A protocol for the management of hyponatremia peri-liver transplant reduces post-transplant neurological complications.

Rapid changes in serum sodium (ΔSNa) peri-liver transplant (LT) predispose to post-LT neurological complications (NC). We aimed to assess whether implementation of a protocol directed at limiting peri-LT ΔSNa reduced post-LT NC. A retrospective single-center review of adult LT recipients from 1/2016 to 10/2017 was performed. Patients with hyponatremia (SNa < 135 mEq/L) within 7 days of LT were analyzed in two eras: pre-protocol (1/2016-9/2016) and post-protocol (10/2016-10/2017). The primary outcome was the development of NC within 1 month of LT. Perioperative ΔSNa (ΔSNaPost-LT) was assessed as a secondary outcome. Among 85 and 107 patients who underwent LT pre- and post-protocol, 39 (46%) and 42 (39%) were hyponatremic within 7 days of LT, respectively. Significantly fewer patients in the post-protocol era developed NC vs. pre-protocol (7.1% vs. 25.6%, p = .02). Additionally, fewer LT recipients in the post-protocol era developed ΔSNaPost-LT ≥ 10 mEq/L (9.5% vs. 30.7%, p = .02). Intraoperatively, more patients post-protocol received hypotonic saline (33.3% vs. 2.6%, p < .01). Multivariable logistic regression revealed that transplantation in the post-protocol era was associated with significantly reduced odds (odds ratio 0.11, 95% confidence interval 0.01-0.50) of developing NC. In conclusion, the implementation of a multidisciplinary protocol aimed at reducing ΔSNa peri-LT was independently associated with a reduction in post-LT NC.

Evaluating the obtunded patient after cardiac surgery: the role of continuous electroencephalography.

PURPOSE: This prospective study was designed to evaluate the role of continuous electroencephalography (EEG) in the management of adult patients with neurological dysfunction early after cardiac surgery. MATERIALS AND METHODS: Seven hundred twenty-three patients undergoing cardiac surgery between December 2010 and June 2011 were divided into 2 groups based on the presence or absence of post-operative neurological dysfunction. All patients with neurological dysfunction underwent continuous EEG. RESULTS: Neurological dysfunction was diagnosed in 12 patients (1.7%), of whom 5 (42%) did not regain consciousness after surgery, 4 (33%) had a clinical event suspicious for seizure and 3 (25%) had neurological deficits. Continuous EEG showed that 2 of the 5 patients who failed to regain consciousness, without clinical signs of seizures, were in electrographic non-convulsive focal status epilepticus. Periodic discharges were present in the continuous EEGs of 3 patients. Three additional patients (25%) had abnormal movements that continuous EEG demonstrated was not due to seizure activity. CONCLUSIONS: Non-convulsive status epilepticus may be an under-recognized cause of obtundation early after cardiac surgery. Continuous EEG monitoring is a non-invasive test that can identify patients that may benefit from anti-epileptic medication. Larger comparative studies are required to establish whether this leads to significant improvements in patient outcomes.

Primary intraosseous cavernous hemangioma of the clivus: case report and review of the literature.

Primary intraosseous hemangiomas are benign, vascular malformations that account for approximately 1% of all primary bone neoplasms. These tumors are mostly found in vertebral bodies and are rarely seen in the calvarium, where they represent 0.2% of bony neoplasms. When found in the skull, they tend to present with vague symptoms and do not have the typical radiological findings suggestive of hemangiomas. Because of this, these tumors can be missed in many cases or may be misinterpreted as more ominous lesions like multiple myeloma or osteosarcoma. Involvement of the skull base is exceedingly rare, and presentation with cranial nerve unilateral polyneuropathies has not been reported. We report a patient case with review of recent pertinent literature.

Dexmedetomidine controls twitch-convulsive syndrome in the course of uremic encephalopathy.

An 85 year old man with a history of chronic renal insufficiency was admitted to the cardiothoracic intensive care unit after aortic valve replacement. His postoperative course was marked by acute oliguric renal failure for high blood urea nitrogen (BUN) and acute hyperactive delirium. At this time he also developed tremors with muscle twitching; he received no other form of sedatives. A neurology consult made the diagnosis of twitch-convulsive syndrome associated with uremic encephalopathy. While the patient was receiving the dexmedetomidine infusion, the signs of the twitch-convulsive syndrome, particularly the twitching and tremors, disappeared. Within 30 minutes of the end of the dexmedetomidine infusion, symptoms of the twitch-convulsive syndrome returned, manifesting as acute tremulousness. After several dialysis treatments, his BUN decreased and the dexmedetomidine was weaned, without return of the symptoms of twitch-convulsive syndrome.

