Cardiovascular procedures: neurologic complications …

Elizabeth Anderson MD

Stroke & Vascular Disorders

Updated 12.03.2025
Released 11.15.1996
Expires For CME 12.03.2028

Cardiovascular procedures: neurologic complications

Author: Elizabeth Anderson MD

See Contributor Disclosures

Editor: Steven R Levine MD

Cite this article

Cardiovascular procedures: neurologic complications

In This Article

Quick Link

Introduction

Overview

The number of cardiac procedures has increased rapidly. Neurologists are often called for consultation before or after cardiac procedures. Ischemic stroke, diffuse encephalopathy, and altered cognitive status are the most important neurologic complications of cardiac procedures.

Key points

	• Most neurologic complications of cardiovascular procedures are due to embolism, hypoperfusion, seizures, infections, metabolic disturbances, or medication side effects.
	• Ischemic stroke rate in the postoperative period is as high or even higher than intraoperatively.
	• Brain MRI is more sensitive than head CT for detecting ischemic stroke.
	• Peripheral nerve injury is mostly due to compression from a local hematoma and is usually transient.

The number of cardiac procedures and, along with them, perioperative neurologic complications, has been steadily increasing. Neurologists are often consulted for both their prevention and management.

This review covers the neurologic complications of cardiovascular procedures, including coronary artery bypass graft surgery, cardiac valve procedures, cardiac catheterization for percutaneous coronary interventions, radiofrequency ablative procedures, closure of the patent foramen ovale, and cardiac transplantation.

Clinical manifestations

Presentation and course

Neurologic complications of heart transplantation. The main neurologic complications of cardiac transplantation are:

• Ischemic stroke
• Seizure
• Opportunistic infections
• Lymphoproliferative disorders

Cerebrovascular events occurring soon after transplantation resemble those seen after valvular or coronary revascularization surgery. The risk factors include hypotension, cardioembolism, seizures, metabolic disturbances, and medication side effects. In a series of 322 patients, preexisting valvular heart disease was associated with ischemic stroke, whereas diabetes and renal failure were associated with seizures (132).

During cardiac transplantation, circulation is supported by a left ventricular assist device or an artificial heart. These devices may generate emboli that can cause a stroke (172). In a study of 382 patients of whom 140 received a left ventricular assist device, the predictors of ischemic stroke were 81 mg or less of aspirin and atrial fibrillation. For hemorrhagic stroke, the predictors were a mean arterial pressure of greater than 90 mm Hg, 81 mg or less of aspirin, and an INR of greater than 3.0 (171).

Another study combining data from the ENDURANCE destination therapy (DT) and ENDURANCE Supplemental (DT2) trials found that out of 604 patients who received a left ventricular assist device over 2 years, 29.5% had at least one stroke or transient ischemic attack; 7.3% had a hemorrhagic stroke, and 19.2% an ischemic stroke. The perioperative stroke rate was 5%. More than 2 weeks after a left ventricular assist device implant, supra- and sub-therapeutic INR values were associated with all stroke subtypes. Mean arterial pressure was higher among those with ischemic stroke but not with hemorrhagic stroke (33).

Any time a transplant patient experiences a delayed awakening following the procedure, one should consider ischemic stroke as a potential etiology, especially if there are prolonged cross-clamping times, hypotension during the procedure, or increased need for transfusion. In comparison to other cardiac surgeries, those who undergo heart transplant have a higher ischemic stroke rate, with incidence being 5% to 11%, and 20% of those patients experiencing their event within the first 2 weeks. Factors that increase the risk of stroke include older age, history of stroke, longer duration of mechanical ventilation, increased need for blood transfusion, and longer time on a transplant waitlist (41).

After cardiac transplantation, the aortic arch and the cervical vessels may also serve as embolic sources. Weeks to months later, the neurologic complications are caused by opportunistic infections, immunosuppression side effects, and lymphoproliferative disorders.

Neurologic complications of coronary artery bypass graft surgery.

	• Central nervous system complications
		- Ischemic stroke and transient ischemic attack - Depressed level of alertness - Altered awareness - Seizure - Asymptomatic embolism
	• Peripheral nervous system complications
		- Brachial plexus injury - Phrenic nerve injury

Ischemic stroke. The perioperative stroke rate at a single center, including 45,432 patients who underwent coronary artery bypass graft, revealed that perioperative stroke rate has declined over the last 30 years. Ischemic stroke occurs postoperatively more often than intraoperatively. Intraoperative stroke rates were lowest with off-pump coronary artery bypass graft (0.14%) and on-pump beating-heart coronary artery bypass graft (0%) and highest with on-pump coronary artery bypass graft with hypothermic circulatory arrest (5.3%) (169). Overall, rates of postoperative stroke have been estimated to be between 0.8% and 5.2% (62).

Brain MRI detects more ischemic lesions than head CT. The most common neuroimaging pattern is of multiple embolic punctate infarcts in the cerebral and cerebellar cortex, including in patients with encephalopathy without focal neurologic findings (185). Interestingly, a small case series that examined patients who completed MRI with DWI after coronary artery bypass graft surgery regardless of neurologic deficit found that between 18% and 26% had some form of ischemia if they were classified as “low-risk” patients, and 45% to 62% had ischemia present if they were considered “high-risk” patients. Lesions noted were often small and multifocal and often were not associated with focal deficits (62).

Microembolic perioperative stroke occurs especially in the border zones, but also in subcortical regions resembling lacunar lesions (78; 104; 99).

Involvement of the border zone between the middle and posterior cerebral arteries causes visual field defects and transcortical sensory aphasia. Lesions located between the middle and anterior cerebral arteries result in proximal-dominant extremities weakness (man in the barrel syndrome) and transcortical motor aphasia. Infarctions between superficial and deep branches of the middle cerebral arteries may present as mutism and rigidity. Watershed infarct of the cerebellum can present as dizziness, vertigo, and ataxia (77; 71).

Border zone infarction in the spinal cord often occurs at the midthoracic level between the spinal arteries and the artery of Adamkiewicz. This may result in acute urinary retention, flaccid paraparesis, and sensory loss with level (71).

Of interest is the timing of surgery in patients with both carotid artery stenosis and coronary artery disease. In simultaneous surgery, the rate of strokes was higher, but mortality was similar compared to surgery for carotid artery stenosis, followed by coronary artery bypass graft. However, there were no significant differences in 1-year mortality, and rates of myocardial infarction and transient ischemic attacks (31).

Depressed level of alertness. Decreased consciousness suggests diffuse encephalopathy. Somnolence occurs when the patient is fully attentive to surroundings while aroused, but alertness decreases rapidly to a sleep-like state. Brief arousal associated with decreased awareness or interest in surroundings is called obtundation. Decreased alertness associated with grimacing or withdrawal from painful stimuli characterizes stupor.

The persistence of the sleep-wake cycle characterizes the vegetative state. Chewing, teeth grinding, or scratching movements can occur. The persistent vegetative state lasts more than 4 weeks, and it becomes permanent after 3 months. The comatose patient is not arousable, but the brainstem reflexes are preserved. Brain death is characterized by the absence of alertness to external stimuli and all brainstem reflexes.

Nonconvulsive status epilepticus must be excluded in patients with altered alertness. Electrolyte imbalance, acute liver or renal dysfunctions, hypoxia, or hypotension should also be considered. Stroke does not usually affect alertness unless it involves the reticular activating system. Large hemorrhagic or ischemic strokes can decrease alertness by increasing intracranial pressure.

Altered awareness. Confusion is characterized by normal alertness but decreased awareness, orientation, or memory. Restlessness or agitation are typical for delirium. Together, they cause cognitive impairment.

Approximately half of the coronary artery bypass graft procedures result in early cognitive impairment. Improvement usually occurs within 6 months, but in one third of cases, the deficits persist up to 12 months (122). Two thirds of patients have complete resolution of neurologic deficits during long-term follow-up (96). However, delayed cognitive impairment may occur after 5 years (123). Prolonged cognitive complaints have been reported in up to 42% of patients 5 years after cardiac surgery.

Prior stroke is a risk factor for delirium after coronary artery bypass graft (144). MRI imaging in patients with cognitive impairment can reveal multiple small brain lesions (92).

Cognitive impairment may be related to cerebral microembolism, hypoperfusion, edema, inflammation, or metabolic derangements.

The levels of tau protein and neurofilament light protein, specific markers for neuronal injury, may help predict the risk of delirium (146; 29). Tau protein level improves with the clinical status of the patient (08). The serum level of neuroserpin, a highly neuron-specific and extremely sensitive protein, is another promising marker for neuroregeneration after off-pump coronary artery bypass graft (166).

Seizure. The incidence of seizures after coronary artery bypass graft is about 0.5% (62). Seizure etiology is multifactorial; stroke, atherosclerotic or air embolism, inflammatory mediators released during surgery, and epileptogenic medications (antifibrinolytics and cephalosporins).

Asymptomatic embolism. Asymptomatic embolism occurs frequently during coronary artery bypass graft and endovascular procedures (63).

Brachial plexus injury and mononeuropathies. Brachial plexus injury and mononeuropathy may occur after compression or stretching during surgery, often occurring due to chest wall retraction utilized with harvesting of the left internal mammary artery (62). The lower trunk of the brachial plexus is more vulnerable than the upper trunk. Injury to the phrenic nerves with unilateral or bilateral diaphragmatic paralysis may result from direct manipulation of the nerve, ischemia, or cold cardioplegia (45; 84).

Neurologic complications of left heart catheterization.

	• Central nervous system complications
		- Ischemic stroke and transient ischemic attack - Altered awareness (delirium) - Transient unresponsiveness - Transient global amnesia - Seizure - Contrast reaction - Migraine
	• Peripheral nervous system complications
		- Lumbosacral plexopathy - Femoral nerve injury

CNS complications after left heart catheterization are rare. Ischemic stroke is the most common (55%), followed by transient ischemic attack (26%), contrast reaction (15%), and neurologic symptoms of unknown etiology (4%). The most common symptom is visual disturbances, including diplopia and visual loss. Hemiparesis or aphasia, facial weakness with or without aphasia or dysarthria, and paresis in the face and arm were also described. Transient unresponsiveness, transient global amnesia, seizures, delirium, and migraine may also follow left heart catheterization.

Ischemic stroke caused by large vessel occlusion has a worse outcome compared with small vessel occlusion (149). Cerebral embolism usually originates from the atheromatous aortic arch or the clots forming at the catheter tip.

Femoral nerve injury. Femoral artery puncture can rarely cause pseudoaneurysm, hematoma, arteriovenous fistula, and femoral artery occlusion. Femoral nerve compression incidence is 0.2%. The severity ranges from mild transient sensory neuropathy to disabling paralysis. The average delay from catheterization to recognition of symptoms is 37 hours; severe pain precedes the diagnosis of neuropathy in about half of patients. Although initially disabling, neuropathy usually resolves completely; surgery is only recommended if there are coexisting complications (87).

Lumbosacral plexopathy. Retroperitoneal hematomas can cause lumbosacral plexopathy, with the femoral and obturator nerves being primarily involved. The size of the hematoma does not correlate with the severity of the sensory or motor deficits.

Neurologic complications of other cardiac procedures.

