Perioperative StrokeMagdy Selim, M.D., Ph.D.N Engl J Med 2007;
356:706-713February 15, 2007ArticleReferencesCiting Articles (58)
Stroke is one of the most feared complications of surgery. to
provide adequate preventive and therapeutic measures, physicians
need to be knowledgeable about the risk factors for stroke during
the perioperative period. In this article, I review the
pathophysiology of perioperative stroke and provide recommendations
for the stratification of risk and the management of risk
factors.IncidenceThe incidence of perioperative stroke depends on
the type and complexity of the surgical procedure. The risk of
stroke after general, noncardiac procedures is very low. Cardiac
and vascular surgeries in particular, combined cardiac procedures
are associated with higher risks1-7 (Table 1Table 1Incidence of
Stroke after Various Surgical Procedures.). The timing of surgery
is also important. More strokes occur after urgent surgery than
after elective surgery.1 Despite advances in surgical techniques
and improvements in perioperative care, the incidence of
perioperative strokes has not decreased, reflecting the aging of
the population and the increased number of elderly patients with
coexisting conditions who undergo surgery. Perioperative strokes
result in a prolonged hospital stay and increased rates of
disability, discharge to long-term care facilities, and death after
surgery.7 PathophysiologyRadiologic and postmortem studies indicate
that perioperative strokes are predominantly ischemic and
embolic.8-10 In a study of 388 patients with stroke after
coronary-artery bypass grafting (CABG), hemorrhage was reported in
only 1% of patients; 62% had embolic infarcts11 (Figure 1Figure
1Mechanisms of Perioperative Stroke.). The timing of embolic
strokes after surgery has a bimodal distribution. Approximately 45%
of perioperative strokes are identified within the first day after
surgery.1,11 The remaining 55% occur after uneventful recovery from
anesthesia, from the second postoperative day onward.1,11 Early
embolism results especially from manipulations of the heart and
aorta or release of particulate matter from the
cardiopulmonary-bypass pump.1,7,13 Delayed embolism is often
attributed to postoperative atrial fibrillation, myocardial
infarction resulting from an imbalance between myocardial oxygen
supply and demand, and coagulopathy.13 Surgical trauma and
associated tissue injury result in hypercoagulability. Several
studies have shown activation of the hemostatic system and reduced
fibrinolysis after surgery, as evidenced by decreased tissue
plasminogen activator (t-PA) and increased plasminogen activator
inhibitor type 1 activity and increased levels of
fibrinogen-degradation products, thrombinantithrombin complex,
thrombus precursor protein, and d-dimer immediately after surgery
and up to 14 to 21 days postoperatively.14-16 General anesthesia,
dehydration, bed rest, stasis in the postoperative period, and
perioperative withholding of antiplatelet or anticoagulant agents
can aggravate surgery-induced hypercoagulability and increase the
risk of perioperative thrombogenic events, including stroke.There
is increasing recognition that short- and long-term cognitive
changes, manifested as short-term memory loss, executive
dysfunction, and psychomotor slowing, occur after CABG.7 The
multifactorial causes of these changes include ischemic injury from
microembolization, surgical trauma, preexisting vascular changes,
and temperature during surgery.Contrary to common belief, most
strokes in patients undergoing cardiac surgery, including those
with carotid stenosis, are not related to hypoperfusion. Deliberate
hypotension induced by anesthesia does not seem to adversely affect
cerebral perfusion, nor does it considerably increase the risk of
perioperative stroke due to hypoperfusion in patients with carotid
stenosis.6,11,15 Most perioperative strokes in such patients are
embolic and are either contralateral to the affected carotid artery
or bilateral (Figure 2Figure 2MRI Scan Showing Embolic Infarcts in
a 74-Year-Old Man with Stroke after CABG.), so they cannot be
attributed to carotid stenosis alone.6 In one study, only 9% of
strokes after CABG were in watershed (hypoperfusion) areas.11 As
expected, most were identified within the first day after surgery.