Predictors and outcomes of seizures after cardiac surgery: a multivariable analysis of 2,578 patients.

BACKGROUND: Limited data exist regarding the epidemiology and prognosis of seizures in adults after cardiac surgery. The aim of this study was to define preoperative predictors of seizures and impact on postoperative outcomes. METHODS: A prospective database of 2,578 consecutive adults who underwent cardiac surgery at a single institution between April 2007 and December 2009 was retrospectively analyzed to determine risk factors for postoperative seizures and prognostic impact. No patient received tranexamic acid or aprotinin. RESULTS: Seizures occurred in 31 patients (1%) at a median of 2 days postoperatively (1 patient had a preoperative diagnosis of seizure disorder). Seizures were classified as generalized tonic-clonic (71%), simple/complex partial (26%), or status epilepticus (3%). Incidence differed according to procedure (coronary bypass 0.1%, isolated valve 1%, valve/coronary bypass 3%, aorta 5%; p <0.001). Patients who experienced seizures had nearly a fivefold higher operative mortality than patients who did not (29% versus 6%, p <0.001). Head computed tomography was performed in 26 patients (84%), of whom ischemic strokes were identified in 14 cases (53%). These were embolic in 9 patients (34%), and watershed in 3 (12%). Hemorrhagic strokes were observed in 2 patients (8%). The occurrence of a new postoperative stroke in seizure patients did not significantly increase the likelihood of in-hospital death. Thirteen patients (41%) were discharged without neurologic deficit. Multivariable logistic regression analysis identified three risk factors for seizure: deep hypothermic circulatory arrest, aortic calcification or atheroma, and critical preoperative state. CONCLUSIONS: Seizures in adults after cardiac surgery are strong independent predictors of permanent neurologic deficit and increased operative mortality. Early head computed tomography may be indicated to identify treatable pathology.

Incidence, imaging analysis, and early and late outcomes of stroke after cardiac valve operation.

The aim of this study was to analyze the incidence, topography, and mechanisms of stroke, independent predictors, and late outcome after cardiac valve operations. We retrospectively analyzed prospectively collected data from 2,808 patients (mean age 63 +/- 15 years, n = 1,610, 55% men) who underwent valve surgery with or without concomitant coronary artery bypass grafting from January 1998 to December 2006. Stroke was defined as any new permanent focal neurologic deficit. Overall incidence of stroke was 2.2% (n = 63) and decreased during the study period from 3.3% (1998 to 2002) to 1.3% (2003 to 2006; p = 0.001). The highest stroke rate was observed after double aortic/mitral valve replacement (5.4%) and valve/coronary artery bypass grafting procedures (3.6%). Brain imaging was positive in 74% (n = 43 of 58) and showed ischemic stroke in all patients and hemorrhagic conversion in 28%. Distribution of acute stroke was large territory embolic artery (n = 33, 77%), watershed (n = 7, 16%), and mixed pattern (n = 3, 7%). Multivariate analysis revealed calcified ascending aorta (odds ratio [OR] 2.7), female gender (OR 2.6), ejection fraction <30% (OR 2.3), diabetes (OR 2.2), age >70 years (OR 2.0), and cardiopulmonary bypass time >120 minutes (OR 3.7) as predictors of stroke. Hospital mortality was 24% and 4.6% in patients with and without stroke, respectively. Survival of stroke patients was 78% and 54% at 1 year and 5 years, respectively, and was significantly decreased compared with patients without stroke. Valve pathology including endocarditis did not influence the incidence of stroke. Intraoperative epiaortic scanning may contribute in decreasing the incidence of this complication and may be warranted in all patients undergoing valvular surgery. In conclusion, stroke after valvular surgery is associated with an increased hospital mortality and morbidity and decreased long-term survival.

Incidence, topography, predictors and long-term survival after stroke in patients undergoing coronary artery bypass grafting.