Aortic aneurysm repair. Aneurysms of the aortic arch are often treated by surgery. In a series of 284 patients undergoing aortic aneurysm repair, death or stroke occurred in 6.6% (165). Transient neurologic dysfunction occurred in 9.2%. Two patients developed brachial plexus injury from axillary artery cannulation. In another report of 103 patients undergoing total aortic arch replacement, about 9% developed stroke, and approximately 7% had transient neurologic deficits. Four percent also had paraparesis or paraplegia (176).

Hypothermic circulatory arrest and selective cerebral perfusion are used to minimize these complications. In a series of 39 consecutive patients undergoing aortic arch replacement surgery with selective brain perfusion by axillary artery cannulation, only one patient had a permanent postoperative neurologic deficit, and two patients had temporary deficits (156).

Endovascular repair of the aortic arch with a branched endograft is an alternative to open surgical repair. Of 147 (99.3%) procedures that were successful, disabling stroke occurred in six (4.1%) patients, and nondisabling stroke in eight (5.4%) (168).

The risk factors for spinal cord ischemic during aortic aneurysm repair are age greater than 65 years; history of neurologic disease, hyperlipidemia, diabetes, coronary artery disease, heart failure, and renal insufficiency; less than 6 months since last aortic repair; chronic anticoagulant use; preoperational hemoglobin less than 9; coagulopathy; hypotension (mean arterial pressure < 70 mm Hg); longer operations (> 100 min); aneurysms longer than 5 cm; and anatomic location of aneurysm caudal to T-11 (12).

Aortic dissection repair. Aortic dissection classification aids in standardizing the management. The American cardiothoracic surgeon DeBakey classified aortic dissection into type I when both ascending and descending segments are involved, type II involves the ascending aorta, and type III involves the descending aorta after the origin of the subclavian artery. Stanford type A dissection includes the segment before the left subclavian artery, and Stanford type B dissection includes the aorta beyond the left subclavian artery. Aortic dissection surgery is lifesaving but can be very complex and associated with severe neurologic symptoms.

Aortic dissection DeBakey type I, which involves both the ascending and descending aorta, remains a severe condition whose repair may result in stroke in 8% and cerebral edema in 1% of patients (47).

In a meta-analysis of 3000 patients who underwent the frozen elephant trunk technique for type A aortic dissection repair, the pooled rates of adverse events were 4.7% for spinal cord stroke, 7.6% for cerebral stroke, and 8.8% for perioperative mortality. The left subclavian artery may occasionally be sacrificed, causing exertion-induced weakness. This may be treated with carotid-subclavian bypass (58).

Retrograde type A acute aortic dissection may benefit from endovascular repair. A retrospective study of 19 patients from one medical center who underwent endovascular repair found no in-hospital or neurologic complications (93).

Type A aortic dissection surgical repair may also cause hemorrhagic stroke, especially if preoperative antithrombotic medication is used. Hemorrhagic stroke was associated with higher complexity of surgery and longer cardiopulmonary bypass and aortic clamping time compared to ischemic stroke. Inpatient mortality, degree of disability, and 5-year mortality were higher in the hemorrhage group (100).

Type B aortic dissection, beyond the left subclavian artery, can lead to life-threatening complications, from rupture to stroke and paraplegia. There is insufficient information regarding the effectiveness and safety of open surgical repair compared to the endovascular approach (80). During thoracic endovascular aortic repair (TEVAR) of type B aortic dissection, the origin of the left subclavian artery is covered in approximately half the cases. The main complications are arm claudication, stroke, and paraplegia (182).

A meta-analysis of left subclavian artery coverage revascularization did not reduce the risk of stroke or mortality (68). However, those who had revascularization before or during TEVAR were less likely to develop neurologic complications (118).

Spinal cord ischemia was significantly higher when the length of the graft exceeded 15 cm or extended beyond T8 (136).

Although unrepaired acute aortic dissection is usually fatal, some unoperated patients survive the acute phase. Out of 205 patients operated after a median duration of dissection of approximately 7 months, 3% had a stroke and 7% had a fatal outcome (187).

Placement of a lumbar drain preoperatively is indicated for the prevention of spinal cord ischemia during TEVAR (54). A study of prophylactic lumbar drain that included 309 procedures performed in 268 patients for 307 endovascular aortic repairs found a complication of 8.1% (4.2 major and 3.9 minor). The complications included paraplegia, intracranial hemorrhage, meningitis, arachnoiditis, CSF leak, bloody tap, and a retained catheter tip (134).

Other methods to prevent ischemia during surgery include the use of cerebral oximetry, intraoperative EEG, bispectral index to measure cerebral perfusion during the procedure, and the use of transcranial Doppler to monitor blood flow (188).

Cardiac valve surgery.

	• Ischemic stroke or transient ischemic attack
	• Seizure
	• Vasovagal syncope

Heart valve repair and replacement have been performed for several decades. The incidence of neurologic complications after heart valve surgery is less documented in the literature compared to the complications after coronary artery bypass graft. The incidence of ischemic events has been estimated to be about 2% to 5%, with rates of other neurologic events ranging from 8% to 20%. When DWI MRI was utilized post-procedure, up to 41% of patients had new infarctions, with 35% of patients being noted to have persistent neurocognitive deficits up to 6 weeks out (62).

Balloon valvuloplasty. Balloon valvuloplasty of the aortic and mitral valves is effective and safe. Of 674 patients enrolled in the National Heart, Lung, and Blood Institute (NHLBI) registry who underwent percutaneous aortic balloon valvuloplasty, 2% had strokes, 5% had seizures, 2% had vasovagal syncope, and 0.6% developed transient neurologic deficits in the peri-procedural period (124). A more recent study completed in 2017 reported a stroke rate of 1.8%, indicating stability over time (03).

Aortic valve replacement. Severe symptomatic aortic stenosis is treated by surgical aortic valve replacement (SAVR). In a single-center retrospective analysis of 132 patients who underwent aortic valve replacement, there were no recorded strokes (34).

Transcatheter aortic valve replacement (TAVR) is less invasive and used for symptomatic aortic stenosis with high surgical risk. In a study of 1660 patients with severe, symptomatic aortic stenosis of intermediate surgical risk, the rate of stroke was lower with TAVR than with SAVR. Moreover, those with strokes after TAVR recovered earlier. However, at 12 months, stroke rates and quality of life were similar in both study groups (48). Another study of 1204 pairs of patients treated for severe aortic stenosis found that SAVR was associated with more frequent early major strokes than TAVR (83).

In a meta-analysis and systematic review, in patients with low and intermediate risk, TAVR was associated with a similar rate of neurologic complications and mortality but a higher risk of arterial complications compared to surgical aortic valve replacement (177). Similarly, in another meta-analysis and systematic review of patients at low risk, transcatheter aortic valve replacement and surgical aortic valve replacement had similar neurologic complications (145). DWI lesions were seen on MRI after aortic valve replacement in 38% of patients, related to the preoperative T2 white matter lesion volume (164).

Several characteristics are associated with a higher risk of cerebrovascular events, including advanced age at the time of surgery, history of atrial fibrillation, and history of chronic kidney disease. In addition, bleeding can be associated with a higher risk of further cerebrovascular events, as this often leads to a cessation of antithrombotic agents and, thus, increased risk of thromboembolic events while those agents are being held post-surgery (07).

Mitral valve repair or replacement. Repair or replacement of a nonfunctional mitral valve is often indicated. In a database of 1250 patients, the incidence of stroke after mitral valve surgery was 4.2% to 5% (60; 173). Mitral valve repair offers excellent short- and long-term outcomes. In the elderly, valve repair was less often, but not statistically significantly associated with neurologic complications (46).

Balloon mitral valvuloplasty is an alternative to open surgery for mitral stenosis. In a study of 45 patients, only one patient had a postprocedural stroke (174). Of 201 consecutive patients undergoing this procedure, three developed “thromboembolism.” It is not clear whether these patients developed strokes (186).

Combined procedures. Combined procedures such as double-valve replacements or valve replacement with coronary artery bypass graft increase the risk of neurologic complications. In a review of 2008 patients undergoing valve surgery, the overall risk of stroke was 2.2%, whereas with combined procedures, it was 5.4%. The risk factors were calcified ascending aortic atherosclerosis, advanced age, diabetes, and an ejection fraction of less than 30%. Stroke increased hospital mortality from 4.6% to 24% (52).

In a study, the subcortical lesions seen on brain MRI after valve replacement surgery were associated with impaired memory, attention, and information processing speed. All these cognitive impairments resolved after 4 months (92).

In high-risk patients, endovascular valve replacement is preferred. However, this approach is associated with more frequent neurologic complications.

New, often multiple, ischemic lesions were observed on brain MRI of 27 (84%) patients (81). In another study of high-risk patients, although the 1-year mortality rate was similar in the endovascular and surgical groups, major stroke was more frequent in the endovascular group (5.1% vs. 2.4%) (159).

Patent foramen ovale closure. Recurrent neurologic events may result from paradoxical embolism through a patent foramen ovale. A clinical trial in patients with stroke attributable to patent foramen ovale presence that enrolled 980 patients between 18 and 60 years of age found that patent foramen ovale closure was not superior to medical treatment alone in intention-to-treat analysis but was superior in the prespecified per-protocol and as-treated analyses. The perioperative complications include groin and retroperitoneal hematoma, nerve injury, and atrial fibrillation. Serious adverse events occurred in 4.2% of the patients in the closure group (28).

A meta-analysis including five randomized trials totaling 1829 patent foramen ovale closure patients and 1611 medical therapy patients found that patent foramen ovale closure prevented cryptogenic ischemic stroke and neurovascular and mortality events but increased the risk of atrial fibrillation 4.6 times (183). A more recent study estimated that the risk of postoperative atrial fibrillation may be underestimated, with rates ranging from 20.9% to 37%. Factors that influence the rate of developing atrial fibrillation include age (older), male sex, and size or type of device used (155).

Radiofrequency ablation for atrial fibrillation. Atrial fibrillation is an important cause of stroke. Rhythm can be controlled by radiofrequency ablation (RFA) or long-term antiarrhythmic drugs (90). Although atrial fibrillation is more common in the elderly, radiofrequency ablation is less effective in this population. Those at medium to high risk should continue oral anticoagulant after the procedure (163). The transseptal puncture during ablation creates an interatrial shunt, which favors paradoxical embolism. Moreover, endothelial damage may activate coagulation. Additional studies have shown that radiofrequency ablation has a similar or lower risk of adverse cardiovascular outcomes compared with medical treatment alone, suggesting that perhaps the previously held view that medication should be a first-line therapy should be challenged (14). However, complications are still possible and should be considered.

Radiofrequency ablation was associated with 1.02% neurologic complications in a study of 93,801 procedures performed in the U.S. between 2000 and 2010 (42). Analysis of 3360 consecutive cases of radiofrequency ablation revealed 0.5% peri-interventional thromboembolic events within 1 month, of which 45% were strokes. Most events occurred within 48 hours. The risk factors for peri-procedural thromboembolism are peripheral vascular disease and previous stroke (94).