Delayed hypoperfusion strokes, when they occur, are often
precipitated by postoperative dehydration or blood loss. Other,
less common causes of perioperative stroke include air, fat, or
paradoxical embolism and arterial dissection resulting from neck
manipulations during induction of anesthesia and neck surgery
(Table 2Table 2Uncommon Causes of Perioperative Stroke.).Risk
StratificationSeveral patient- and procedure-related factors are
associated with an increased risk of perioperative stroke (Table
3Table 3Risk Factors for Perioperative Stroke.).2,4,6,8,13,15,16
Evaluating the riskbenefit ratio for each patient before surgery is
essential to optimize care. There are several models for
stratifying the risk of perioperative stroke.7,17 Investigators
from the Northern New England Cardiovascular Disease Study Group
used bootstrapping techniques to develop and validate a model
predicting the risk of stroke after CABG, according to weights
assigned to seven preoperative variables. These variables were
identified in an observational study of 33,062 consecutive patients
undergoing CABG.17 Table 4Table 4Model for Predicting the Risk of
Stroke among Patients Undergoing CABG. summarizes the major
elements of this predictive model.18 Risk ModificationPhysicians
can implement diagnostic, therapeutic, and procedural measures to
modify the perioperative risk in order to prevent stroke and
minimize morbidity. A history of stroke or transient ischemic
attack is a strong predictor of perioperative
stroke.2,4,6-8,12,13,17 Therefore, physicians must inquire
specifically about such a history and fully investigate and treat
the cause of a stroke or transient ischemic attack that has
occurred within the previous 6 months, especially if a previous
evaluation was not done or was incomplete or if the patient's
neurologic status worsened after the event. Brain vascular reserve
is often tenuous in the days after a stroke, so it is important to
allow sufficient time after a stroke for the patient's hemodynamic
and neurologic status to stabilize before an elective surgical
procedure is performed.The risk of perioperative stroke is high
among patients with symptomatic carotid stenosis.6,19 Such patients
should be evaluated by means of carotid Doppler ultrasound;
patients with carotid stenosis that has been symptomatic within the
previous 6 months benefit from carotid revascularization before
undergoing cardiac or major vascular surgery.20 In patients with
both cardiac and carotid disease who are undergoing urgent cardiac
surgery a population in which the risks of complications and death
from cardiac causes exceed the risk of stroke a reversed-stage
approach (carotid revascularization after CABG) or a combined
approach (simultaneous carotid revascularization and CABG) may be
undertaken. However, the combined approach may be associated with
higher morbidity.21 The safety of carotid endarterectomy as
compared with carotid stenting is under investigation. Preliminary
evidence suggests that carotid stenting is probably more suitable
for patients with concomitant symptomatic carotid and coronary
artery disease in whom preoperative carotid revascularization is
being considered.22 The effect of asymptomatic carotid stenosis,
especially when it is unilateral, on the risk of perioperative
stroke is often overstated. A review of the literature from 1970 to
2000 showed an overall risk of stroke of 2% after CABG; the risk
increased to 3% among patients with asymptomatic unilateral carotid
stenosis of 50 to 99%, 5% among those with bilateral stenoses of 50
to 99%, and 7% among those with carotid occlusion.6 Sixty percent
of perioperative infarcts in patients with carotid stenosis were
attributed to causes other than carotid disease.6 The discovery of
asymptomatic carotid stenosis often begins with the detection of a
cervical bruit during preoperative evaluation. Since the presence
of an asymptomatic bruit, in itself, is not correlated with the
risk of perioperative stroke or the severity of the underlying
carotid stenosis,23 routine carotid evaluation by means of Doppler
ultrasound is unnecessary in these circumstances. However, carotid
ultrasound may be warranted in patients with bruits who have a
recent history of transient ischemic attacklike symptoms.
Furthermore, few data provide support for the routine use of
prophylactic revascularization before major cardiovascular surgery
in patients with asymptomatic carotid stenosis.24 Revascularization
before surgery is generally unwarranted because it exposes patients
to the risks of perioperative stroke and myocardial infarction
twice without significantly reducing the risk of stroke.6,19,20
However, some patients with hemodynamically significant,
high-grade, asymptomatic carotid stenosis in particular those with
bilateral stenoses may benefit from carotid revascularization
before elective surgery. Therefore, the extent of the preoperative
evaluation of patients with asymptomatic carotid disease should be
individualized. At a minimum, the evaluation should include a
detailed neurologic examination, a history taking designed to
elicit unreported symptoms of transient ischemic attack, and brain
computed tomographic (CT) or magnetic resonance imaging (MRI)
studies to rule out silent ipsilateral infarcts. Additional tests
such as transcranial Doppler ultrasonography and intracranial CT or
magnetic resonance angiography to determine the microembolic signal
load, intracranial blood flow, and hemodynamic significance of the
carotid stenosis25,26 may provide incremental information to
identify patients who could benefit from carotid revascularization
before surgery. However, the clinical usefulness and
cost-effectiveness of hemodynamic testing before surgery are
debatable, and further development and validation of these tests
are required before their routine preoperative use in patients with
carotid stenosis can be advocated.Aortic atherosclerosis is an
independent predictor of the risk of perioperative stroke,
particularly among patients undergoing cardiac surgery and
revascularization of the left main-stem artery.1,13 Identifying the
extent and location of aortic atherosclerosis before or at the time
of surgery by means of transesophageal echocardiography or
intraoperative epiaortic ultrasound is important to modify the
surgical technique and change the site of aortic cannulation or
clamping to avoid calcified plaques. The use of
echocardiography-guided aortic cannulation27 and intraaortic
filtration28 during CABG can reduce the risk of perioperative
stroke.Systolic dysfunction increases the risk of perioperative
stroke, particularly among patients with atrial fibrillation.13
Preoperative echocardiography to assess the ejection fraction and
to look for intracardiac emboli and aortic atherosclerosis may help
to stratify the risk of stroke and modify the treatment strategy
for patients with heart failure, atrial fibrillation, or suspected
valvular disease and those undergoing revascularization of the left
main stem.Atrial fibrillation occurs in 30 to 50% of patients after
cardiac surgery, with a peak incidence between the second and
fourth postoperative days, and it is a major cause of many
perioperative strokes.1,8,9,13,17,18,29 Postoperative electrolyte
imbalance and shifts in the intravascular volume increase atrial
ectopic activity, which confers a predisposition to arrhythmia29
(Table 5Table 5Predictors of Postoperative Atrial Fibrillation.).
