New brain infarcts on magnetic resonance imaging after coronary artery bypass graft surgery: Lesion patterns, mechanism, and predictors

Nah, Hyun Wook; Lee, Jae Won; Chung, Cheol Hyun; Choo, Suk Jung; Kwon, Sun U.; Kim, Jong Seung; Warach, Steven; Kang, Dong Wha

doi:10.1002/ana.24238

Cited by 48 publications

(29 citation statements)

References 43 publications

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“…The vast majority of these cardioembolic strokes involve lesions in a cortical territory. 50 In contrast, lacunar stroke is by definition restricted to a subcortical location. 51 About half of cardioembolic strokes involve multiple cerebral arterial territories (i.e., both internal cerebral arteries or one internal cerebral artery as well as the basilar artery), 50 which distinguishes cardiac embolism from artery-to-artery embolism due to large-artery atherosclerosis in the cerebral circulation.…”

Section: Diagnostic Criteria For Cardioembolic Strokementioning

confidence: 99%

Cardioembolic Stroke

Kamel

Healey

2017

Circulation Research

322

253

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Cardiac embolism accounts for an increasing proportion of ischemic strokes, and might multiply several-fold over the next decades. However, research points to several potential strategies to stem this expected rise in cardioembolic stroke. First, although one-third of strokes are of unclear cause, it is increasingly accepted that many of these cryptogenic strokes arise from a distant embolism rather than in-situ cerebrovascular disease, leading to the recent formulation of “embolic stroke of undetermined source” (ESUS) as a distinct target for investigation. Second, recent clinical trials have indicated that ESUS may often stem from subclinical atrial fibrillation (AF) which can be diagnosed with prolonged heart-rhythm monitoring. Third, emerging evidence indicates that a thrombogenic atrial substrate can lead to atrial thromboembolism even in the absence of AF. Such an atrial cardiopathy may explain many cases of ESUS, and oral anticoagulant drugs may prove to reduce stroke risk from atrial cardiopathy given its parallels to AF. Non-vitamin K antagonist oral anticoagulant (NOAC) drugs have recently expanded therapeutic options for preventing cardioembolic stroke and are currently being tested for stroke prevention in patients with ESUS, including specifically those with atrial cardiopathy. Fourth, increasing appreciation of thrombogenic atrial substrate and the common co-existence of cardiac and extra-cardiac stroke risk factors suggests benefits from global vascular risk factor management in addition to anticoagulation. Finally, improved imaging of ventricular thrombus plus the availability of NOAC drugs may lead to better prevention of stroke from acute myocardial infarction and heart failure.

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Section: Diagnostic Criteria For Cardioembolic Strokementioning

confidence: 99%

Cardioembolic Stroke

Kamel

Healey

2017

Circulation Research

322

253

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“…After 30 min tHI, the ipsilateral hemisphere showed poorer recovery of SaO 2 than the contralateral cortex (~28% compared with ~39% in normoxia and ~53% versus ~70% under 100% oxygen) (Figure 1D) (n>3 times). This pattern suggests that a transient episode of HI may impair subsequent cortical oxygenation 5 .…”

Section: Resultsmentioning

confidence: 94%

“…A recent study showed that 27.5% of CABG patients developed new brain infarct on diffusion-weighted imaging (DWI). Among them, 3.1% showed overt symptoms while the other 24.1% were clinically silent 5 . This high rate of silent infarct may relate to the phenomenon of post-surgery decline of cognitive functions 6 .…”

Section: Discussionmentioning

confidence: 99%

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Prophylactic Edaravone Prevents Transient Hypoxic-Ischemic Brain Injury