A rare, potentially fatal complication of radiofrequency ablation is the atrioesophageal fistula. A retrospective analysis of 28 cases of atrioesophageal fistula found that complications developed within 1 month of the procedure. They included fever, neurologic symptoms, and hematemesis. The neurologic symptoms are confusion, seizures, meningitis, stroke, and post-prandial transient ischemic attack. Blood tests, including cultures, were consistent with sepsis. Lumbar puncture may show pleocytosis, elevated protein, lactate, and bacteria. The fistula may be aggravated by the insertion of a nasogastric tube, endoscopy, or transesophageal echocardiography (162). CT of the chest is the preferred diagnostic test. Esophageal repair may be lifesaving (32).

Watchman left atrial appendage closure for atrial fibrillation. The Watchman left atrial closure device was not inferior to warfarin for the prevention of stroke due to nonvalvular atrial fibrillation (76). In a systematic review of thrombosis associated with 2118 devices (Watchman, Amplatzer cardiac plug, and Amulet), the incidence of thrombosis was 3.9%. The median time to diagnosis was 1.5 months (97). However, in a small pilot study of 21 patients who underwent brain MRI 48 hours before and 24 hours after the insertion of Watchman, Amplatzer, or Amulet devices, the rate of silent cerebral infarcts was not significantly increased (95). Recurrent neurologic symptoms may be caused by late device dislodgement, which requires device extraction (115).

Prognosis and complications

Postoperatively, the prediction of early neurologic complications may accelerate diagnosis as well as early intervention (05). Less than one third of perioperative strokes cause severe disability at the time of discharge (154; 109; 99).

Several biomarkers were studied to predict perioperative neurologic complications. Preoperative serum NMDA receptor antibody levels correlate with neurologic complications in a study of 557 high-risk patients who underwent coronary artery bypass graft or valve replacement (17). Elevated preoperative serum C-reactive protein level correlated to higher mortality after coronary artery bypass graft (82).

Preoperative S100-β level did not correlate with perioperative neurologic complications (17). However, the persistent postoperative elevation of S100-β, a calcium-regulating astroglial protein released by brain injury, correlated with cardiopulmonary bypass time and decreased Mini-Mental State Examination score (50). Another study of 35 patients who underwent abdominal aorta repair failed to confirm a correlation between plasma or CSF S100-β level and cardiopulmonary bypass (143).

Analysis of 92 neurologic-related proteins in the serum and CSF of 23 patients, before and after aorta surgery, aimed to assess the risk of neurologic injury. Spinal cord injury was associated with IL-6, GFAP, CSPG4, delirium with TR4 and EZH2, and hallucinations with NF1 (101).

However, cognitive dysfunction after cardiac surgery does not correlate with global cortical beta-amyloid deposition (91). Research by the NIH has found that postoperative levels of GFAP, NFL, tau, and UCHL1 (all biomarkers) increase regardless of whether the patient experiences postoperative neurocognitive change. This suggests that cardiac surgery results in some form of neuroaxonal damage (as evidenced by increases in NFL, tau, and UCHL1) and glial activation (as evidenced by an increase in GFAP) (184).

The response to surgery is only partially explained by patients’ characteristics or procedure variables. Knowledge of genetic variability may improve short- and long-term outcome prediction. Neurologic complications range from subtle cognitive deficits (up to 69%) to stroke and coma (up to 6%). For example, the APOE genotype modulates the inflammatory response, atherosclerosis, and autoregulation. Genetic variants in platelet membrane glycoproteins modulate thrombosis, and along with the inflammatory mediators, the propensity for perioperative stroke. The intensity of neuroendocrine and metabolic response to surgical trauma, like antidiuretic and stress hormones, the renin-angiotensin system, depends on the severity of trauma or sepsis. Insulin resistance is related to perioperative adverse events after cardiac surgery (135).

APOE4 genotype may be related to adverse cerebral events (170). Moreover, the APOE4 allele is associated with worse cognitive recovery 5 years after surgery (10). Genetic variants of the C-reactive protein and interleukin-6 genes are associated with stroke after cardiac surgery (65).

Biological basis

The main causes of neurologic complications of cardiac procedures are:

	• Embolism of blood clots, atherosclerotic debris, or originating in the devices used to maintain circulation.
	• Activation of coagulation on contact between blood and cardiopulmonary bypass circuit or left ventricular assist device.
	• Alteration of the cerebral excitability by medication
	• Compression of peripheral nervous fibers
	• Infection
	• Immunosuppression

Etiology and pathogenesis

Ischemic stroke or transient ischemic attack after cardiac procedures. Cerebral dysfunction after cardiac surgery is attributed to embolism and intraoperative alterations in blood pressure (57). The mechanisms underlying postoperative neurologic dysfunction include microemboli and hypoperfusion during surgery and postoperative atrial fibrillation (111).

In a retrospective study of 16,184 patients, the risk factors for stroke after cardiac surgery were prior stroke, hypertension, diabetes, peripheral vascular disease, preoperative infection, and prolonged cardiopulmonary bypass (23). Additionally, older age (especially over 80 years), more severe cardiovascular disease, and cumulative vascular risk factors increase the risk for stroke after cardiac procedures (89).

The acute brain edema seen on the MRI FLAIR sequence shortly after surgery primarily affects the cortex. This correlates with the pathological finding of the cortex and deep gray matter arteriolar and capillary dilatations (70). The vascular dilatations noted after cardiopulmonary bypass are thought to be caused by emboli (114). Overall, the leading differential diagnosis for the cause of cerebral ischemia after cardiac procedures is of embolic origin, supported by the finding that ischemia is often found in multiple vascular territories (89).

Emboli are classified as macroemboli (if greater than or equal to 200 microns) and microemboli (16). Embolization can occur during aorta cannulation, decannulation, cross-clamping, or the use of an intraaortic balloon pump. Emboli may consist of cholesterol particles from the proximal aorta, air from the heart or open aorta, calcium particles from the aorta or mitral and aortic valves, and blood clots from the left atrium or ventricle (142). Other microemboli consist of gas bubbles from oxygenators, fat from cardiotomy cell clumps, and silicone particles from the bypass pump. The smallest emboli scatter widely and are more likely to cause generalized neuropsychological alterations than hypoxia (71). The number of fatty microemboli increases with the duration of the cardiopulmonary bypass (22). Large vessel occlusion can cause symptoms corresponding to its distribution and result in stroke or coma (18).

Coagulation pathway activation by the cardiopulmonary bypass circuit leads to platelets and coagulation factor consumption (02; 88). The release of tissue factor is the main trigger of coagulation during the cardiopulmonary bypass (44).

Impaired autoregulation may explain the increased risk of perioperative stroke in patients with a history of stroke and diabetes mellitus (142).

Mechanisms of stroke in cardiovascular procedures

(Source: Devgun JK, Gul S, Mohananey D, et al. Cerebrovascular events after cardiovascular procedures: risk factors, recognition, and prevention strategies. J Am Coll Cardiol 2018;71(17):1910-20.)

Cognitive impairment after cardiac procedures. The mechanism of the biphasic cognitive decline after coronary artery bypass graft surgery is unclear. Some early short-term cognitive changes may be multifactorial and reversible (150). Perioperative ischemic stroke is not always related to cognitive decline (36).

Risk factors associated with cognitive impairment after surgery can often be separated into factors present before surgery and those present intraoperatively. Preoperatively, factors include advanced age, pre-existing cognitive impairment, depression, diabetes, and lower education levels. Additionally, there is some evidence that the APOE4 genotype could play a role. Intraoperatively, surgical approach, need for bypass, surgery duration, blood pressure, and hemoglobin levels play a role (180).

The perioperative burden of hypertension or hypotension affects both short- and long-term outcomes in cardiac interventions, including stroke, delirium, and death (102).

Cerebral autoregulation in the spared brain is diminished perioperatively and may lead to cognitive dysfunction, worse clinical outcome, and even death (103).

Epidemiology

The main complications of cardiac procedures are:

	• Stroke
	• Encephalopathy
	• Cognitive impairment
	• Headache
	• Seizures
	• Infections

Percutaneous coronary intervention . Most coronary revascularization is achieved by percutaneous coronary intervention, an increasingly popular approach due to higher safety than coronary artery bypass graft (105). The incidence of stroke (ischemic and hemorrhagic) after cardiac catheterization ranges from is 0.07% to 7.0%(89). However, many perioperative embolic events are clinically silent. Approximately 15% of patients who underwent cardiac catheterization had asymptomatic ischemic cerebral lesions on MRI-DWI (25).

Coronary artery bypass graft. In a retrospective study of 2985 patients who underwent coronary artery bypass graft, the incidence of stroke was 1.6%, similar to conventional coronary artery bypass graft and off-pump coronary artery bypass graft. However, more recent studies have been compiled into the https://www.sts.org/research-data/registries/sts-national-database, which estimates the incidence of stroke after coronary artery bypass graft to be around 1.3%, an overall decreasing trend over the years (56). The mechanism is large artery embolism in 76% and watershed in 15% of cases. Previous stroke, extensive aortic calcification, female gender, and congestive heart failure were predictors of stroke. The in-hospital mortality and long-term survival rate were affected by perioperative stroke (53). In prospective studies, the incidence of stroke after coronary artery bypass graft was 1.5% to 5.2% (110; 152; 24).

Of 4140 patients who underwent isolated coronary artery bypass graft, 2.5% had early (less than 24 hours) and 0.9% late (more than 24 hours to discharge) stroke. To that end, the major etiologies of stroke during the intraoperative period remain thromboembolism and hypoperfusion, whereas the major etiologies of stroke in the early postoperative stage (first 7 days) include arrhythmias and hemodynamic instability. In later days (days 7 to 30), patient risk factors come into play, including older age, previous stroke, hypertension, hypercholesterolemia, diabetes, and peripheral vascular disease (56).

Combined surgery. In a single-center study of 4335 patients, in coronary artery bypass graft with or without aortic valve replacement, stroke was detected in 1.8%. The combination of coronary artery bypass graft with carotid endarterectomy increased the risk of perioperative stroke from 0% to 15.1% (98).

Percutaneous coronary intervention versus coronary artery bypass graft. Pooled data analysis of 11 randomized clinical trials, including 11,518 patients, found a reduced risk of stroke at 30 days and 5 years after the procedure. Patients who had a stroke within 30 days after the procedure had significantly higher mortality compared to those who did not have a stroke (72).

Heart transplantation. Experience from a single center, including 200 patients, revealed that 23% had neurologic complications: ischemic stroke, seizures, diffuse encephalopathy, headache, and cerebral infections. Preoperative mechanical circulatory support requirement was the most important predictor of poor neurologic outcome (189). The risk factors for ischemic stroke after cardiac transplant are prior stroke and dilated cardiomyopathy (79; 13).

Prevention

Prevention of perioperative neurologic complications includes:

	• Preoperative evaluation should include prior stroke, large vessel atherosclerosis, valvular disease, and atrial fibrillation.
	• Treatment of hyperglycemia, hypotension, and hyperthermia is recommended.
	• Dexmedetomidine administered perioperatively does not prevent perioperative delirium.
	• Cerebral protection devices may be tested.

Comprehensive preoperative evaluation of risk factors, including prior stroke, carotid stenosis, and aortic atherosclerotic plaques, may help prevent complications after coronary artery bypass graft surgery (27).