It is therefore important to monitor patients for arrhythmias for a
minimum of 3 days after cardiac procedures as well as to correct
electrolytes and fluid volume during the postoperative period. The
incidence of postoperative atrial fibrillation and stroke may be
reduced by the prophylactic administration of amiodarone and
beta-blockers, beginning 5 days before cardiac surgery.30 Patients
with preexisting atrial fibrillation may be receiving
antiarrhythmic or rate-controlling agents, which should be
continued throughout the perioperative period, with the use of
intravenous formulations if needed. No controlled trials have
specifically addressed the use of anticoagulation therapy for
new-onset, postoperative atrial fibrillation, which often resolves
spontaneously after 4 to 6 weeks. The American College of Chest
Physicians recommends the consideration of heparin therapy
particularly for high-risk patients, such as those with a history
of stroke or transient ischemic attack, in whom atrial fibrillation
develops after surgery and the continuation of anticoagulation
therapy for 30 days after the return of a normal sinus rhythm.31
The discontinuation of warfarin or antiplatelet agents in
anticipation of surgery exposes patients to an increased risk of
perioperative stroke.32,33 The risk is particularly high among
patients with coronary artery disease.32 A review of the
perioperative outcomes of patients requiring long-term warfarin
therapy showed that rates of thromboembolic events varied according
to the management strategy; the rate was 0.6% for discontinuation
of warfarin without the administration of intravenous heparin and
0% for discontinuation of warfarin with intravenous heparin used as
bridge therapy.34 The rate of major bleeding that occurred while
the patient was receiving a therapeutic dose of warfarin was 0.2%
for dental procedures and 0% for arthrocentesis, cataract surgery,
and upper endoscopy or colonoscopy with or without biopsy.A study
of patients at high risk for thromboembolism who were undergoing
knee or hip replacement surgery showed that continued use of
moderate-dose warfarin therapy (international normalized ratio, 1.8
to 2.1) during the perioperative period was safe and effective in
preventing embolic events.35 These studies suggest that most
patients can undergo dental procedures, arthrocentesis, cataract
surgery, diagnostic endoscopy, and even orthopedic surgery without
interrupting their antiplatelet or oral anticoagulation regimen.
When oral anticoagulation must be withheld for other invasive
procedures, the time during which anticoagulation is being withheld
should be minimized. Bridge therapy with heparin after
discontinuation of warfarin and early postoperative resumption of
anticoagulation is recommended, especially in patients at high risk
for thromboembolism, such as those with a history of systemic
embolism or atrial fibrillation and those with mechanical valves.36
Surgeons should attempt to minimize the duration of surgery
whenever possible. Lengthy operations are associated with higher
risks for perioperative illness and stroke. The choice of the
surgical technique according to the patient's risk profile is also
important. Among patients with a low ejection fraction, the risk of
stroke may be lower with coronary angioplasty than with CABG,37 and
off-pump as compared with on-pump cardiopulmonary bypass may be
associated with a lower risk of stroke among patients with severe
atheromatous aortic disease.38 A no-touch technique, avoiding
manipulations of the ascending aorta, is advised whenever feasible
in patients with aortic arch disease.39 The type of anesthesia and
the anesthetic agent are additional considerations. Regional
anesthesia is less likely than general anesthesia to result in
perioperative complications.40 Some data suggest that isoflurane
and thiopentone may provide neuroprotection.41 The optimal level of
blood pressure during surgery is debatable.12,17 In one study, the
incidence of cardiac and neurologic complications, including
stroke, was significantly lower when the mean systemic arterial
pressure was 80 to 100 mm Hg during CABG, as compared with 50 to 60
mm Hg, suggesting that a higher mean systemic arterial pressure
during CABG is safe and improves outcomes.42 Charlson et al.43
suggested that intraoperative blood pressure should be evaluated in
relation to preoperative blood pressure; they reported that
prolonged changes of more than 20 mm Hg or 20% in relation to
preoperative levels result in perioperative complications. Efforts
to match intraoperative and early postoperative blood pressure to
the patient's preoperative range can reduce the risks of
perioperative stroke and death.27 The management of the patient's
temperature during surgery also influences outcomes. A review
showed a trend toward a reduction in the rate of perioperative
stroke when the patient's core body temperature during
cardiopulmonary bypass was 31.4 to 33.1C, as compared with a
temperature of more than 33.2C.44 However, this benefit is offset
by a higher rate of death among patients with lower core
temperatures. On balance, it is advisable to maintain mild
hypothermia (approximately 34C) during cardiopulmonary bypass and
to avoid rapid rewarming and hyperthermia after surgery in order to
minimize the risk of cognitive impairment after CABG.44
Hyperglycemia, intraoperatively and postoperatively, is associated
with increased rates of atrial fibrillation, stroke, and death.45
Intensive monitoring and control of the patient's glucose level
during the perioperative period is important. The administration of
insulin and potassium during and after surgery to keep blood
glucose levels below 140 mg per deciliter (7.8 mmol per liter) is
associated with improved outcomes.46 The prevention and treatment
of inflammation and infections during the preoperative and
postoperative periods are always indicated. A high white-cell count
correlates with an increased incidence of stroke, poor outcome, and
the development of postoperative atrial fibrillation.47,48
Postoperative systolic dysfunction and arrhythmias are associated
with an increased incidence of postoperative stroke.1,7-9
Therefore, electrolyte levels and fluid volume should be optimized,
and the patient must be closely monitored for signs of heart
failure and arrhythmias during the postoperative period. It is also
helpful to encourage early postoperative mobility and implement
prophylactic measures to prevent deep-vein thrombosis. A
paradoxical embolism leading to stroke may occur in patients with a
right-to-left shunt.Finally, there is evidence that initiation of
antiplatelet therapy such as aspirin after cardiac and carotid
surgeries reduces the incidence of postoperative stroke without
increasing the odds of bleeding complications.49,50 There is also
evidence that supports the preoperative use of statins,
irrespective of the patient's lipid profile, to reduce the risk of
perioperative stroke in patients undergoing cardiovascular
surgery.51 ManagementIn patients who have recently undergone major
surgery, treatment with intravenous t-PA is contraindicated because
of an increased risk of bleeding. However, intraarterial
administration of t-PA and endovascular mechanical clot disruption
are alternative options. A few case series suggest that the use of
intraarterial thrombolysis within 6 hours after the onset of a
perioperative stroke is relatively safe.52,53 In a study of 36
patients who received intraarterial t-PA after a perioperative
stroke, partial to complete recanalization was achieved in 80% of
the patients, 38% had no symptoms or only slight disability after
discharge, and the mortality rate was similar to that reported in
nonsurgical patients treated with intraarterial thrombolysis.53
Bleeding at the surgical site occurred in 17% of the patients. Most
of this bleeding was minor. Intracranial hemorrhage occurred in 25%
of the patients; however, only 8% had worsening symptoms.
