BACKGROUND: To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke, following transcatheter aortic valve implantation (TAVI). MATERIALS AND METHODS: Using data from the National Inpatient Sample database for analysis, patients who underwent TAVI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Various preoperative and perioperative risk factors and their association with perioperative strokes were studied. RESULTS: Data on 7566 patients who underwent a TAVI procedure from 2012 to 2013 were extracted. The average age of the patient population was 81.2 ± 0.32 years. The overall perioperative stroke rate in our patient cohort was 2.79%. Majority (94.6%) of the strokes were ischemic. Multivariate analysis showed the following independent risk factors for perioperative strokes after TAVI: female gender odds ratio (OR) = 2.25 (95% confidence interval [CI], 1.42-3.57), higher van Walraven score OR = 6.6 (95% CI = 3.71-11.73), bilateral CS OR = 4.46 (95% CI = 2.03-9.82), and TAVI with a cardiac procedure done under cardiopulmonary bypass OR = 2.84 (95% CI = 1.57-5.14). CONCLUSION: Bilateral carotid disease is a significant risk factor for perioperative strokes following TAVI. Preoperative screening with carotid Doppler to identify high-risk patients appears to be warranted. In addition, patients of female gender were found to have an increased risk for carotid disease.

Carotid artery disease and perioperative stroke risk after surgical aortic valve replacement: A nationwide inpatient sample analysis.

To study the role of carotid stenosis (CS) and cerebrovascular disease as independent risk factors for perioperative stroke following surgical aortic valve replacement (SAVR). The National Inpatient Sample (NIS) database was used for our study. All patients who underwent SAVR from 1999 to 2011 were identified using ICD-9 codes. Univariate and multivariate analysis of baseline characteristics, Elixhauser comorbidities and other covariates were examined to identify independent predictors of perioperative strokes following SAVR. Data on 50,979 patients who underwent SAVR from 1999 to 2011 was obtained. The mean age of the study cohort was 60.5. The study patients were predominantly Caucasian (79.3%) and males (60.01%). The incidence of perioperative stroke was 2.48%. CS (OR 1.8, 95%CI 1.1-2.8, p=0.009) and cerebral arterial occlusion (OR 3.4, 95% CI 1.3-8.9) significantly increased perioperative stroke risk following SAVR. Infective endocarditis (OR 4.6, 95%CI 3.8-5.6, p=0.00) and neurological disorders (OR 4.8, 95% CI 4-5.8, p=0.00) appeared to be the strongest risk factors for strokes. Other risk factors found to be significant predictors of perioperative strokes (p<0.05) were - age, higher VWR scores, CS, cerebral arterial occlusion, infective endocarditis, DM, HTN, renal failure, neurological disorders, coagulopathy and hypothyroidsm. In conclusion, perioperative stroke risk has remained more or less constant despite advancements in surgical techniques with risk having gone up in patients <65years of age. CS and cerebral arterial occlusion significantly increase stroke risk following SAVR. Improved patient selection with pre-operative risk stratification and institution of preventive strategies are necessary to improve operative outcomes following SAVR.

Perioperative Strokes and Early Outcomes in Mitral Valve Surgery: A Nationwide Analysis.

OBJECTIVE: To demonstrate the role of perioperative stroke as an independent risk factor for in-hospital morbidity and mortality after mitral valve surgery and review the trends in the early outcomes of mitral valve surgery over the past decade. DESIGN: Using data from the National Inpatient Sample database for analysis, all patients who underwent isolated mitral valve procedures were identified using International Classification of Diseases-Ninth Revision codes. Univariate and multivariate analyses of risk factors of in-hospital mortality and morbidity were performed. SETTING: Multi-institutional. PARTICIPANTS: The study comprised patients who underwent mitral valve procedures from 1999 to 2011. INTERVENTIONS: Mitral valve repair or replacement. MEASUREMENTS AND MAIN RESULTS: Data on 21,821 patients showed an in-hospital mortality of 5.5% and morbidity of 63.30% (p<0.05). Perioperative strokes were experienced by 3.89% of the cohort after isolated mitral valve surgery (p<0.05). Independent predictors of adverse outcomes were age, female sex, emergency surgery, arrhythmias, hypertension, renal failure, coagulopathy, neurologic disorders, weight loss, anemia, postoperative cardiac arrest, and myocardial infarction. Perioperative strokes were found to be the strongest risk factor for postoperative mortality (odds ratio 2.34, 95% confidence interval 1.83-2.98) and morbidity (odds ratio 4.53, 95% confidence interval 3.34-6.15). CONCLUSION: Age, female sex, emergency surgery, arrhythmias, hypertension, renal failure, coagulopathy, neurologic disorders, weight loss, fluid and electrolyte imbalance, anemia, postoperative cardiac arrest, and myocardial infarction were found to be significant predictors of morbidity and mortality after mitral valve surgery, with perioperative strokes posing the strongest risk. The trends in the last 10 years indicated a decrease in mortality and an increase in morbidity. Preoperative risk stratification and intraoperative identification for impending strokes appear warranted.

Transcranial Doppler Monitoring in Carotid Endarterectomy: A Systematic Review and Meta-analysis.