Hyperthermia after coronary artery bypass graft is associated with decreased cognitive function (64). Off-pump coronary artery bypass graft surgery patients experience less hyperthermia than on-pump patients. The reason may be a lower level of inflammation during off-pump coronary artery bypass graft. Measures to avoid hyperthermia are reasonable (35).

A systematic review and meta-analysis including 34,650 patients found that a glycosylated hemoglobin level lower than 7% is associated with a decreased risk of stroke and transient ischemic attack (risk ratio 0.53; 95% confidence interval, 0.39-0.70; P < .0001). This suggests that optimal glycemic control before cardiac surgery is reasonable (37).

Preoperative statins have been shown to reduce mortality from coronary artery bypass graft surgery but not the risk of stroke (128). In a retrospective study, beta-blockers and statins reduced the number of perioperative strokes (19). Ideally, an LDL of less than 55 should be targeted, and if not reached with high-dose statins, ezetimibe can be introduced to reach the target level (51).

Postoperative atrial fibrillation was associated with cognitive impairment (160). In a systematic review with meta-analysis of five studies of treatment with oral anticoagulation for atrial fibrillation after cardiac surgery, including 203,946 patients, the risk of thromboembolic complications was reduced, but the risk of hemorrhagic complications was higher than without anticoagulation. Further studies are needed to confirm this finding (121). Use of rate-control medications pre-operatively and postoperatively remains controversial, as evidence of the benefits of use is still lacking. If introduced, it should be done cautiously, with gradual dose adjustment and short-acting agents (51).

Cerebral embolism after transcatheter aortic valve replacement did not differ significantly between the groups receiving dual antiplatelet and anticoagulation with edoxaban (129).

In a systematic review and meta-analysis, including 6018 patients, mild hypothermia during surgery is associated with a lower risk of stroke compared with deep hypothermia (OR 0.50; 95% CI 0.28-0.89).

A systematic review found that dexmedetomidine does not decrease delirium as it was initially thought (130).

Neurologic complication risk factors associated with general cardiac surgery. Several studies have attempted to identify the subset of patients at high risk preoperatively.

A. Factors predicting postoperative neurologic complications (141)
	1. Preoperative factors
		a. Carotid stenosis greater than 50% b. Prior heart surgery c. Prior stroke
	2. Intraoperative factors
		a. Valve surgery
B. Factors predicting higher postoperative mortality (99)
	1. Preoperative factors
		a. Carotid stenosis greater than 50% b. Prior heart surgery c. Peripheral vascular disease d. Hypercholesterolemia
	2. Intraoperative factors
		a. Longer cardiopulmonary bypass
C. Factors predicting perioperative stroke (110)
	1. Preoperative factors
		a. Age b. Previous stroke c. Presence of carotid bruit d. History of hypertension e. History of diabetes mellitus
	2. Intraoperative factors
		a. Longer cardiopulmonary bypass
D. Factors predicting postoperative delirium (23)
	1. Preoperative factors
		a. Prior cerebrovascular disease b. Peripheral vascular disease c. Atrial fibrillation d. Diabetes mellitus e. Ejection fraction less than 30% f. Urgent operation
	2. Intraoperative factors
		a. Need for massive blood transfusion b. Operation time greater than 3 hours
E. Factors predicting postoperative neurologic complications (151)
	1. Preoperative factors
		a. Hypertension b. Diabetes c. Prior stroke d. Smoking e. Aortic atherosclerosis
	2. Intraoperative factors
		a. Severe hypotension b. Manipulation of the atherosclerotic aorta c. Prolonged bypass time
	3. Postoperative factors
		a. Occurrence of atrial fibrillation
F. Factors predicting postoperative seizure (107)
	1. Preoperative factors
		a. Renal dysfunction b. Advanced age c. Prior cardiac surgery d. Peripheral vascular disease e. Cardiac arrest
	2. Intraoperative factors
		a. Open heart surgery b. Prolonged cardiopulmonary bypass time (less than 120 minutes) c. Exposure to high dose tranexamic acid (less than 100 mg/kg)

Age. Advanced age is a major predictor of stroke and cognitive dysfunction following cardiac surgery (61). In a study of 2000 patients who underwent cardiopulmonary bypass, the neurologic deficits occurred nine times more often in those 75 years or older compared to those younger than 65 years of age. The mortality rate was nine times higher (35.7% vs. 4.0%) in patients with perioperative neurologic deficits than in those without deficits (113). Fortunately, new surgical techniques have improved the outcome in elderly patients (140).

Sex. Women have an increased risk of perioperative neurologic complications and mortality (74).

Previous stroke. A history of stroke predicts perioperative complications or stroke. Awakening from anesthesia is prolonged, and the likelihood of confusion or reintubation is higher. The risk of focal neurologic deficits, new strokes, and reappearance or worsening of previous stroke symptoms is increased (138; 75).

Open heart surgery. Intracardiac air embolism may complicate open-heart surgery. Leaflet and annulus calcium deposits embolization during cardiac valve replacement, high-intensity transient signals (HITS). The number of high-intensity transient signals correlates with the neuropsychological outcome (137).

Ascending aorta atheroma. The presence of ascending aorta atheroma predicts neurologic events, stroke, prolonged hospitalization, and mortality after surgery (39; 40; 09; 139). Embolism is reduced by avoiding aortic manipulation during surgery (178).

Off-pump surgery lowers the incidence of stroke compared to the on-pump group (0.4% vs. 3.9%) (131). The off-pump, no-touch surgical technique avoids aortic manipulation and the effects of cardiopulmonary bypass (139; 26). Intraoperative ultrasound of the proximal aorta helps to avoid the area of plaque before clamp placement and prevent perioperative stroke (113; 126).

Cardiopulmonary bypass. Cardiopulmonary bypass provides circulatory support during cardiac surgery. However, the bypass circuit is thrombogenic. Coating the bypass circuits with phosphoryl-choline or heparin seems to reduce thromboembolic complications (43; 73). Longer duration of cardiopulmonary bypass increases the perioperative neurologic complications (113; 99).

In a small study, surgery performed without cardiopulmonary bypass, the off-pump technique, has reduced overall morbidity and mortality compared with on-pump surgery (04). However, another study, enrolling 2203 patients who underwent coronary artery bypass graft, did not find a significant difference in the composite outcome, stroke, or neuropsychological decline between the two groups at 30 days (157).

Perioperative mean arterial pressure. Cerebral blood flow remains constant to sustain the brain metabolism. Blood flow is defined as cerebral perfusion pressure divided by cerebrovascular resistance. Autoregulation maintains the cerebral blood flow relatively constant at cerebral perfusion pressure values between 50 and 130 mmHg.

Cerebral perfusion pressure is the difference between the mean arterial and intracranial pressure. As the intracranial pressure is constant, around 10 mmHg, it is suggested to maintain the mean arterial pressure between 60 and 140 mmHg during the procedure.

Initial studies suggested maintenance of mean arterial pressure at greater than 50 mmHg to prevent cerebral dysfunction. Subsequent studies did not confirm these findings (55; 113; 158).

Carotid artery stenosis. The incidence of hemodynamically significant carotid stenosis is 11% to 20% in patients undergoing cardiac operations (167).

In a retrospective review of 1022 coronary artery bypass surgery patients, the overall rate of perioperative stroke was 2.2%. The rate was increased with the severity of extracranial carotid stenosis, from 4.7% in less than 70% stenosis, 5% in 70% to 99% stenosis to 8% in total occlusion (38).

In patients with asymptomatic carotid stenosis undergoing coronary artery bypass graft, the risk of in-hospital stroke or death was similar regardless of the degree of carotid stenosis (148).

Summary. Common risk factors are advanced age, carotid artery stenosis, prior heart surgery, prior stroke, peripheral vascular disease, hypertension, diabetes mellitus, aortic atheroma, open heart surgery, and prolonged cardiopulmonary bypass time.

Risk factors associated with left heart catheterization.

Risk factors of CNS complications. Risk factors include female sex, peripheral vascular disease, left ventricular hypertrophy, severe coronary disease, poor left ventricular ejection fraction, concomitant peripheral vascular disease, percutaneous coronary intervention, longer fluoroscopy times, and protruding aortic atheroma (175; 96; 149). Aspirin administration before percutaneous coronary intervention has been associated with decreased risk of in-hospital mortality and stroke (86).

Risk factors of peripheral nervous system complications. Thrombocytopenia, female sex, and excessive anticoagulation (aPTT > 150 seconds) are strong predictors of retroperitoneal hemorrhage. However, there is no strong correlation between the hematoma size and the severity of neurologic deficits. Most patients are treated by transfusion alone (an average of 4 units). Urgent surgery is needed if hypotension is refractory to fluid administration (87). Neurologic complications during intra-aortic balloon pump include peripheral nerve injuries and, rarely, paraplegia related to spinal cord infarction (11).

Further risk factors for stroke during left heart catheterization include pre-existing atherosclerotic plaque in the aorta or aortic arch, complex anatomy, multiple catheter exchanges mid-procedure, and need for stiff or wide- or large-bore catheters (106).

Management

	• Intravenous thrombolysis may be contraindicated in patients who have undergone a recent surgical procedure.
	• Intra-arterial thrombolysis has been used successfully in strokes following cardiac catheterization.
	• Mechanical thrombectomy is an option if a large cerebral artery is occluded.
	• Perfusion studies may help select patients with large arterial occlusion up to 24 hours from stroke onset.
	• Permissive hypertension should be used cautiously in unstable cardiac patients.
	• The risk of death or severe cardiovascular morbidity is high, but there is no significant difference between synchronous and staged carotid artery revascularization and coronary artery bypass graft surgery.

Management of peri-procedural stroke. Treatment of periprocedural stroke is similar to that of ischemic stroke. Urgent head CT is needed to exclude intracerebral hemorrhage. Intravenous tissue plasminogen activator can be given within 4.5 hours from the stroke onset unless contraindicated by coagulopathy or recent surgical procedure. Large vessel occlusion with salvageable penumbra, less likely to respond to tPA, may be treated, within 24 hours in selected cases, with endovascular thrombectomy. Cerebral perfusion imaging by CT or MRI may help with the selection for mechanical thrombectomy of large vessel occlusion with a significant mismatch between the penumbra and infarct core (108). In a retrospective database of 5022 consecutive patients, 870 underwent endovascular thrombectomy and had excellent outcomes (67).

In the acute period, permissive hypertension should be avoided in certain cardiac conditions like pulmonary edema, aortic dissection, and acute myocardial infarction, or when organ injury is suspected.

During cardiac catheterization. There is anecdotal evidence of successful intra-arterial thrombolysis for ischemic stroke during or after cardiac catheterization (89).

After coronary artery bypass surgery. Recent surgery is a contraindication to intravenous tPA. There is anecdotal evidence of benefit from intra-arterial thrombolysis (85). Permissive hypertension may be used cautiously after surgery to prevent bleeding from an unhealed surgical site.

After cardiac transplantation. Patients waiting for cardiac transplantation require circulatory support from a left ventricular assist device. This device is thrombogenic and requires anticoagulation, a contraindication for intravenous tPA (117). Mechanical thrombectomy can be used for large vessel occlusion. Permissive hypertension should be cautiously used in patients with heart failure.

Management of potential stroke risk factors that are commonly found during preprocedural screening.