Intracranial hemorrhage was most common in patients who underwent a
craniotomy. There are few data on the use of mechanical
thrombectomy or embolectomy in patients with perioperative stroke.
However, these techniques may be useful in the postoperative
setting, especially when the use of intraarterial thrombolysis is
contraindicated. The limited window for implementing these
interventions highlights the importance of rapid recognition of
perioperative stroke and immediate neurologic consultation.Future
DirectionsPreoperative prophylaxis against perioperative stroke is
an appealing concept. A few randomized trials have assessed the
effect of neuroprotective drugs on the risk of stroke and cognitive
decline among patients undergoing CABG.54-56 Preoperative
administration of statins51 or beta-blockers30 does appear to
reduce the incidence of stroke and cognitive decline after CABG.
There is also some evidence, albeit controversial, that the
antifibrinolytic agent aprotinin may have similar effects.56 These
results indicate that neuroprotection may be successful in the
perioperative setting and that it merits further investigation.
Randomized, controlled clinical trials are also needed to identify
the best preventive and management strategies for perioperative
stroke.Dr. Selim reports receiving grant support from Cierra. No
other potential conflict of interest relevant to this article was
reported.Source InformationFrom the Department of Neurology,
Division of Cerebrovascular Diseases, Beth Israel Deaconess Medical
Center, Boston.Address reprint requests to Dr. Selim at the
Department of Neurology, Division of Cerebrovascular Diseases, Beth
Israel Deaconess Medical Center, 330 Brookline Ave., Palmer 127,
Boston, MA 02215, or at [email protected].
1Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac
surgery: a risk factor analysis of 16,184 consecutive adult
patients. Ann Thorac Surg 2003;75:472-478CrossRef | Web of Science
| Medline2. 2Kam PC, Calcroft RM. Peri-operative stroke in general
surgical patients. Anaesthesia 1997;52:879-883CrossRef | Web of
Science | Medline3. 3Gutierrez IZ, Barone DL, Makula PA, Currier C.
The risk of perioperative stroke in patients with asymptomatic
carotid bruits undergoing peripheral vascular surgery. Am Surg
1987;53:487-489Web of Science | Medline4. 4Nosan DK, Gomez CR,
Maves MD. Perioperative stroke in patients undergoing head and neck
surgery. Ann Otol Rhinol Laryngol 1993;102:717-723Web of Science |
Medline5. 5Bond R, Rerkasem K, Shearman CP, Rothwell PM. Time
trends in the published risks of stroke and death due to
endarterectomy for symptomatic carotid stenosis. Cerebrovasc Dis
2004;18:37-46CrossRef | Web of Science | Medline6. 6Naylor AR,
Mehta Z, Rothwell PM, Bell PR. Carotid artery disease and stroke
during coronary artery bypass: a critical review of the literature.
Eur J Vasc Endovasc Surg 2002;23:283-294CrossRef | Web of Science |
Medline7. 7McKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA,
Selnes OA. Stroke and encephalopathy after cardiac surgery: an
update. Stroke 2006;37:562-571CrossRef | Web of Science | Medline8.
8Limburg M, Wijdicks EF, Li H. Ischemic stroke after surgical
procedures: clinical features, neuroimaging, and risk factors.
Neurology 1998;50:895-901Web of Science | Medline9. 9Restrepo L,
Wityk RJ, Grega MA, et al. Diffusion- and perfusion-weighted
magnetic resonance imaging of the brain before and after coronary
artery bypass grafting surgery. Stroke 2002;33:2909-2915CrossRef |
Web of Science | Medline10. 10Brooker RF, Brown WR, Moody DM, et
al. Cardiotomy suction: a major source of brain lipid emboli during
cardiopulmonary bypass. Ann Thorac Surg 1998;65:1651-1655CrossRef |
Web of Science | Medline11. 11Likosky DS, Marrin CA, Caplan LR, et
al. Determination of etiologic mechanisms of strokes secondary to
coronary artery bypass graft surgery. Stroke
2003;34:2830-2834CrossRef | Web of Science | Medline12. 12Likosky
DS, Caplan LR, Weintraub RM, et al. Intraoperative and
postoperative variables associated with strokes following cardiac
surgery. Heart Surg Forum 2004;7:E271-E276CrossRef | Web of Science
| Medline13. 13Hogue CW Jr, Murphy SF, Schechtman KB, Davila-Roman
VG. Risk factors for early or delayed stroke after cardiac surgery.
