Impact of the Haga Braincare Strategy on the burden ofhaemodynamic and emb...
Friso Duynsteea, RuudW.M. Keunena,*, Agnes van Sonderena, Ali M. Keyhan-Falsafib, Gerard J.F. Hoohenkerkb, Gayleen Stephensb, Erik Teeuwsb, Jan W.K. van Alphenc, De´nes L.J. Tavya, ArneMoscha, Sebastiaan F.T.M. de Bruijna, Hans van Overhagend, Frank E.E. Treurnietd, Lucas C. vanDijkd and PaulienM. van Kampene
OBJECTIVES: This study prospectively evaluates the impact of the Haga Braincare Strategy (HBS) on the occurrence of haemodynamic and embolic stroke in a cohort of patients who underwent coronay artery bypass grafting (CABG), valve replacement of a combination of both types of surgery between 2012 and 2015 at the Haga Teaching Hospitals.
METHODS: The HBS is a dual strategy based on a preoperative vascular work-up of the cerebral circulation by transcranial Doppler and a perioperative monitoring of the cerebral circulation by cerebral oximetry. Duplex of the carotid arteries and/or computed tomography angiography prior to surgery was performed in high-risk patients. Patients with severe carotid artery stenosis were scheduled for carotid angioplasty prior to surgery or waived from surgery.
RESULTS: A total of 1065 patients were included. Poor cerebral haemodynamics were identified by transcranial Doppler in 2.1% of patients (n = 22). Based on the HBS, 3 patients were waived from surgery, 4 received preoperative carotid angioplasty followed by cardiac surgery and the remaining patients were operated while being monitored with bilateral cerebral oximetry sensors. In all, 2.2% of the study group experienced a stroke (n = 23), of which none were classified as haemodynamic. Most of the remaining presumed embolic strokes showed a minor to moderate stroke severity.
CONCLUSIONS: In this single-centre prospective follow-up study, surveillance of cerebral perfusion by the HBS eliminated the occurrence of haemodynamic stroke while most of the residual strokes had a good to favourable prognosis.
Keywords: TCD • cerebral oximetry • CABG • Stroke
Perioperative stroke (POS) can be a devastating complication following cardiac surgery. The incidence of POS in the literature varies between 1 and 5% [1, 2]. POS is an important cause of morbidity and mortality after cardiac surgery. Most of POS are embolic in nature and presumed to be the result of intraoperative surgical manipulation of the aortic arch or postoperative atrial fibrillation (AF). However, a substantial number of the POS are haemodynamic in nature. Haemodynamic strokes are due to the combination of (i) high-grade stenosis or occlusions of conductance vessels (for instance the brachiocephalic artery, carotid and/or middle cerebral arteries [MCAs]), (ii) poor collaterals and/or (iii) a drop in systemic blood pressure and/or blood oxygenation. On computed tomography (CT) and magnetic resonance imaging a haemodynamic stroke appears as a so-called watershed infarct (see Fig. 1). With the ischaemia sensitive diffusion weighted magnetic resonance imaging watershed infarcts can be seen in up to 48% of the patients following a cardiosurgical procedure . A recent systemic review and observational studies estimated that 10–50% of POS in cardiac surgery are haemodynamic in nature [4–6]. Recent CABG trials in patients with occlusive cerebrovascular disease showed stroke/death ratios ranging from 3.8% to 20.6%, indicating that poor-cerebral perfusion is associated with poor outcome. carotid arteries. Moreover, we combined preoperative TCD with non-invasive cerebral oximetry monitoring during and after the first hours of surgery in order to detect perioperative cerebral low-flow states. We called this dual strategy the ‘Haga Braincare Strategy’ (HBS). It turned out that implementation of the HBS reduced the incidence of ischaemic postoperative delirium at the Haga by more than 50% . Since the last years, we have systematically implemented and documented the results of the HBS in a prospective follow-up study. In this article, we describe the results with special focus on the impact of the HBS on stroke epidemiology and how it influenced decision making.