Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery

Abstract

Introduction: Acute ischemic stroke (AIS) can be a catastrophic complication of cardiac surgery previously without effective treatment. Endovascular thrombectomy (EVT) is a potentially life-saving intervention. We examined patients at our institution who had EVT to treat AIS post cardiac surgery.

Methods: We retrospectively reviewed a stroke database from January 1, 2016 to October 31, 2021 to identify patients who had undergone EVT to treat AIS following cardiac surgery. Demographic data, operation type, stroke severity, imaging features, management and outcomes (mortality and modified Rankin Score (mRS)) were assessed.

Results: Of 5022 consecutive patients with AIS, 870 underwent EVT. Seven patients (0.8%) had EVT following cardiac surgery. Operations varied: two coronary artery bypass grafting (CABG), two transcatheter AVR, one redo surgical aortic valve replacement (AVR), one mitral valve repair and one patient with combined aortic and mitral valve replacements and CABG. Meantime postsurgery to stroke symptoms onset was 3 days (range 0-9 days). Median NIHSS was 26 (range 10-32). Five patients had middle cerebral artery occlusion and two internal carotid artery (n = 2). Median time between onset of symptoms and recanalization was 157 min (range 97-263). Two patients received Intra-arterial Thrombolysis. All patients survived and were discharged to another hospital (n = 3), home (n = 2), or rehabilitation facility (n = 2). Median 3-month mRS was 3 (range 0-6).

Conclusion: We report the largest case series of EVT after cardiac surgery. EVT can be associated with excellent outcomes in these patients. Close neurological monitoring postoperatively to identify patients who may benefit from intervention is key.

Keywords: cardiovascular pathology; cardiovascular research; coronary artery disease; valve repair/replacement.

Figure 1

Digital subtraction cerebral angiography showing an occluded left ICA (Patient #1). ICA, internal carotid artery.

Figure 2

Computed tomography perfusion showing favorable characteristics and penumbra map with irreversible brain ischemia volume (cerebral blood volume<30%) of 92 ml and total ischemic brain volume (delay time>3 s) of 471 ml (Patient #1)

Figure 3

Deployment of proximal left ICA stent with TICI 3 reperfusion (Patient #1). ICA, internal carotid artery.

Figure 4

CTA showing left M1 occlusion (Patient #2). CTA, computed tomography angiography.

Figure 5

Computed tomography perfusion showed favorable imaging characteristics with irreversible brain ischemic volume (cerebral blood volume<30%) of 14 ml and total ischemic brain volume (delay time>3 s) of 94 ml (Patient #2).

Figure 6

Postprocedural CTA showing TICI 2c reperfusion (Patient #2). CTA, computed tomography angiography.

Figure 7

MRI at 24 h showing multifocal small left MCA territory and small right medial thalamic infarcts (Patient #2). MCA, middle cerebral artery; MRI, magnetic resonance imaging

Figure 8

Digital subtraction angiography showing an occluded right ICA (Patient #3). ICA, internal carotid artery.

Figure 9

Computed tomography perfusion demonstrating favorable imaging characteristics with irreversible brain ischemia volume (cerebral blood volume<30%) of 36 ml and predicted total ischemic brain tissue volume (delay time>3 s) of 320 ml (Patient #3).

Figure 10

Computed tomography brain showed a large right hemispheric infarction complicated by severe cerebral edema with subfalcine and uncal herniation (Patient #3).