BACKGROUND: Previous studies on stroke after coronary artery bypass grafting (CABG) provide limited data about the timing (early vs delayed) of this event and findings of brain imaging analysis. This information is of significant importance because it provides insight into the etiology of stroke, potentially allowing the development of preventive measures. This study analyzed the incidence and timing of stroke, the topography and mechanisms of cerebral lesions, independent predictors, and late outcome after the occurrence of this complication in patients undergoing CABG. METHODS: We retrospectively analyzed prospectively collected data from 2985 patients (2064 men [67%]), with a mean age of 66 +/- 11 years, who underwent CABG between January 1998 and December 2006. Stroke was defined as any new permanent focal neurologic deficit (early stroke, < or = 24 hours; delayed, > 24 hours postoperatively). RESULTS: The incidence of stroke was 1.6% (n = 48) and similar between conventional CABG (1.6%) and off-pump CABG (1.4%). Early stroke occurred in 25 patients (52%). Brain imaging was obtained in 44 patients (92%): 44 had computed tomography, 3 had magnetic resonance imaging. Results were positive in 33 of 44 patients (75%), showing large embolic stroke in 25 (76%), watershed in 5 (15%), and mixed pattern in 3 (9%). Chronic ischemic changes were found in 17 patients. Multivariate analysis revealed extensive aortic calcification (odds ratio [OR], 4.2), previous stroke (OR, 2.2), female sex (OR, 1.9), and congestive heart failure (OR, 2.6) as predictors of stroke. The hospital mortality rate after stroke was 16.7% (n = 8) compared with 1.5% (n = 44) in those without (p < 0.001). The mortality rate was higher in early stroke at 24% (6 of 25) compared with 9% (2 of 23) in late stroke. Survival of stroke patients was 87% at 1 year and 62% at 5 years and was significantly reduced compared with 96% and 85%, respectively, in patients without stroke (p<0.001). CONCLUSIONS: Most strokes after CABG occurred early after surgery. This complication is associated with an increased hospital mortality and morbidity and reduced long-term survival. The infarction type had no impact on early and late outcome. Preoperative computed tomography scan seems warranted in patients at risk and without any previous history of stroke.

Epidemiology of stroke after cardiac surgery in the current era.

OBJECTIVE: Previous studies of the epidemiology of stroke in patients undergoing cardiac surgery have been based primarily on patients having coronary bypass surgery and therefore have limited applicability to the more heterogenous populations seen in the current era. We examine the epidemiology of stroke after cardiac surgery in a contemporary surgical population. METHODS: Retrospective analysis was conducted of a prospective database of 5085 adults (coronary bypass 2401, isolated valve 1003, valve/coronary bypass 546, thoracic aorta 517, transplant/assist device 179, adult congenital 124, other 315) who had cardiac surgery at a single institution over a 6-year period (1998-2004). RESULTS: Stroke occurred in 134 (2.6%) patients. Incidence varied according to procedure (coronary bypass 1.7%, isolated valve 1.8%, valve/coronary bypass 4.4%, and ascending aorta 4.6%). Patients who had a stroke had a higher perioperative mortality rate than that of patients who did not (32.8% vs 4.9%; P < .0001) and a longer period of hospitalization (median 30 days vs 7 days; P < .0001). Multivariate logistic analysis identified 10 preoperative predictors of stroke: gender, age, aortic surgery, previous stroke, critical preoperative state, poor ventricular function, diabetes, peripheral vascular disease, unstable angina, and pulmonary hypertension. A logistic model was developed on the basis of these risk factors to predict the likelihood of stroke. CONCLUSIONS: We have demonstrated a relatively low incidence of stroke in a diverse contemporary cardiac surgical cohort. By enabling preoperative identification of patients at risk, our logistic model has the potential to improve preoperative patient counseling and selection and could help to define high-risk cohorts for research into stroke prevention.

Neurologic complications of cardiac surgery: current concepts and recent advances.

Neurologic complications following cardiac surgery result in increased morbidity and mortality. The incidence of stroke is 2% to 4%, but is substantially higher in patients with a prior history of stroke. The success of off-pump techniques in altering this risk is controversial. The efficacy and safety of simultaneous carotid endarterectomy and coronary artery bypass surgery are still debated. Mechanical clot retrievers may offer new opportunity to treat postoperative large, middle cerebral artery strokes. The risk of cognitive deficits is debatable but may be due to factors other than the use of bypass and may not differ from similar deficits after noncardiac surgery. Short-term cognitive deficits usually resolve by 1 to 3 months. Long-term risks are not clearly established. Novel approaches may decrease the incidence of neurocognitive dysfunction. Postoperative seizures may result from global or focal cerebral ischemia due to hypoperfusion, particulate or air emboli, or metabolic causes. Newer anticonvulsant drugs may offer additional management opportunities.