Circulation 1999;100:642-647Web of Science | Medline14. 14Dixon B,
Santamaria J, Campbell D. Coagulation activation and organ
dysfunction following cardiac surgery. Chest
2005;128:229-236CrossRef | Web of Science | Medline15. 15Paramo JA,
Rifon J, Llorens R, Casares J, Paloma MJ, Rocha E. Intra- and
postoperative fibrinolysis in patients undergoing cardiopulmonary
bypass surgery. Haemostasis 1991;21:58-64Medline16. 16Hinterhuber
G, Bohler K, Kittler H, Quehenberger P. Extended monitoring of
hemostatic activation after varicose vein surgery under general
anesthesia. Dermatol Surg 2006;32:632-639CrossRef | Web of Science
| Medline17. 17van Wermeskerken GK, Lardenoye JW, Hill SE, et al.
Intraoperative physiologic variables and outcome in cardiac
surgery: Part II. Neurologic outcome. Ann Thorac Surg
2000;69:1077-1083CrossRef | Web of Science | Medline18.
18Charlesworth DC, Likosky DS, Marrin CA, et al. Development and
validation of a prediction model for strokes after coronary artery
bypass grafting. Ann Thorac Surg 2003;76:436-443CrossRef | Web of
Science | Medline19. 19Gerraty RP, Gates PC, Doyle JC. Carotid
stenosis and perioperative stroke risk in symptomatic and
asymptomatic patients undergoing vascular or coronary surgery.
Stroke 1993;24:1115-1118Web of Science | Medline20. 20Chaturvedi S,
Bruno A, Feasby T, et al. Carotid endarterectomy -- an
evidence-based review: report of the Therapeutics and Technology
Assessment Subcommittee of the American Academy of Neurology.
Neurology 2005;65:794-801CrossRef | Web of Science | Medline21.
21Das SK, Brow TD, Pepper J. Continuing controversy in the
management of concomitant coronary and carotid disease: an
overview. Int J Cardiol 2000;74:47-65CrossRef | Web of Science |
Medline22. 22Yadav JS, Wholey MH, Kuntz RE, et al. Protected
carotid-artery stenting versus endarterectomy in high-risk
patients. N Engl J Med 2004;351:1493-1501Full Text | Web of Science
| Medline23. 23Mackey AE, Abrahamowicz M, Langlois Y, et al.
Outcome of asymptomatic patients with carotid disease. Neurology
1997;48:896-903Web of Science | Medline24. 24Birincioglu CL,
Bayazit M, Ulus AT, Bardakci H, Kucuker SA, Tasdemir O. Carotid
disease is a risk factor for stroke in coronary bypass operations.
J Card Surg 1999;14:417-423CrossRef | Web of Science | Medline25.
25Molloy J, Markus HS. Asymptomatic embolization predicts stroke
and TIA risk in patients with carotid artery stenosis. Stroke
1999;30:1440-1443Web of Science | Medline26. 26Soinne L, Helenius
J, Tatlisumak T, et al. Cerebral hemodynamics in asymptomatic and
symptomatic patients with high-grade carotid stenosis undergoing
carotid endarterectomy. Stroke 2003;34:1655-1661CrossRef | Web of
Science | Medline27. 27Gold JP, Torres KE, Maldarelli W, Zhuravlev
I, Condit D, Wasnick J. Improving outcomes in coronary surgery: the
impact of echo-directed aortic cannulation and perioperative
hemodynamic management in 500 patients. Ann Thorac Surg
2004;78:1579-1585CrossRef | Web of Science | Medline28.
28Wimmer-Greinecker G. Reduction of neurologic complications by
intra-aortic filtration in patients undergoing combined
intracardiac and CABG procedures. Eur J Cardiothorac Surg
2003;23:159-164CrossRef | Web of Science | Medline29. 29Lahtinen J,
Biancari F, Salmela E, et al. Postoperative atrial fibrillation is
a major cause of stroke after on-pump coronary artery bypass
surgery. Ann Thorac Surg 2004;77:1241-1244CrossRef | Web of Science
| Medline30. 30Crystal E, Garfinkle MS, Connolly SS, Ginger TT,
Sleik K, Yusuf SS. Interventions for preventing post-operative
atrial fibrillation in patients undergoing heart surgery. Cochrane
Database Syst Rev 2004;4:CD003611-CD003611Medline31. 31Epstein AE,
Alexander JC, Gutterman DD, Maisel W, Wharton JM. Anticoagulation:
American College of Chest Physicians guidelines for the prevention
and management of postoperative atrial fibrillation after cardiac
surgery. Chest 2005;128:Suppl 2:24S-27SCrossRef | Web of Science |
Medline32. 32Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J.
Effect of discontinuing aspirin therapy on the risk of brain
ischemic stroke. Arch Neurol 2005;62:1217-1220CrossRef | Web of
Science | Medline33. 33Genewein U, Haeberli A, Straub PW, Beer JH.