Patent foramen ovale. Patent foramen ovale allows an embolus to travel from the venous to the arterial systemic circulation. Larger right-to-left shunts are linked to higher rates of embolism. Patent foramen ovale closure reduces the risk of stroke in selected patients without other risk factors for stroke, which is not the case in most perioperative strokes (112).

Carotid artery stenosis. Carotid endarterectomy may benefit carefully selected patients with symptomatic and asymptomatic carotid stenosis (69). As coronary artery disease and carotid stenosis may coexist, optimal timing of carotid endarterectomy relative to coronary artery bypass graft surgery has been of interest. Carotid duplex ultrasound screening is reasonable before elective coronary artery bypass graft surgery in patients older than 65 years of age and those with left main coronary stenosis, peripheral arterial disease, a history of cigarette smoking, a history of stroke or transient ischemic attack, or carotid bruit.

A systematic review of 97 studies of combined carotid endarterectomy and coronary artery bypass graft surgery did not find a significant difference between the synchronous and staged procedures. The risk of stroke or major cardiovascular morbidity was 10% to 12% (119). In a meta-analysis of 12 studies including coronary artery bypass graft patients with asymptomatic unilateral carotid stenosis, the lowest risk of stroke or death was observed in the synchronous carotid endarterectomy and off-pump coronary artery bypass graft surgery group (2.2%), whereas the risk of the other groups was 7% to 8% (49).

Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (21). A meta-analysis of 11 studies examined the overall operative risk of cardiovascular events in patients undergoing staged carotid artery stenting plus coronary artery bypass graft surgery. In a cohort of predominantly asymptomatic unilateral carotid disease patients, the 30-day risk of death/any stroke was 9.1% (120). Data from randomized controlled trials suggest that carotid artery stenting and carotid endarterectomy are similar when it comes to long-term benefits, but perioperative stroke risk and death rate are higher with carotid endarterectomy (01).

Additionally, carotid revascularization by endarterectomy or stenting with embolic protection before or concurrent with myocardial revascularization surgery is reasonable in symptomatic patients with stenosis of more than 80%. However, the safety and efficacy of carotid revascularization in patients with asymptomatic carotid stenosis, even if severe, are not well established (20).

General management of cardiac transplanted patients. Usually, opportunistic CNS infections occur 3 weeks after surgery. Post-transplantation lymphoproliferative disorder may be confined to the nervous system or disseminated. The response to treatment is poor (133).

Some antiepileptic drugs may reduce immunosuppressant levels in post-transplantation patients (30). Newer agents are not subject to this interaction.

Outcomes

Out of 100 patients who underwent heart valve procedures, 24 had focal deficits, of which 92% recovered completely at 5 months (158). Vocal cord dysfunction due to direct trauma or recurrent laryngeal nerve injury can lead to partial laryngeal obstruction and may require reintubation (153).

Cognitive decline after cardiac surgery may affect 7% to 49% of patients at 3 months and up to 33% after 1 year (179). Of concern was also the late decline of cognitive function after the cardiac procedures. However, this is most likely related to the progression of preexisting vascular disease, another neurodegenerative disease, or new neurologic events (111).

Analysis of the Veterans’ Affairs Quality Improvement Program database, including 1422 patients, found that the median survival time of patients with stroke after coronary artery bypass graft was 6.7 years. The mortality of patients with stroke compared to those without a stroke within the first 30 days postoperatively was 79% versus 96%, 58 versus 83%, and 36% versus 63% at 1, 5, and 10 years, respectively. Predictors of 1-year mortality were renal failure, prolonged ventilation, coma, and reoperation for bleeding (181).

