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Ann Thorac Surg 2001;72:1938-1939
© 2001 The Society of Thoracic Surgeons

Invited commentary

^a Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 South Euclid Ave, Box 8086, St. Louis, MO 63110, USA
^b Department of Anesthesiology, Washington University School of Medicine, 660 South Euclid Ave, Box 8086, St. Louis, MO 63110, USA

e-mail: vdavila{at}im.wustl.edu

Stroke is the third leading cause of death in the United States and is also a significant cause of morbidity and mortality for patients undergoing cardiac surgery [1]. For these patients, potential causes of postoperative stroke are many, and include hemodynamic alterations (ie, hypoperfusion), cerebral embolization (ie, atherosclerotic plaque, platelets, air, fat), and in-situ thrombosis or vasospasm due to alterations in procoagulant and inflammatory mediators activated during surgery. The majority (more than 75%) of perioperative strokes are delayed (ie, they occur after an initial, uneventful neurological recovery from surgery) [2]. Strategies to prevent perioperative stroke consist of identification of high-risk patients (such as those with previous neurology events, the elderly, and women), detection of atherosclerosis of the ascending aorta in conjunction with alterations in surgical techniques to avoid atheroembolism, development of neuroprotective drugs that can be used in the perioperative period, and early identification of postoperative stroke followed by aggressive intervention strategies [3, 4].

In their article Dr Moazani and colleagues describe their experience with the use of intraarterial thrombolytic therapy in 13 patients that suffered a delayed perioperative stroke 1 to 12 days after cardiac surgery. Neurologic recovery occurred in 5 patients (38%); three patients (23%) died, one patient experienced a small cerebellar bleed; 10 patients were discharged home or a rehabilitation facility.

The small number of patients and the retrospective nature of this study limits any definitive conclusions. These are encouraging results, however the report raises a number of issues worth of discussion regarding the use of thrombolytic therapy for stroke after cardiac surgery. Some of these involve patient selection for thrombolytic therapy (ie, prospectively defined criteria), choice of thrombolytic agent (ie, urokinase vs t-PA), or route of administration (intravenous vs intraarterial), and post-procedure management (ie, use of heparin or antiplatelet agents).

For thrombolytic agents to be effective in acute stroke, in-situ thrombosis, or thrombotic embolism should be suspected. Studies supportive of atheroembolism as a major cause of post-operative stroke after cardiac surgery are overwhelming. The eight patients who lacked neurologic improvement could very well have had an atheroembolic stroke; this is supported in part by the poor thrombolysis in myocardial infarction (TIMI) blood flow documented after intraarterial thrombolysis.

Major surgery within two weeks of an acute ischemic stroke has been considered an exclusion criterion for the use of thrombolytic therapy due to the risk of intracranial bleeding (particularly in those with hypertension), and after cardiac surgery there is the additional risk of pericardial tamponade. The most important contribution of this report is that it challenges the conventional wisdom that thrombolytics are contraindicated in patients after cardiac surgery. Prospective, randomized clinical trials of thrombolytic agents in cardiac surgical patients that develop an acute stroke are needed. Until such studies are conducted, the safety and clinical utility of this strategy remains to be determined.

References

1. Roach G.W., Kanchuger M., Mora-Mangano C., et al. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med 1996;335:1857-1863.[Medline]
2. Hogue C.W., Murphy S.F., Schechtman K.B., Dávila-Román V.G. Risk factors for early or delayed stroke after cardiac surgery. Circulation 1999;100:642-647.[Abstract/Free Full Text]
3. Dávila-Román V.G., Murphy S.F., Nickerson N.J., Kouchoukos N.T., Schechtman K.B., Barzilai Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. J Am Coll Cardiol 1999;33:1308-1316.[Medline]
4. Hogue C.W., Sundt T.M., Goldberg M., Barner H., Dávila-Román V.G. Neurological complications of cardiac surgery: the need for new paradigms in prevention and treatment. Semin Thorac Cardiovasc Surg 1999;11:105-115.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Davila-Roman, V. G. Articles by Hogue, C. W. Search for Related Content PubMed Articles by Davila-Roman, V. G. Articles by Hogue, C. W., Jr Related Collections Cardiac - other Related Article