Rebound after cessation of oral anticoagulant therapy: the
biochemical evidence. Br J Haematol 1996;92:479-485CrossRef | Web
of Science | Medline34. 34Dunn AS, Turpie AG. Perioperative
management of patients receiving oral anticoagulants: a systematic
review. Arch Intern Med 2003;163:901-908CrossRef | Web of Science |
Medline35. 35Larson BJ, Zumberg MS, Kitchens CS. A feasibility
study of continuing dose-reduced warfarin for invasive procedures
in patients with high thromboembolic risk. Chest
2005;127:922-927CrossRef | Web of Science | Medline36. 36Dunn AS,
Wisnivesky J, Ho W, Moore C, McGinn T, Sacks HS. Perioperative
management of patients on oral anticoagulants: a decision analysis.
Med Decis Making 2005;25:387-397CrossRef | Web of Science |
Medline37. 37O'Keefe JH Jr, Allan JJ, McCallister BD, et al.
Angioplasty versus bypass surgery for multivessel coronary artery
disease with left ventricular ejection fraction < or = 40%. Am J
Cardiol 1993;71:897-901CrossRef | Medline38. 38Sharony R, Grossi
EA, Saunders PC, et al. Propensity case-matched analysis of
off-pump coronary artery bypass grafting in patients with
atheromatous aortic disease. J Thorac Cardiovasc Surg
2004;127:406-413CrossRef | Web of Science | Medline39. 39Lev-Ran O,
Braunstein R, Sharony R, et al. No-touch aorta off-pump coronary
surgery: the effect on stroke. J Thorac Cardiovasc Surg
2005;129:307-313CrossRef | Web of Science | Medline40. 40Breen P,
Park KW. General anesthesia versus regional anesthesia. Int
Anesthesiol Clin 2002;40:61-71CrossRef | Medline41. 41Turner BK,
Wakim JH, Secrest J, Zachary R. Neuroprotective effects of
thiopental, propofol, and etomidate. AANA J
2005;73:297-302Medline42. 42Gold JP, Charlson ME, Williams-Russo P,
et al. lmprovement of outcomes after coronary artery bypass: a
randomized trial comparing intraoperative high versus low mean
arterial pressure. J Thorac Cardiovasc Surg
1995;110:1302-1311CrossRef | Web of Science | Medline43. 43Charlson
ME, MacKenzie CR, Gold JP, Ales KL, Topkins M, Shires GT.
Intraoperative blood pressure: what patterns identify patients at
risk for postoperative complications? Ann Surg
1990;212:567-580CrossRef | Web of Science | Medline44. 44Rees K,
Beranek-Stanley M, Burke M, Ebrahim S. Hypothermia to reduce
neurological damage following coronary artery bypass surgery.
Cochrane Database Syst Rev 2001;1:CD002138-CD002138Medline45.
45Gandhi GY, Nuttall GA, Abel MD, et al. Intraoperative
hyperglycemia and perioperative outcomes in cardiac surgery
patients. Mayo Clin Proc 2005;80:862-866CrossRef | Web of Science |
Medline46. 46Krinsley JS. Effect of an intensive glucose management
protocol on the mortality of critically ill adult patients. Mayo
Clin Proc 2004;79:992-1000[Erratum, Mayo Clin Proc
2005;80:1101.]CrossRef | Web of Science | Medline47. 47Albert AA,
Beller CJ, Walter JA, et al. Preoperative high leukocyte count: a
novel risk factor for stroke after cardiac surgery. Ann Thorac Surg
2003;75:1550-1557CrossRef | Web of Science | Medline48. 48Lamm G,
Auer J, Weber T, Berent R, Ng C, Eber B. Postoperative white blood
cell count predicts atrial fibrillation after cardiac surgery. J
Cardiothorac Vasc Anesth 2006;20:51-56CrossRef | Web of Science |
Medline49. 49Mangano DT. Aspirin and mortality from coronary bypass
surgery. N Engl J Med 2002;347:1309-1317Full Text | Web of Science
| Medline50. 50Engelter S, Lyrer P. Antiplatelet therapy for
preventing stroke and other vascular events after carotid
endarterectomy. Cochrane Database Syst Rev
2003;3:CD001458-CD001458Medline51. 51Durazzo AE, Machado FS, Ikeoka
DT, et al. Reduction in cardiovascular events after vascular
surgery with atorvastatin: a randomized trial. J Vasc Surg
2004;39:967-975CrossRef | Web of Science | Medline52. 52Moazami N,
Smedira NG, McCarthy PM, et al. Safety and efficacy of
intraarterial thrombolysis for perioperative stroke after cardiac
operation. Ann Thorac Surg 2001;72:1933-1937CrossRef | Web of
Science | Medline53. 53Chalela JA, Katzan I, Liebeskind DS, et al.
Safety of intra-arterial thrombolysis in the postoperative period.
Stroke 2001;32:1365-1369Web of Science | Medline54. 54Taggart DP,
Browne SM, Wade DT, Halligan PW. Neuroprotection during cardiac
surgery: a randomised trial of a platelet activating factor
antagonist. Heart 2003;89:897-900CrossRef | Web of Science |
Medline55. 55Arrowsmith JE, Harrison MJ, Newman SP, Stygall J,
Timberlake N, Pugsley WB. Neuroprotection of the brain during
cardiopulmonary bypass: a randomized trial of remacemide during
coronary artery bypass in 171 patients. Stroke 1998;29:2357-2362Web
of Science | Medline56. 56Sedrakyan A, Treasure T, Elefteriades JA.
Effect of aprotinin on clinical outcomes in coronary artery bypass
graft surgery: a systematic review and meta-analysis of randomized
clinical trials. J Thorac Cardiovasc Surg 2004;128:442-448CrossRef
| Web of Science | MedlineCiting Articles1. 1R. D. Sanders, V.
