This Article Full Text Full Text (PDF) All Versions of this Article: 34/12/2830    most recent 01.STR.0000098650.12386.B3v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Likosky, D. S. Articles by O’Connor, G. T. Search for Related Content PubMed PubMed Citation Articles by Likosky, D. S. Articles by O’Connor, G. T. Pubmed/NCBI databases Medline Plus Health Information Coronary Artery Bypass Surgery Stroke Related Collections CV surgery: coronary artery disease Acute Cerebral Infarction Embolic stroke

(Stroke. 2003;34:2830.)
© 2003 American Heart Association, Inc.

Original Contributions

Determination of Etiologic Mechanisms of Strokes Secondary to Coronary Artery Bypass Graft Surgery

Donald S. Likosky, PhD; Charles A.S. Marrin, MB, BS; Louis R. Caplan, MD; Yvon R. Baribeau, MD; Jeremy R. Morton, MD; Ronald M. Weintraub, MD; Gregg S. Hartman, MD; Felix Hernandez, Jr, MD; Steven P. Braff, MD; David C. Charlesworth, MD; David J. Malenka, MD; Cathy S. Ross, MS Gerald T. O’Connor, PhD for the Northern New England Cardiovascular Disease Study Group

From the Departments of Medicine (D.S.L., C.A.S.M., D.J.M., C.S.R., G.T.O.), Surgery (C.A.S.M.), Anesthesiology (G.S.H.), and Community and Family Medicine (D.S.L., D.J.M., C.S.R., G.T.O.), Dartmouth-Hitchcock Medical Center, Hanover, NH; Departments of Neurology (L.R.C.) and Surgery (R.M.W.), Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Catholic Medical Center, Manchester, NH (Y.R.B., D.C.C.); Department of Surgery, Maine Medical Center, Portland (J.R.M.); Department of Surgery, Eastern Maine Medical Center, Bangor (F.H.); and Department of Radiology, Fletcher Allen Health Care, Burlington, Vt (S.P.B.).

Reprint requests to Donald S. Likosky, PhD, Clinical Research Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756. E-mail Donald.Likosky{at}Dartmouth.edu

Background and Purpose— Current research focused on stroke in the setting of coronary artery bypass graft (CABG) surgery has missed important opportunities for additional understanding by failing to consider the range of different stroke mechanisms. We developed and implemented a classification system to identify the distribution and timing of stroke subtypes.

Methods— We conducted a regional study of 388 patients with the diagnosis of stroke after isolated CABG surgery in northern New England from 1992 to 2000. Data were collected on patient and disease characteristics, intraoperative and postoperative care, and outcomes. Stroke etiology was classified into 1 of the following: hemorrhage, thromboembolic (embolic, thrombotic, lacunar), hypoperfusion, other (subtype not listed above), multiple (2 competing mechanisms), or unclassified (unknown mechanism). The reliability of the classification system was determined by percent agreement and statistics.

Results— Embolic strokes accounted for 62.1% of strokes, followed by multiple etiologies (10.1%), hypoperfusion (8.8%), lacunar (3.1%), thrombotic (1.0%), and hemorrhage (1.0%). There were 54 strokes with unknown etiology (13.9%). There were no strokes classified as "other." Nearly 45% (105/235) of the embolic and 56% (18/32) of hypoperfusion strokes occurred within the first postoperative day.

Conclusions— We used a locally developed classification system to determine the etiologic mechanism of 388 strokes secondary to CABG surgery. The principal etiologic mechanism was embolic, followed by stroke having multiple mechanisms and hypoperfusion. Regardless of mechanism, strokes predominantly occurred within the first postoperative day.

Key Words: cerebral infarction • coronary artery bypass • embolism

This article has been cited by other articles:

				T. C. Lisle, K. M. Barrett, L. M. Gazoni, B. R. Swenson, C. D. Scott, A. Kazemi, J. A. Kern, B. B. Peeler, I. L. Kron, and K. C. Johnston Timing of stroke after cardiopulmonary bypass determines mortality. Ann. Thorac. Surg., May 1, 2008; 85(5): 1556 - 1562. [Abstract] [Full Text] [PDF]

				R. M. Mentzer Jr, C. Bartels, R. Bolli, S. Boyce, G. D. Buckberg, B. Chaitman, A. Haverich, J. Knight, P. Menasche, M. L. Myers, et al. Sodium-Hydrogen Exchange Inhibition by Cariporide to Reduce the Risk of Ischemic Cardiac Events in Patients Undergoing Coronary Artery Bypass Grafting: Results of the EXPEDITION Study Ann. Thorac. Surg., April 1, 2008; 85(4): 1261 - 1270. [Abstract] [Full Text] [PDF]

				S. J. Durham and J. P. Gold Late Complications of Cardiac Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 535 - 548. [Full Text]

				A. C. Anyanwu, F. Filsoufi, S. P. Salzberg, D. J. Bronster, and D. H. Adams Epidemiology of stroke after cardiac surgery in the current era. J. Thorac. Cardiovasc. Surg., November 1, 2007; 134(5): 1121 - 1127. [Abstract] [Full Text] [PDF]