OBJECTIVES: To evaluate the efficacy of intraoperative transcranial Doppler monitoring in predicting perioperative strokes after carotid endarterectomy (CEA). METHODS: An electronic search of PubMed, Embase, and Web of Science databases was conducted for studies on transcranial Doppler monitoring in CEA published from January 1970 through September 2015. All titles and abstracts were independently screened on the basis of predetermined inclusion criteria, which included randomized clinical trials and prospective or retrospective cohort reviews, patients who underwent CEA with intraoperative transcranial Doppler monitoring (either middle cerebral artery velocity [MCAV] or cerebral microembolic signals [MES]) and postoperative neurologic assessments up to 30 days after the surgery, and studies including an abstract, published in English on adult humans 18 years and older with a sample size of 50 or greater. RESULTS: A total of 25articles with a sample population of 4705 patients were analyzed. Among the study patients, 189 developed perioperative strokes. Transcranial Doppler monitoring (either MCAV or MES) showed specificity of 72.7% (95% confidence interval [CI], 61.2%-81.8%) and sensitivity of 56.1% (95% CI, 46.8%-65.0%) for predicting perioperative strokes. Intraoperative MCAV changes during CEA showed strong specificity of 84.1% (95% CI, 74.4%-90.6) and sensitivity of 49.7% (95% CI, 40.6%-58.8) for predicting perioperative strokes. CONCLUSIONS: Patients with perioperative strokes are 4 times more likely to have had transcranial Doppler changes (either MCAV or MES) during CEA compared to patients without strokes. Simultaneous MCAV and MES monitoring by transcranial Doppler sonography and combined intraoperative monitoring of transcranial Doppler sonography with somatosensory evoked potentials and electroencephalography during CEA to predict perioperative stroke could not be evaluated because of a lack of clinical studies combining these measures.

Multiple cerebrospinal cavernous angiomas.

Cavernous angiomas represent 5-12% of all spinal vascular lesions and 1% of all intramedullary lesions in pediatric patients. Intramedullary spinal cavernomas are relatively rare with only 24 cases reported till date to the best of our knowledge. A 15 -year-old boy presented to the clinic with acute onset motor weakness in all four limbs. He was diagnosed with multiple cerebral cavernomas and an acutely bleeding spinal cavernoma. Complete surgical excision of the spinal cavernoma was done. Postoperatively the patient's weakness gradually improved to a power of 4/5 in all his limbs over a period of 10 days. Only 24 cases of pediatric spinal cavernomas have been reported in the current literature. Current consensus on management of these rare lesions is based on previously published case reports/series and surgery appears to be the only definitive treatment. Further studies regarding any non-surgical expectant management appears warranted.

Diagnostic Value of Somatosensory-Evoked Potential Monitoring During Cerebral Aneurysm Clipping: A Systematic Review.

BACKGROUND: Perioperative stroke is a known complication in patients undergoing surgical clipping of cerebral aneurysms. OBJECTIVE: To evaluate whether intraoperative changes in somatosensory-evoked potential (SSEP) monitoring during cerebral aneurysm clipping is diagnostic of perioperative stroke. METHODS: An electronic search of PubMed, Embase, and Web of Science databases was done for studies published through May 2015 on SSEP monitoring in cerebral aneurysm clipping for predicting postoperative outcomes. All titles and abstracts were screened independently on the basis of predetermined criteria. Inclusion criteria included randomized clinical trials and prospective or retrospective cohort reviews; patients with intracranial aneurysms who underwent surgical clipping with intra-operative SSEP monitoring and postoperative neurologic assessment; studies published in English on adult humans ≥18 years with sample size of ≥50; and studies inclusive of an abstract with adequate details on outcomes. RESULTS: A total of 14 articles with a sample population of 2015 patients were analyzed. SSEP monitoring demonstrated a strong mean specificity of 84.5% (95% confidence interval [95% CI] -76.3 to 90.3) but weaker sensitivity of 56.8% (95% CI 44.1-68.6) for predicting stroke. A diagnostic odds ratio of 7.772 (95% CI 5.133-11.767) suggested that the odds of observing an SSEP change among those with a postoperative neurologic deficit were 7 times greater than those without a neurologic deficit. CONCLUSION: Intraoperative SSEP monitoring is highly specific for predicting neurologic outcome after cerebral aneurysm clipping. Patients with postoperative neurologic deficits are 7 times more likely to have had intraoperative SSEP changes. SSEP monitoring may help design prevention strategies to reduce stroke rates after cerebral aneurysm clipping.

Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: A simple, safe, cost-effective procedure.

OBJECTIVE: Trigeminal neuralgia (TN) is a condition that has been studied over decades and whose pathogenesis has still not been well defined. Various open and minimally invasive procedures are in vogue for the treatment of intractable TN. All these procedures have their complications and recurrence rates. Percutaneous retrogasserian glycerol rhizotomy (PRGR) is one of the minimally invasive procedures that have been popular for quite a long time. MATERIAL AND METHODS: This paper is a prospective study analyzing the results of 93 patients with refractory TN who were treated with PRGR. RESULTS: There was an immediate pain relief in 96.8% of patients and long-term pain relief in 89.4% of patients, with a mean follow-up duration of 18.8 months. Recurrence of pain was seen in 10.4% of patients. CONCLUSIONS: The PRGR is a simple, safe, cost-effective procedure without any need for expensive equipment and with a good outcome that is compared to the other relatively more expensive open and minimally invasive procedures.