Degos, W. L. Young. (2011) Cerebral perfusion under pressure: is
the autoregulatory plateau a level playing field for all?.
Anaesthesiano-noCrossRef 2. 2, , M. Tendera, V. Aboyans, M.-L.
Bartelink, I. Baumgartner, D. Clement, J.-P. Collet, A. Cremonesi,
M. De Carlo, R. Erbel, F. G. R. Fowkes, M. Heras, S. Kownator, E.
Minar, J. Ostergren, D. Poldermans, V. Riambau, M. Roffi, J.
Rother, H. Sievert, M. van Sambeek, T. Zeller, , J. Bax, A.
Auricchio, H. Baumgartner, C. Ceconi, V. Dean, C. Deaton, R.
Fagard, C. Funck-Brentano, D. Hasdai, A. Hoes, J. Knuuti, P. Kolh,
T. McDonagh, C. Moulin, D. Poldermans, B. Popescu, Z. Reiner, U.
Sechtem, P. A. Sirnes, A. Torbicki, A. Vahanian, S. Windecker, , P.
Kolh, A. Torbicki, S. Agewall, A. Blinc, M. Bulvas, F. Cosentino,
T. De Backer, A. Gottsater, D. Gulba, T. J. Guzik, B. Jonsson, G.
Kesmarky, A. Kitsiou, W. Kuczmik, M. L. Larsen, J. Madaric, J.-L.
Mas, J. J. V. McMurray, A. Micari, M. Mosseri, C. Muller, R.
Naylor, B. Norrving, O. Oto, T. Pasierski, P.-F. Plouin, F.
Ribichini, J.-B. Ricco, L. Ruilope, J.-P. Schmid, U. Schwehr, B. G.
M. Sol, M. Sprynger, C. Tiefenbacher, C. Tsioufis, H. Van Damme.
(2011) ESC Guidelines on the diagnosis and treatment of peripheral
artery diseases: Document covering atherosclerotic disease of
extracranial carotid and vertebral, mesenteric, renal, upper and
lower extremity arteries * The Task Force on the Diagnosis and
Treatment of Peripheral Artery Diseases of the European Society of
Cardiology (ESC). European Heart JournalCrossRef 3. 3C. S.
Burkhart, A. Rossi, S. Dell-Kuster, M. Gamberini, A. Mockli, M.
Siegemund, M. Czosnyka, S. P. Strebel, L. A. Steiner. (2011) Effect
of age on intraoperative cerebrovascular autoregulation and
near-infrared spectroscopy-derived cerebral oxygenation. British
Journal of AnaesthesiaCrossRef 4. 4Alice M. Arch, Nigel J.N.
Harper. (2011) Xenon: An element of protection. Trends in
Anaesthesia and Critical CareCrossRef 5. 5G. Lacroix, B. Prunet, A.
Faivre, J. Bordes, A. Montcriol. (2011) Coma brutal sous
rachianesthsie. Annales Franaises d'Anesthsie et de
RanimationCrossRef 6. 6S. Shmygalev, A.R. Heller. (2011) Erblindung
nach nichtophthalmologischen Eingriffen. Der AnaesthesistCrossRef
7. 7Irina Lasarzik, Rdiger R. Noppens, Thorsten Wolf, Henrike
Bauer, Clara Luh, Christian Werner, Kristin Engelhard, Serge C.
Thal. (2011) Dose-Dependent Influence of Sevoflurane Anesthesia on
Neuronal Survival and Cognitive Outcome After Transient Forebrain
Ischemia in Sprague-Dawley Rats. Neurocritical CareCrossRef 8.
8Steven Shea, Marco Di Tullio. (2011) Post-Coronary Artery Bypass
Grafting Stroke. Journal of the American College of Cardiology
57:18, 1819-1821CrossRef 9. 9Eun-Jae Lee, Kyoung-Hyo Choi, Ju-Seok
Ryu, Sang-Beom Jeon, Seung-Whan Lee, Seong-Wook Park, Seung-Jung
Park, Jae-Won Lee, Suk-Jung Choo, Cheol-Hyun Chung, Sung-Ho Jung,
Dong-Wha Kang, Jong S. Kim, Sun U. Kwon. (2011) Stroke Risk After
Coronary Artery Bypass Graft Surgery and Extent of Cerebral Artery
Atherosclerosis. Journal of the American College of Cardiology
57:18, 1811-1818CrossRef 10. 10Ewa Wypasek, Ewa Stepien, Malgorzata
Kot, Dariusz Plicner, Boguslaw Kapelak, Jerzy Sadowski, Anetta
Undas. (2011) Fibrinogen Beta-Chain -C148T Polymorphism is
Associated with Increased Fibrinogen, C-Reactive Protein, and
Interleukin-6 in Patients Undergoing Coronary Artery Bypass
Grafting. InflammationCrossRef 11. 11George A. Mashour, Amy M.
Shanks, Sachin Kheterpal. (2011) Perioperative Stroke and
Associated Mortality after Noncardiac, Nonneurologic Surgery.
Anesthesiology1CrossRef 12. 12K. C. Gersh, S. Zaitsev, D. B. Cines,
V. Muzykantov, J. W. Weisel. (2011) Flow-dependent channel
formation in clots by an erythrocyte-bound fibrinolytic agent.