References

01: Abou-Assi S, Hanak CR, Khalifeh A, et al. Concomitant carotid and coronary artery disease management: a review of the literature. Ann Vasc Surg 2025;113:319-26. PMID 39343361
02: Addonizio VP, Smith JB, Strauss J, Colman RW, Edmunds L. Thromboxane synthesis and platelet secretion during cardiopulmonary bypass with bubble oxygenator. J Thorac Cardiovasc Surg 1980;79:91-6. PMID 7350392
03: Alkhouli M, Zack CJ, Sarraf M, et al. Morbidity and mortality associated with balloon aortic valvuloplasty: a national perspective. Circ Cardiovasc Interv 2017;10(5):e004481. PMID 28495894
04: Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002;359(9313):1194-9. PMID 11955537
05: Arrowsmith JE, Grocott HP, Reves JG, Newman MF. Central nervous system complications of cardiac surgery. Br J Anesth 2000;84:378-93. PMID 10793601
06: Avidan MS, Fritz BA, Maybrier HR, et al. The prevention of delirium and complications associated with surgical treatments (PODCAST) study: protocol for an international multicentre randomised controlled trial. BMJ Open 2014;4(9):e005651. PMID 25231491
07: Avvedimento M, Cepas-Guillén P, Garcia CB, et al. Incidence, predictors, and prognostic impact of neurologic events after TAVRaccording to VARC-3 criteria. JACC Cardiovasc Interv 2024;17(15):1795-807. PMID 39142756
08: Ballweg T, White M, Parker M, et al. Association between plasma tau and postoperative delirium incidence and severity: a prospective observational study. Br J Anaesth 2021;126(2):458-66. PMID 33228978
09: Barbut D, Lo YW, Hartman GS, et al. Aortic atheroma is related to outcome but not numbers of emboli during coronary bypass. Ann Thorac Surg 1997;64:454-9. PMID 9262593
10: Bartels K, Li YJ, Li YW, et al. Apolipoprotein epsilon 4 genotype is associated with less improvement in cognitive function 5 years after cardiac surgery: a retrospective cohort study. Can J Anaesth 2015;62(6):618-26. PMID 25744138
11: Beholz S, Braun J, Ansorge K, Wollert HG, Eckel L. Paraplegia caused by aortic dissection after intraaortic balloon pump assist. Ann Thorac Surg 1998;65:603-4. PMID 9485296
12: Behzadi F, Simon JE, Zielke TJ, et al. Risk factors associated with spinal cord ischemia during aortic aneurysm repair. Ann Vasc Surg 2023;91:36-49. PMID 36603707
13: Belvis R, Marti-Fabregas J, Cocho D, et al. Cerebrovascular disease as a complication of cardiac transplantation. Cerebrovasc Dis 2005;19:267-71. PMID 15731558
14: Benali K, Khairy P, Hammache N, et al. Procedure-related complications of catheter ablation for atrial fibrillation. J Am Coll Cardiol 2023;81(21):2089-99. PMID 37225362
15: Bhuva AN, Moralee R, Moon JC, Manisty CH. Making MRI available for patients with cardiac implantable electronic devices: growing need and barriers to change. Eur Radiol 2020;30(3):1378-84. PMID 31776746
16: Blauth CI. Macroemboli and microemboli during cardiopulmonary bypass. Ann Thorac Surg 1995;59:1300-3. PMID 7733756
17: Bokesch PM, Izykenova GA, Justice JB, Easley KA, Dambinova SA. NMDA receptor antibodies predict adverse neurological outcome after cardiac surgery in high-risk patients. Stroke 2006;37(6):1432-6. PMID 16627793
18: Borger MA, Ivanov J, Weisel RD, Rao V, Peniston CM. Stroke during coronary bypass surgery: principal role of cerebral macroemboli. Eur J Cardiothoracic Surg 2001;19:627-32. PMID 11343943
19: Bouchard D, Carrier M, Demers P, et al. Statin in combination with β-blocker therapy reduces postoperative stroke after coronary artery bypass graft surgery. Ann Thorac Surg 2011;91;654-9. PMID 21352973
20: Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv 2013;81(1):E76-123. PMID 23281092
21: Brott TG, Hobson RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;363(1):11-23. PMID 20505173
22: Brown W, Moody DM, Challa VR, Stump DA, Hammon JW. Longer duration of cardiopulmonary Bypass is associated with greater numbers of cerebral microemboli. Stroke 2000;31:707-13. PMID 10700508
23: Bucerius J, Gummert JF, Borger MA, et al. Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery. J Thorac Cardiovasc Surg 2004a;127:57-64. PMID 14752413
24: Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2004b;78(2):755-6.
25: Busing KA, Schulte-Sasse C, Fluchter S, et al. Cerebral Infarction: incidence and risk factors after diagnostic and interventional cardiac catheterization—prospective evaluation at diffusion-weighted MR Imaging. Radiology 2005;235:177-83. PMID 15731373
26: Calafiore AM, Di Mauro M, Teodori G, et al. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. Ann Thorac Surg 2002;73:1387-93. PMID 12022522
27: Caplan L. Translating what is known about neurological complications of coronary artery bypass graft surgery into action. Arch Neurol 2009;66:1062-4. PMID 19752294
28: Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368(12):1092-100. PMID 23514286
29: Casey CP, Lindroth H, Mohanty R, et al. Postoperative delirium is associated with increased plasma neurofilament light. Brain 2020;143(1):47-54. Erratum in: Brain. 2020;143(3):e24. PMID 31802104
30: Chabolla DR, Wszolek ZK. Pharmacologic management of seizures in organ transplant. Neurology 2006;67(12 Suppl 4):S34-8. PMID 17190920
31: Chan JS, Shafi AM, Grafton-Clarke C, Singh S, Harky A. Concomitant severe carotid and coronary artery diseases: a separate management or concomitant approach. J Card Surg 2019;34(9):803-13. PMID 31269295
32: Chavez P, Messerli FH, Casso Dominguez A, et al. Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart 2015;2(1):e000257. PMID 26380098
33: Cho SM, Starling RC, Teuteberg J, et al. Understanding risk factors and predictors for stroke subtypes in the ENDURANCE trials. J Heart Lung Transplant 2020;39(7):639-47. PMID 32044205
34: Chukwuemeka A, Rao V, Armstrong S, Ivanov J, David T. Aortic valve replacement: a safe and durable option in patients with impaired left ventricular dysfunction. Eur J Cardiothorac Surg 2006;29(2):133-8. PMID 16386914
35: Clark JA, Bar-Yosef S, Anderson A, Newman MF, Landolfo K, Grocott HP. Postoperative hyperthermia following off-pump versus on-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2005;19(4):426-9. PMID 16085244
36: Cook DJ, Huston J, Trenerry MR, Brown RD, Zehr KJ, Sundt T. Postcardiac surgical cognitive impairment in the aged using diffusion-weighted magnetic-resonance imaging. Ann Thorac Surg 2007;83(4):1389-95. PMID 17383345
37: Corazzari C, Matteucci M, Kołodziejczak M, et al. Impact of preoperative glycometabolic status on outcomes in cardiac surgery: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2022;164(6):1950-60.e10. PMID 34176617
38: Dashe JF, Pessin MS, Murphy RE, Payne DD. Carotid occlusive disease and stroke risk in coronary artery bypass graft surgery. Neurology 1997;49(3):678-86. PMID 9305322
39: Davila-Roman VG, Barzilai B, Wareing TH, Davila RM, Kouchoukos NT, Barzilai B. Intraoperative ultrasonic evaluation of the ascending aorta in 100 consecutive patients undergoing cardiac surgery. Circulation 1991;84:47-53. PMID 1934441
40: Davila-Roman VG, Murphy SF, Nickerson NJ, Schechtman KB, Barzilai B. Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. J Am Coll Cardiol 1999;33:1308-16. PMID 10193732
41: Demiralp G, Arrigo RT, Cassara C, Johnson MR. Heart transplantation-postoperative considerations. Crit Care Clin 2024;40(1):137-57. PMID 37973350
42: Deshmukh A, Patel NJ, Pant S, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation 2013;128(19):2104-12. PMID 24061087
43: De Somer F, Francois K, van Oeveren W, et al. Phosphorylcholine coating of extracorporeal circuits provides natural protection against blood activation by the material surface. Eur J Cardiothorac Surg 2000;18:602-6. PMID 11053824
44: De Somer F, Van Belleghem Y, Caes F, et al. Tissue factor as the main activator of the coagulation system during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2002;123:951-8. PMID 12019381
45: Dimopoulou I, Daganou M, Dafni U, et al. Phrenic nerve dysfunction after cardiac operations: electrophysiologic evaluation of risk factors. Chest 1998;113:8-14. PMID 9440560
46: Di Tommaso E, Rapetto F, Guida GA, Zakkar M, Bruno VD. Benefits of mitral valve repair over replacement in the elderly: a systematic review and meta-analysis. J Card Surg 2021;36(7):2524-30. PMID 33783032
47: Doenges JE, Reed AB, Huddleston S, Wang Q, Valentine RJ. Persistent malperfusion after central aortic repair in acute type I aortic dissections. J Vasc Surg 2023;77(6):1618-24. PMID 36796591
48: Durko AP, Reardon MJ, Kleiman NS, et al. Neurological complications after transcatheter versus surgical aortic valve replacement in intermediate-risk patients. J Am Coll Cardiol 2018;72(18):2109-19. PMID 30360820
49: Fareed KR, Rothwell PM, Mehta Z, Naylor AR. Synchronous carotid endarterectomy and off-pump coronary bypass: an updated, systematic review of early outcomes. Eur J Vasc Endovasc Surg 2009;37(4):375-8. PMID 19211276
50: Farsak B, Gunaydin S, Yorgancioglu C, Zorlutuna Y. Elevated levels of s-100beta correlate with neurocognitive outcome after cardiac surgery. J Cardiovasc Surg (Torino) 2003;44(1):31-5. PMID 12627069
51: Fatima M, Bazarbaev A, Rana A, et al. Neuroprotective strategies in coronary artery disease interventions. J Cardiovasc Dev Dis 2025;12(4):143. PMID 40278202
52: Filsoufi F, Rahmanian PB, Castillo JG, Bronster D, Adams DH. Incidence, imaging analysis, and early and late outcomes of stroke after cardiac valve operation. Am J Cardiol 2008a;101(10):1472-8. PMID 18471460
53: Filsoufi F, Rahmanian PB, Castillo JG, Bronster D, Adams DH. Incidence, topography, and long-term survival after stroke in patients undergoing coronary artery bypass grafting. Ann Thoracic Surg 2008b;85(3):862-71. PMID 18291158
54: Foley ED, Kumar V. Protecting the spinal cord during thoracic endovascular aortic repair-who should place the spinal drain? J Spine Surg 2023;9(2):186-90. PMID 37435327
55: Gardner TJ, Horneffer PJ, Manolio TA, et al. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985;40:574-581. PMID 3878134
56: Gaudino M, Angiolillo DJ, Di Franco A, et al. Stroke after coronary artery bypass grafting and percutaneous coronary intervention: incidence, pathogenesis, and outcomes. J Am Heart Assoc 2019;8(13):e013032. PMID 31242821
57: Gilman S. Cerebral disorders after open-heart operations. N Engl J Med 1965;272:489-98. PMID 14250198
58: Goebel N, Holder SA, Huether F, Bail DH, Franke UF. Left subclavian artery sacrifice in acute aortic dissection repair using the frozen elephant trunk. Thorac Cardiovasc Surg 2022;70(8):623-9. PMID 35038756
59: Gofton T, Chu M, Norton N, et al. A prospective observational study of seizures after cardiac surgery using continuous EEG monitoring. Neurocrit Care 2014;21(2):220-7. PMID 24710654
60: Goldsmith I, Lip GY, Kaukuntla H, Patel RL. Hospital morbidity and mortality and changes in quality of life following mitral valve surgery in the elderly. J Heart Valve Dis 1999;8(6):702-7. PMID 10616251
61: Goto T, Maekawa K. Cerebral dysfunction after coronary artery bypass surgery. J Anesth 2014;28(2):242-8. PMID 23982856
62: Gottesman RF, McKhann GM, Hogue CW. Neurological complications of cardiac surgery. Semin Neurol 2008;28(5):703-15. PMID 19115176
63: Gress DR. The problem with asymptomatic cerebral embolic complications in vascular procedures: what if they are not asymptomatic. J Am Coll Cardiol 2012;60(17):1614-6. PMID 22999732
64: Grocott HP, Mackensen GB, Grigore AM, et al. Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery. Stroke 2002;33:537-41. PMID 11823666
65: Grocott HP, White WD, Morris R, et al. Genetic polymorphisms and the risk of stroke after cardiac surgery. Stroke 2005;36:1854-8. PMID 16051899
66: Guclu CY, Ünver S, Aydınlı B, Kazancı D, Dilber E, Özgök A. The effect of sevoflurane vs. TIVA on cerebral oxygen saturation during cardiopulmonary bypass – randomized trial. Adv Clin Exp Med 2014;23(6):919-24. PMID 25618118
67: Gupta AK, Sabab A, Goh R, et al. Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery. J Card Surg 2022;37(12):4562-70. PMID 36335602
68: Hajibandeh S, Hajibandeh S, Antoniou SA, Torella F, Antoniou GA. Meta-analysis of left subclavian artery coverage with and without revascularization in thoracic endovascular aortic repair. J Endovasc Ther 2016;23(4):634-41. PMID 27225214
69: Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004;363(9420):1491-502. PMID 15135594
70: Harris DN, Bailey SM, Smith PL, Taylor KM, Oatridge A, Bydder GM. Brain swelling in first hour after coronary artery bypass surgery. Lancet 1993;342:586-7. PMID 8102722
71: Harrison MJ. Neurologic complications of coronary artery bypass grafting: diffuse or focal ischemia. Ann Thorac Surg 1995;59:1356-8. PMID 7733768
72: Head SJ, Milojevic M, Daemen J, et al. Stroke rates following surgical versus percutaneous coronary revascularization. J Am Coll Cardiol 2018;72(4):386-98. PMID 30025574
73: Heyer EJ, Lee KS, Manspeizer HE, et al. Heparin-bonded cardiopulmonary bypass circuits reduce cognitive dysfunction. J Cardiothorac Vasc Anesth 2002;16:37-42. PMID 11854876
74: Hogue CW, Barzilai B, Pieper KS, et al. Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report. Circulation 2001;103(17):2133-7. PMID 11331252
75: Hogue CW, De Wet CJ, Schechtman KB, Davila-Roman VG. The importance of prior stroke for the adjusted risk of neurologic injury after cardiac surgery for women and men. Anesthesiology 2003;98(4):823-9. PMID 12657841
76: Holmes DR, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 2014;64(1):1-12. Erratum in: J Am Coll Cardiol 2014;64(11):1186. PMID 24998121
77: Howard R, Trend P, Russell RW. Clinical features of ischemia in cerebral arterial border zones after periods of reduced cerebral blood flow. Arch Neurol 1987;44:934-40. PMID 3619713
78: Hupperts R, Wetzelaer W, Heuts-van Raak L, Lodder J. Is hemodynamically compromise a specific cause of border zone brain infarcts following cardiac surgery. Eur Neurol 1995;35:276-80. PMID 8542916
79: Jarquin-Valdivia AA, Wijdicks EF, McGregor C. Neurologic complications following heart transplantation in the modern era: decreased incidence, but postoperative stroke remains prevalent. Transplant Proc 1999;31:2161-2. PMID 10456001
80: Jordan F, FitzGibbon B, Kavanagh EP, et al. Endovascular versus open surgical repair for complicated chronic Type B aortic dissection. Cochrane Database Syst Rev 2021;12(12):CD012992. PMID 34905228
81: Kahlert P, Knipp SC, Schlamann M, et al. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation – a diffusion weighted magnetic resonance imaging study. Circulation 2010;121:870-8. PMID 20177005
82: Kangasniemi OP, Biancari F, Luukkonen J, et al. Preoperative C-reactive protein is predictive of long-term outcome after coronary artery bypass surgery. Eur J Cardiothorac Surg 2006;29(6):983-5. PMID 16682213
83: Kapadia SR, Huded CP, Kodali S, et al. Stroke After Surgical Versus Transfemoral Transcatheter Aortic Valve Replacement in the PARTNER Trial. J Am Coll Cardiol 2018;72(20):2415-26. PMID 30442284
84: Katz MG, Katz R, Schachner A, Cohen AJ. Phrenic nerve injury after coronary artery bypass grafting: will it go away. Ann Thorac Surg 1998;65(1):32-5. PMID 9456091
85: Katzan IL, Masaryk TJ, Furlan AJ, et al. Intra-arterial thrombolysis for perioperative stroke after open heart surgery. Neurology 1999;52:1081-4. PMID 10102437
86: Kenaan M, Seth M, Aronow HD, et al. The clinical outcomes of percutaneous coronary intervention performed without pre-procedural aspirin. J Am Coll Cardiol 2013;62(22):2083-9. PMID 24055844
87: Kent KC, Moscucci M, Gallagher SG, DiMattia ST, Skillman JJ. Neuropathy after cardiac catheterization: incidence, clinical patterns, and long-term outcome. J Vasc Surg 1994;19:1008-13. PMID 8201701
88: Kestin AS, Valeri CR, Khuri SF, et al. The platelet function defect of cardiopulmonary bypass. Blood 1993;82:107-17. PMID 7686785
89: Khatri P, Kasner S. Ischemic strokes after cardiac catheterization: opportune thrombolysis candidates. Arch Neurol 2006;63:817-9. PMID 16769862
90: Khoo CW, Lip GY. Radiofrequency catheter ablation of atrial fibrillation and thromboembolic risk. Eur J Neurol 2008;15(12):1261-2. PMID 19049540
91: Klinger RY, James OG, Borges-Neto S, et al. 18F-florbetapir positron emission tomography-determined cerebral β-amyloid deposition and neurocognitive performance after cardiac surgery. Anesthesiology 2018;128(4):728-44. PMID 29389750
92: Knipp SC, Matatko N, Schlamann M, et al. Small ischemic brain lesions after cardiac valve replacement detected by diffusion-weighted magnetic resonance imaging: relation to neurocognitive function. Eur J Cardiothorac Surg 2005;28(1):88-96. PMID 15922616
93: Koizumi S, Inoue Y, Shinzato K, et al. Surgical outcomes of thoracic endovascular aortic repair for retrograde Stanford type a dissection. Eur J Cardiothorac Surg 2023;63(4):ezad062. PMID 36847451
94: Kosiuk J, Kornej J, Bollmann A, et al. Early cerebral thromboembolic complications after radiofrequency catheter ablation of atrial fibrillation: incidence, characteristics, and risk factors. Heart Rhythm 2014;11(11):1934-40. PMID 25086257
95: Laible M, Möhlenbruch M, Horstmann S, et al. Peri-procedural silent cerebral infarcts after left atrial appendage occlusion. Eur J Neurol 2017;24(1):53-7. PMID 27647674