				R. Lee, N. Matsutani, A. C. Polimenakos, L. C. Levers, M. Lee, and R. G. Johnson Preoperative Noncontrast Chest Computed Tomography Identifies Potential Aortic Emboli Ann. Thorac. Surg., July 1, 2007; 84(1): 38 - 42. [Abstract] [Full Text] [PDF]

				M. Selim Perioperative Stroke N. Engl. J. Med., February 15, 2007; 356(7): 706 - 713. [Full Text] [PDF]

				F. Biancari, M. Mosorin, E. Rasinaho, J. Lahtinen, J. Heikkinen, E. Niemela, V. Anttila, M. Lepojarvi, and T. Juvonen Postoperative stroke after off-pump versus on-pump coronary artery bypass surgery J. Thorac. Cardiovasc. Surg., January 1, 2007; 133(1): 169 - 173. [Abstract] [Full Text] [PDF]

				A. Kollar, S. D. Lick, K. N. Vasquez, and V. R. Conti Relationship of Atrial Fibrillation and Stroke After Coronary Artery Bypass Graft Surgery: When is Anticoagulation Indicated? Ann. Thorac. Surg., August 1, 2006; 82(2): 515 - 523. [Abstract] [Full Text] [PDF]

				K. G. Shann, D. S. Likosky, J. M. Murkin, R. A. Baker, Y. R. Baribeau, G. R. DeFoe, T. A. Dickinson, T. J. Gardner, H. P. Grocott, G. T. O'Connor, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 283 - 290.e3. [Full Text] [PDF]

				T. F. Floyd, P. N. Shah, C. C. Price, F. Harris, S. J. Ratcliffe, M. A. Acker, J. E. Bavaria, H. Rahmouni, B. Kuersten, S. Wiegers, et al. Clinically Silent Cerebral Ischemic Events After Cardiac Surgery: Their Incidence, Regional Vascular Occurrence, and Procedural Dependence Ann. Thorac. Surg., June 1, 2006; 81(6): 2160 - 2166. [Abstract] [Full Text] [PDF]

				B. Zingone, E. Rauber, G. Gatti, A. Pappalardo, B. Benussi, L. Dreas, and L. Lattuada The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 720 - 728. [Abstract] [Full Text] [PDF]

				J. P. Mathew, H. M. Rinder, B. R. Smith, M. F. Newman, and C. S. Rinder Transcerebral Platelet Activation After Aortic Cross-Clamp Release is Linked to Neurocognitive Decline. Ann. Thorac. Surg., May 1, 2006; 81(5): 1644 - 1649. [Abstract] [Full Text] [PDF]

				G. M. McKhann, M. A. Grega, L. M. Borowicz Jr, W. A. Baumgartner, and O. A. Selnes Stroke and Encephalopathy After Cardiac Surgery: An Update Stroke, February 1, 2006; 37(2): 562 - 571. [Abstract] [Full Text] [PDF]

				V. L. Babikian and P. A. Wolf Retinal and Cerebral Microembolism During On-Pump and Off-Pump Coronary Artery Bypass Graft Surgery Circulation, December 20, 2005; 112(25): 3816 - 3817. [Full Text] [PDF]

				C. Lund, K. Sundet, B. Tennoe, P. K. Hol, K. A. Rein, E. Fosse, and D. Russell Cerebral Ischemic Injury and Cognitive Impairment After Off-Pump and On-Pump Coronary Artery Bypass Grafting Surgery Ann. Thorac. Surg., December 1, 2005; 80(6): 2126 - 2131. [Abstract] [Full Text] [PDF]

				D. S. Likosky, W. C. Nugent, and C. S. Ross Improving Outcomes of Cardiac Surgery Through Cooperative Efforts: The Northern New England Experience Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 119 - 121. [Abstract] [PDF]

				R. C. Groom and Cardiovascular Disease Study Group A Systematic Approach to the Understanding and Redesigning of Cardiopulmonary Bypass Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 159 - 161. [Abstract] [PDF]

				L. J. Dacey, D. S. Likosky, B. J. Leavitt, S. J. Lahey, R. D. Quinn, F. Hernandez Jr, H. B. Quinton, J. P. Desimone, C. S. Ross, G. T. O'Connor, et al. Perioperative Stroke and Long-Term Survival After Coronary Bypass Graft Surgery Ann. Thorac. Surg., February 1, 2005; 79(2): 532 - 536. [Abstract] [Full Text] [PDF]

				T. J. Gardner INVITED COMMENTARY Ann. Thorac. Surg., February 1, 2005; 79(2): 537 - 537. [Full Text] [PDF]

				R C Groom, D S Likosky, R J Forest, G T O'Connor, J R Morton, C S Ross, C Clark, and R Kramer A model for cardiopulmonary bypass redesign Perfusion, July 1, 2004; 19(4): 257 - 261. [Abstract] [PDF]

				What Causes Strokes That Are Secondary to CABG? Journal Watch Cardiology, January 30, 2004; 2004(130): 4 - 4. [Full Text]