Sun

Wali

et al. 2015

Stroke

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Background and Purpose Hypoperfusion-induced thrombosis is an important mechanism for post-surgery stroke and cognitive decline, but there are no perioperative neuroprotectants to date. This study investigated whether prophylactic application of Edaravone, a free radical scavenger already used in treating ischemic stroke in Japan, can prevent infarct and cognitive deficits in a murine model of transient cerebral hypoxia-ischemia. Methods Adult male C57BL/6 mice were subjected to transient hypoxic-ischemic (tHI) insult that consists of 30-min occlusion of the unilateral common carotid artery and exposure to 7.5% oxygen. Edaravone or saline was prophylactically applied to compare their effects on cortical oxygen saturation, blood flow, coagulation, oxidative stress, metabolites, and learning-memory using methods that include photoacoustic imaging, laser speckle contrast imaging, solid state NMR and Morris water maze. The effects on infarct size by Edaravone application at different time-points after tHI were also compared. Results Prophylactic administration of Edaravone (4.5 mg/kg × 2, IP, 1 h before and 1 h after tHI) improved vascular reperfusion, oxygen saturation, and the maintenance of brain metabolites, while reducing oxidative stress, thrombosis, white-matter injury, and learning impairment after tHI insult. Delayed Edaravone treatment after 3 h post-tHI became unable to reduce infarct size. Conclusions Acute application of Edaravone may be a useful strategy to prevent post-surgery stroke and cognitive impairment, especially in patients with severe carotid stenosis.

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“…Given the strong circumstantial evidence favouring an embolic aetiology of most cryptogenic strokes,3 4 investigators have recently used the term embolic stroke of undetermined source (ESUS) to describe non-lacunar stroke without evidence of ipsilateral extracranial or intracranial large artery stenosis of 50% or more, a major cardioembolic source such as atrial fibrillation (AF) or other specific mechanism of stroke 5. Identifying the root cause of ischaemic stroke is more than an academic issue, since the specific stroke subtype often guides secondary stroke prevention measures.…”

Section: Introductionmentioning

confidence: 99%

Cardiac magnetic resonance imaging: a new tool to identify cardioaortic sources in ischaemic stroke

Yaghi

Liberman

Atalay

et al. 2016

J Neurol Neurosurg Psychiatry

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Stroke of undetermined aetiology or 'cryptogenic' stroke accounts for 30-40% of ischaemic strokes despite extensive diagnostic evaluation. The role and yield of cardiac imaging is controversial. Cardiac MRI (CMR) has been used for cardiac disorders, but its use in cryptogenic stroke is not well established. We reviewed the literature (randomised trials, exploratory comparative studies and case series) on the use of CMR in the diagnostic evaluation of patients with ischaemic stroke. The literature on the use of CMR in the diagnostic evaluation of ischaemic stroke is sparse. However, studies have demonstrated a potential role for CMR in the diagnostic evaluation of patients with cryptogenic stroke to identify potential aetiologies such as cardiac thrombi, cardiac tumours, aortic arch disease and other rare cardiac anomalies. CMR can also provide data on certain functional and structural parameters of the left atrium and the left atrial appendage which have been shown to be associated with ischaemic stroke risk. CMR is a non-invasive modality that can help identify potential mechanisms in cryptogenic stroke and patients who may be targeted for enrolment into clinical trials comparing anticoagulation to antiplatelet therapy in secondary stroke prevention. Prospective studies are needed to compare the value of CMR as compared to transthoracic and transesophageal echocardiography in the diagnostic evaluation of cryptogenic stroke.

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New brain infarcts on magnetic resonance imaging after coronary artery bypass graft surgery: Lesion patterns, mechanism, and predictors

Abstract: Post-CABG new brain infarcts are mostly silent and cortically located. Old age, aortic arch atherosclerosis, use of cardiopulmonary bypass, and systemic inflammatory response may contribute to the pathogenesis of post-CABG new brain infarcts.

Cited by 48 publications

References 43 publications

Cardioembolic Stroke

Cardioembolic Stroke

Prophylactic Edaravone Prevents Transient Hypoxic-Ischemic Brain Injury

Cardiac magnetic resonance imaging: a new tool to identify cardioaortic sources in ischaemic stroke

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