96: Lazar JM, Uretsky BF, Denys BG, Reddy PS, Counihan PJ, Ragosta M. Predisposing risk factors and natural history of acute neurologic complications of left-sided cardiac catheterization. Am J Cardiol 1995;75:1056-60. PMID 7747689
97: Lempereur M, Aminian A, Freixa X, et al. Device-associated thrombus formation after left atrial appendage occlusion: A systematic review of events reported with the watchman, the Amplatzer cardiac plug and the amulet. Catheter Cardiovasc Interv 2017;90(5):E111-21. PMID 28145040
98: Li Y, Walicki D, Mathiesen C, et al. Stroke after cardiac surgery and relationship to carotid stenosis. Arch Neurol 2009;66:1091-6. PMID 19752298
99: Libman RB, Wirkowski E, Neystat M, Barr W, Gelb S, Graver M. Stroke associated with cardiac surgery. Determinants, timing, and stroke subtypes. Arch Neurol 1997;54:83-7. PMID 9006418
100: Lin CY, Lee CY, Lee HF, et al. Postoperative stroke after type A aortic dissection repair: hemorrhage versus ischemia. World J Surg 2022;46(3):690-700. PMID 34751804
101: Lindblom RP, Shen Q, Axén S, et al. Protein profiling in serum and cerebrospinal fluid following complex surgery on the thoracic aorta identifies biological markers of neurologic injury. J Cardiovasc Transl Res 2018;11(6):503-16. PMID 30367354
102: Lizano-Diez I, Poteet S, Burniol-Garcia A, Cerezales M. The burden of perioperative hypertension/hypotension: a systematic review. PLoS One 2022;17(2):e0263737. PMID 35139104
103: Longhitano Y, Iannuzzi F, Bonatti G, et al. Cerebral autoregulation in non-brain injured patients: a systematic review. Front Neurol 2021;12:732176. PMID 34899560
104: Macdonald RL, Kowalczuk A, Johns L. Emboli enter penetrating arteries of monkey brain in relation to their size. Stroke 1995;26:1247-50. PMID 7604423
105: Mack MJ, Brown PB, Kugelmass AD, et al. Current status and outcomes of coronary revascularization 1999-2002, 148396 surgical and percutaneous procedures. Ann Thorac Surg 2004;77:761-8. PMID 14992867
106: Manda YR, Baradhi KM. Cardiac catheterization risks and complications. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2023. PMID 30285356
107: Manji RA, Grocott HP, Manji JS, Menkis AH, Jacobsohn E. Recurrent seizures following cardiac surgery: risk factors and outcomes in a historical cohort study. J Cardiothorac Vasc Anesth 2015;29(5):1206-11. PMID 26119411
108: Marks MP, Heit JJ, Lansberg MG, et al. Endovascular treatment in the DEFUSE 3 study. Stroke 2018;49(8):2000-3. PMID 29986935
109: Martin TD, Craver JM, Gott JP, et al. Prospective, randomized trial of retrograde warm blood cardioplegia: myocardial benefit and neurologic threat. Ann Thorac Surg 1994;57:298-302; discussion 302-294. PMID 8311588
110: McKhann GM, Goldsborough MA, Borowicz LM, et al. Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg 1997;63:516-21. PMID 9033330
111: McKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA, Selnes OA. Stroke and encephalopathy after cardiac surgery: an update. Stroke 2006;37(2):562-71. PMID 16373636
112: Messe SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: patent foramen ovale and secondary stroke prevention: report of the Guideline Subcommittee of the American Academy of Neurology. Neurology 2020;94(20):876-85. PMID 32350058
113: Mills SA. Risk factors for cerebral injury and cardiac surgery. Ann Thorac Surg 1995;59:1296-9. PMID 7733755
114: Moody DM, Brown WR, Challa VR, Stump DA, Reboussin DM, Legault C. Brain microemboli associated with cardiopulmonary bypass: a histologic and magnetic resonance imaging study. Ann Thorac Surg 1995;59:1304-7. PMID 7733757
115: Moradi N, Tosonian S, Askari A, Sontz EM. Delayed dislodgment of a watchman device: A rare complication manifesting as a transient ischemic event. J Cardiovasc Electrophysiol 2020;31(7):1848-50. PMID 32459024
116: Munawar DA, Chan JEZ, Emami M, et al. Magnetic resonance imaging in non-conditional pacemakers and implantable cardioverter-defibrillators: a systematic review and meta-analysis. Europace 2020;22(2):288-98. PMID 31995177
117: Nakatani T, Noda H, Beppu S, et al. Thrombus in a natural left ventricle during left ventricular assist: another thromboembolic risk factor. ASAIO Trans 1990;36:M711-4. PMID 2252791
118: Natour AK, Shepard A, Onofrey K, et al. Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection. J Vasc Surg 2023;78(5):1170-9.e2. PMID 37524152
119: Naylor AR, Cuffe RL, Rothwell PM, Bell PR. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg 2003;25(5):380-9. PMID 12713775
120: Naylor AR, Mehta Z, Rothwell PM. A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg 2009;37(4):379-87. PMID 19201215
121: Neves IA, Magalhães A, Lima da Silva G, et al. Anticoagulation therapy in patients with post-operative atrial fibrillation: systematic review with meta-analysis. Vascul Pharmacol 2022;142:106929. PMID 34757209
122: Newman MF, Croughwell ND, Blumenthal JA, et al. Predictors of cognitive decline after cardiac operation. Ann Thorac Surg 1995;59:1326-30. PMID 7733762
123: Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary- artery bypass surgery. N Engl J Med 2001;344:395-402. PMID 11172175
124: NHLBI Balloon Valvuloplasty Registry Participants. Percutaneous balloon aortic valvuloplasty. Circulation 1991;84:2383-97.
125: Ordidge RJ, Shellock FG, Kanal E. A Y2000 Update of current safety issues related to MRI. J Magn Reson Imaging 2000;12:1. PMID 10931559
126: Ozatik MA, Gol MK, Fansa I, et al. Risk factors for stroke following coronary artery bypass operations. J Card Surg 2005;20:52-7. PMID 15673410
127: Padmanabhan D, Kella DK, Deshmukh AJ, et al. Safety of thoracic magnetic resonance imaging for patients with pacemakers and defibrillators. Heart Rhythm 2019;16(11):1645-51. PMID 31150818
128: Pan W, Pintar T, Anton J, Lee VV, Vaughn WK, Collard CD. Statins are associated with a reduced incidence of perioperative mortality after coronary artery bypass graft surgery. Circulation 2004;110(11 Suppl 1):II45-9. PMID 15364837
129: Park DW, Ahn JM, Kang DY, et al. Edoxaban versus dual antiplatelet therapy for leaflet thrombosis and cerebral thromboembolism after TAVR: The ADAPT-TAVR randomized clinical trial. Circulation 2022;146(6):466-79. PMID 35373583
130: Patel M, Onwochei DN, Desai N. Influence of perioperative dexmedetomidine on the incidence of postoperative delirium in adult patients undergoing cardiac surgery. Br J Anaesth 2022;129(1):67-83. PMID 35279278
131: Patel NC, Pullan DM, Fabri BM. Does off-pump total arterial revascularization without aortic manipulation influence neurological outcome. A study of 226 consecutive, unselected cases. Heart Surg Forum 2002;5:28-32. PMID 11937459
132: Perez-Miralles F, Sanchez-Manso JC, Almenar-Bonet L, Sevilla-Mantecon T, Martinez-Dolz L, Vilchez-Padilla JJ. Incidence of and risk factors for neurologic complications after heart transplantation. Transplant Proc 2005;37(9):4067-70. PMID 16386628
133: Phan TG, O'Neill BP, Kurtin PJ. Posttransplant primary CNS lymphoma. Neuro Oncol 2000;2:229-38. PMID 11265232
134: Plotkin A, Han SM, Weaver FA, et al. Complications associated with lumbar drain placement for endovascular aortic repair. J Vasc Surg 2021;73(5):1513-24.e2. PMID 33053415
135: Podgoreanu MV, Schwinn DA. New paradigms in cardiovascular medicine: emerging technologies and practices: perioperative genomics. J Am Coll Cardiol 2005;46(11):1965-77. PMID 16325027
136: Preventza O, Liao JL, Olive JK, et al. Neurologic complications after the frozen elephant trunk procedure: a meta-analysis of more than 3000 patients. J Thorac Cardiovasc Surg 2020;160(1):20-33.e4. PMID 31757456
137: Pugsley W, Klinger L, Paschalis C, Treasure T, Harrison M, Newman S. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 1994;25:1393-9. PMID 8023354
138: Redmond JM, Greene PS, Goldsborough MA, et al. Neurologic injury in cardiac surgical patients with a history of stroke. Ann Thorac Surg 1996;61:42-7. PMID 8561618
139: Ricci M, Karamanoukian HL, D'Ancona G, Bergsland J, Salerno TA. Preventing neurologic complications in coronary artery surgery: the "off-pump, no-touch" technique. Am Heart J 2000;140:345-7. PMID 10966526
140: Ricci M, Karamanoukian HL, Dancona G, Bergsland J, Salerno TA. On-pump and off-pump coronary artery bypass grafting in the elderly: predictors of adverse outcome. J Card Surg 2001;16(6):458-66. PMID 11925026
141: Ricotta JJ, Faggioli GL, Castilone A, Hassett JM. Risk factors for stroke after cardiac surgery: Buffalo Cardiac-Cerebral Study Group. J Vasc Surg 1995;21:359-63;discussion 364. PMID 7853607
142: Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996;335:1857-63. PMID 8948560
143: Roberts DJ, Hall RI, Wang Y, Julien LC, Wood J, Goralski KB. S100B as a biomarker of blood-brain barrier disruption after thoracoabdominal aortic aneurysm repair: a secondary analysis from a prospective cohort study. Can J Anaesth 2021;68(12):1756-68. PMID 34570352
144: Rolfson DB, McElhaney JE, Rockwood K, et al. Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Can J Cardiol 1999;15:771-6. PMID 10411615
145: Saleem S, Younas S, Syed MA. Meta-analysis comparing transcatheter aortic valve implantation to surgical aortic valve replacement in low surgical risk patients. Am J Cardiol 2019;124(8):1257-64. PMID 31439283
146: Saller T, Petzold A, Zetterberg H, et al. A case series on the value of tau and neurofilament protein levels to predict and detect delirium in cardiac surgery patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019;163(3):241-6. PMID 31530945
147: Schukro C, Puchner SB. Safety and efficiency of low-field magnetic resonance imaging in patients with cardiac rhythm management devices. Eur J Radiol 2019;118:96-100. PMID 31439265
148: Schwartz LB, Bridgman AH, Kieffer RW, et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vasc Surg 1995;21:146-53. PMID 7823353
149: Segal AZ, Abernethy WB, Palacios IF, BeLue R, Rordorf G. Stroke as a complication of cardiac catheterization: risk factors and clinical features. Neurology 2001;56:975-7. PMID 11294941
150: Selnes OA, Goldsborough MA, Borowicz LM, Enger C, Quaskey SA, McKhann GM. Determinants of cognitive change after coronary artery bypass surgery: a multifactorial problem. Ann Thorac Surg 1999;67:1669-76. PMID 10391273
151: Selnes OA, Gottesman RF, Grega MA, et al. Cognitive and neurologic outcomes after coronary-artery bypass surgery. N Engl J Med 2012;366(3):250-7. PMID 22256807
152: Selnes OA, McKhann GM. Coronary-artery bypass surgery and the brain. N Engl J Med 2001;344:451-2. PMID 11172183
153: Shafei H, el-Kholy A, Azmy S, Ebrahim M, al-Ebrahim K. Vocal cord dysfunction after cardiac surgery: an overlooked complication. Eur J Cardiothorac Surg 1997;11:564-66. PMID 9105825
154: Shaw PJ, Bates D, Cartlidge NE, et al. Neurologic and neuropsychological morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery. Stroke 1987;18(4):700-7. PMID 3496690
155: Shi F, Sha L, Li H, et al. Recent progress in patent foramen ovale and related neurological diseases: a narrative review. Front Neurol 2023;14:1129062. PMID 37051056
156: Shimazaki Y, Watanabe T, Takahashi T, et al. Minimized mortality and neurological morbidity in surgery for chronic aortic aneurysm. J Card Surg 2004;19:338-43. PMID 15245465
157: Shroyer AL, Grover FL, Hattler B, et al. On pump versus off pump coronary artery bypass surgery. New Engl J Med 2009;361:1827-37. PMID 19890125
158: Sotaniemi KA. Long-term neurologic outcome after cardiac operation. Ann Thorac Surg 1995;59:1336-9. PMID 7733764
159: Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. New Engl J Med 2011;364:2187-98. PMID 21639811
160: Stanley TO, Mackensen GB, Grocott HP, et al. The impact of postoperative atrial fibrillation on neurocognitive outcome after coronary artery bypass graft surgery. Anesth Analg 2002;94:290-5. PMID 11812686
161: Steed L, Kong R, Stygall J, et al. The role of apolipoprotein E in cognitive decline after cardiac operation. Ann Thorac Surg 2001;71:823-6. PMID 11269459
162: Stöllberger C, Pulgram T, Finsterer J. Neurological consequences of atrioesophageal fistula after radiofrequency ablation in atrial fibrillation. Arch Neurol 2009;66(7):884-7. PMID 19597091
163: Stollberger C, Schneider B, Winkler-Dworak M, Finsterer J. Prevention of embolic stroke by catheter ablation of atrial fibrillation. Eur J Neurol 2008;15(12):1419-20. PMID 19049566
164: Stolz E, Gerriets T, Kluge A, Klovekorn WP, Kaps M, Bachmann G. Diffusion-weighted magnetic resonance imaging and neurobiochemical markers after aortic valve replacement: implications for future neuroprotective trials? Stroke 2004;35(4):888-92. PMID 14976326
165: Strauch JT, Spielvogel D, Lauten A, et al. Axillary artery cannulation: routine use in ascending and arch aorta replacement. Ann Thoracic Surg 2004;78:103-8. PMID 15223412
166: Szwed K, Słomka A, Pawliszak W, et al. Novel markers for predicting type 2 neurologic complications of coronary artery bypass grafting. Ann Thorac Surg 2020;110(2):599-607. PMID 31863758
167: Takach TJ, Reul GJ, Cooley DA, et al. Is an integrated approach warranted for concomitant carotid and coronary artery disease. Ann Thorac Surg 1997;64:16-22. PMID 9236329
168: Tan SZ, Surkhi AO, Singh S, et al. Favorable neurological outcomes in thoracic endovascular aortic repair with RELAY™ branched—an international perspective. J Card Surg 2022;37(11):3556-63. PMID 36124429
169: Tarakji KG, Sabik JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA 2011;305(4):381-90. PMID 21266685
170: Tardiff BE, Newman MF, Saunders AM, et al. Preliminary report of a genetic basis for cognitive decline after cardiac operations. The Neurologic Outcome Research Group of the Duke Heart Center. Ann Thorac Surg 1997;64(3):715-20. PMID 9307463
171: Teuteberg JJ, Slaughter MS, Rogers JG, et al. The HVAD left ventricular assist device: risk factors for neurological events and risk mitigation strategies. JACC Heart Fail 2015;3(10):818-28. PMID 26450000
172: Thomas CE, Jichici D, Petrucci R, Urrutia VC, Schwartzman RJ. Neurologic complications of the Novacor left ventricular assist device. Ann Thorac Surg 2001;72(4):1311-5. PMID 11603452
173: Thourani VH, Weintraub WS, Guyton RA, et al. Outcomes and long term survival for patients undergoing mitral valve repair versus replacement. Circulation 2003;108;298-304. PMID 12835220
174: Tucker PA, Ferguson JJ, Harlan M, Gaos CM, Massumi A. Balloon mitral valvuloplasty: clinical experience at the Texas Heart Institute. Tex Heart Inst J 1992;19:270-7. PMID 15227453
175: Tunick PA, Rosenzweig BP, Katz ES, Freedberg RS, Perez JL, Kronzon I. High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol 1994;23:1085-90. PMID 8144773
176: Ueda T, Shimizu H, Hashizume K, et al. Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion. Ann Thoracic Surg 2003;76:1951-6. PMID 14667620
177: Ueshima D, Fovino LN, D'Amico G, Brener SJ, Esposito G, Tarantini G. Transcatheter versus surgical aortic valve replacement in low- and intermediate-risk patients: an updated systematic review and meta-analysis. Cardiovasc Interv Ther 2019;34(3):216-25. PMID 30232711
178: van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol 2001;38:131-5. PMID 11451262
179: van Dijk D, Moons KG, Keizer AM, et al. Association between early and three month cognitive outcome after off-pump and on-pump coronary bypass surgery. Heart 2004;90(4):431-4. PMID 15020522
180: Vu T, Smith JA. An update on postoperative cognitive dysfunction following cardiac surgery. Front Psychiatry 2022;13:884907. PMID 35782418
181: Wagner BD, Grunwald GK, Hossein Almassi G, Li X, Grover FL, Shroyer AL. Factors associated with long-term survival in patients with stroke after coronary artery bypass grafting. J Int Med Res 2020;48(7):300060520920428. PMID 32723120
182: Wang C, Pozzoli A, von Segesser LK, Berdajs D, Tozzi P, Ferrari E. Management of left subclavian artery in type B aortic dissection treated with thoracic endovascular aorta repair. J Vasc Surg 2023;77(5):1553-61.e2. PMID 36272506
183: Wang TK, Wang MT, Ruygrok P. Patent foramen ovale closure versus medical therapy for cryptogenic stroke: meta-analysis of randomised trials. Heart Lung Circ 2019;28(4):623-31. PMID 29602754
184: Wiredu K, McKay TB, Qu J, Akeju O. Evaluating neurological biomarkers in serum after major cardiac surgery: a study of tau, neurofilament light chain, glial fibrillary acidic protein, and ubiquitin C-terminal hydrolase L1. Anesth Analg 2024;139(5):1122-4. PMID 39088364
185: Wityk RJ, Goldsborough M, Hillis A, et al. Diffusion and perfusion weighted magnetic resonance imaging in patients with neurologic complications after cardiac surgery. Arch Neurol 2001;58:571-6. PMID 11295987
186: Yates LA, Harper RW, Peverill RE, Smolich JJ. Balloon mitral valvuloplasty at Monash medical center: follow up of 201 procedures over an 11 year period. Heart Lung Circ 2001;10;83-5. PMID 16352044
187: Zea-Vera R, Green SY, Amarasekara HS, et al. Contemporary midterm outcomes after primary repair of chronic type A aortic dissection. Ann Thorac Surg 2023;116(3):459-66. PMID 36528124
188: Zeldich D, Bierowski M, Shabo L, Yaddanapudi S, Marhefka G. Neurovascular complications of acute aortic syndrome. J Stroke 2025;27(1):19-29. PMID 39916451
189: Zierer A, Melby SJ, Voeller RK, et al. Significance of neurologic complications in the modern era of cardiac transplantation. Ann Thorac Surg 2007;83:1684-90. PMID 17462379

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Elizabeth Anderson MD

Dr. Anderson of NYC Health and Hospitals/Kings County has no relevant financial relationships to disclose.
See Profile

Editor

Steven R Levine MD

Dr. Levine of the SUNY Health Science Center at Brooklyn has no relevant financial relationships to disclose.
See Profile

Former Authors

Elzbieta J Wirkowski MD
James F Meschia MD
Pablo R Castillo MD
Khalid Shahram MD
Pawani Sachar MD
Kumar Rajamani MD
Yongwoo Kim MD
Adrian Marchidann MD
Richard Libman MD (original authors)

Patient Profile

Age range of presentation: 0 month to 65+ years
Sex preponderance: male=female
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

ICD & OMIM codes

ICD-10: Atherosclerotic cardiovascular disease: I25.0

Complications of procedures not elsewhere classified: T81
ICD-11: Other specified chronic ischaemic heart disease: BA5Y

Cardiac procedure associated with injury or harm in therapeutic use: PK80.1

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Cardiovascular procedures: neurologic complications

Associated Disorders

Aseptic meningitis
Border-zone infarction
Brachial plexus injury
Femoral neuropathy
Hypoxic or ischemic encephalopathy
- Lumbosacral plexopathy
- Neuromuscular disorders
- Polyneuropathy
- Posterior reversible leukoencephalopathy
- Small vessel infarction
- Watershed infarction

Differential Diagnosis

nonsurgical factors (surgical and catheter manipulations)
drugs
infection
post-transplantation lymphoproliferative disorders
metabolic derangements

Also Relevant

Cardiac catheterization: neurologic complications
Cardiovascular intervention: neurologic complications
Carotid TIAs
Cerebral gas embolism
Congenital heart disease: neurologic complications
- Ischemic stroke
- Patent foramen ovale
- Stroke associated with cerebral angiography

Clinical Categories

Stroke & Vascular Disorders

Patient Handouts

Coma

Web References

Clinical Trials

Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis

	• Head CT
	• Brain MRI. There is increasing evidence of safety in patients with cardiac pacemakers and defibrillators.
	• Coagulation profile
	• Blood and fungal cultures
	• Lumbar puncture
	• EEG

Cardiovascular procedures: neurologic complications …

Cardiovascular procedures: neurologic complications

Cite this article

Introduction

Overview

Key points

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Special considerations

Anesthesia

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Stroke associated with cerebral angiography

Fibromuscular dysplasia

Brainstem hemorrhage

Cardiac catheterization: neurologic complications

Intracranial atherosclerosis

Cerebellar infarction and cerebellar hemorrhage

Lobar hemorrhage

Nontraumatic intracerebral hemorrhage

Cardiovascular procedures: neurologic complications

Cite this article

Introduction

Overview

Key points

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Special considerations

Anesthesia

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Stroke associated with cerebral angiography

Fibromuscular dysplasia

Brainstem hemorrhage

Cardiac catheterization: neurologic complications

Intracranial atherosclerosis

Cerebellar infarction and cerebellar hemorrhage

Lobar hemorrhage

Nontraumatic intracerebral hemorrhage

This is an article preview.
Start a Free Account
to access the full version.