BloodCrossRef 13. 13David L. McDonagh, Joseph P. Mathew. (2011)
Perioperative Stroke. Anesthesiology1CrossRef 14. 14Qianzi Yang,
Hui Dong, Jiao Deng, Qiang Wang, Ruidong Ye, Xuying Li, Sheng Hu,
Hailong Dong, Lize Xiong. (2011) Sevoflurane Preconditioning
Induces Neuroprotection Through Reactive Oxygen Species-Mediated
Up-Regulation of Antioxidant Enzymes in Rats. Anesthesia &
Analgesia1CrossRef 15. 15Solne Grandpierre, Emmanuel Desandes,
Benoit Meneroux, Wassila Djaballah, Damien Mandry, Fanny Netter,
Denis Wahl, Renaud Fay, Gilles Karcher, Pierre-Yves Marie. (2011)
Arterial Foci of F-18 Fluorodeoxyglucose Are Associated With an
Enhanced Risk of Subsequent Ischemic Stroke in Cancer Patients.
Clinical Nuclear Medicine 36:2, 85-90CrossRef 16. 16Hak Young Rhee,
Dae Hyun Kim, Young Tae Kwak, Jae Woo Lee, Sung Hun Kim. (2011)
Cerebral Air Embolism as a Result of Inducing Pneumoperitoneum
After Bilobectomy. The Annals of Thoracic Surgery 91:1,
293-295CrossRef 17. 17Rami Abu Fanne, Taher Nassar, Achinoam Mazuz,
Otailah Waked, Samuel N. Heyman, Nuha Hijazi, Gadi Goelman, Abd
Al-Roof Higazi. (2011) Neuroprotection by glucagon: role of
gluconeogenesis. Journal of Neurosurgery 114:1, 85-91CrossRef 18.
18Christian Werner. (2010) Neuroprotection in acute cerebral
ischemia: Can we improve clinical outcomes?. Best Practice &
Research Clinical Anaesthesiology 24:4, vii-xCrossRef 19. 19J. Van
der Heyden, H.W. Plokker. (2010) Part Two: Against the Motion
Carotid Disease is Responsible for the Increased Risk of Stroke
after Coronary Bypass Surgery. European Journal of Vascular and
Endovascular Surgery 40:6, 693-695CrossRef 20. 20Stacy L.
Fairbanks, Ansgar M. Brambrink. (2010) Preconditioning and
postconditioning for neuroprotection: The most recent evidence.
Best Practice & Research Clinical Anaesthesiology 24:4,
521-534CrossRef 21. 21Yuebing Li, John Castaldo, Jan Van der
Heyden, Herbert W.M. Plokker. (2010) Is carotid artery disease
responsible for perioperative strokes after coronary artery bypass
surgery?. Journal of Vascular Surgery 52:6, 1716-1721CrossRef 22.
22Mutsuhito Kikura, Brian T. Bateman, Kenichi A. Tanaka. (2010)
Perioperative ischemic stroke in non-cardiovascular surgery
patients. Journal of Anesthesia 24:5, 733-738CrossRef 23. 23W. Zhu,
L. Wang, L. Zhang, J.M. Palmateer, N.L. Libal, P.D. Hurn, P.S.
Herson, S.J. Murphy. (2010) Isoflurane preconditioning
neuroprotection in experimental focal stroke is androgen-dependent
in male mice. Neuroscience 169:2, 758-769CrossRef 24. 24Kiyobumi
Ota, Takashi Matsumoto, Hiroaki Tanaka, Hidehito Kuroki, Noriyuki
Tabuchi. (2010) Intravenous rt-PA therapy for postoperative stroke
on the fifteenth day after aortic valve replacement: A case report.
Nosotchu 32:4, 373-378CrossRef 25. 25Hiroshi Haneda, Masayuki
Tanahashi, Satoru Moriyama, Eriko Suzuki, Naoko Yoshii, Tsutomu
Nishida, Hironori Tanaka, Hiroshi Niwa. (2010) Perioperative
management for thrombosis prevention (pulmonary embolism and
stroke) after lung cancer surgery-Anticoagulant therapy based on
evaluation of the risk of thrombosis-. The Journal of the Japanese
Association for Chest Surgery 24:2, 127-133CrossRef 26. 26Jae Jun
Lee, Sung Mi Hwang, Hyoung Soo Kim, Byoung Yoon Ryu, Jin Kim, Ji Su
Jang, So Young Lim. (2010) Acute, fatal postoperative myocardial
infarction after laparoscopic cholecystectomy in a cardiac patient
-A case report-. Korean Journal of Anesthesiology 59:Suppl,
S110CrossRef 27. 27Don Poldermans, Jeroen J Bax, Eric Boersma,
Stefan De Hert, Erik Eeckhout, Gerry Fowkes, Bulent Gorenek,
Michael G Hennerici, Bernard Iung, Malte Kelm. (2010) Guidelines
for pre-operative cardiac risk assessment and perioperative cardiac
management in non-cardiac surgery : The Task Force for Preoperative
Cardiac Risk Assessment and Perioperative Cardiac Management in
Non-cardiac Surgery of the European Society of Cardiology (ESC) and
endorsed by the European Society of Anaesthesiology (ESA). European
Journal of Anaesthesiology 27:2, 92CrossRef 28. 28Alina M. Grigore,
Catherine Friederich Murray, Harish Ramakrishna, George Djaiani.
(2009) A Core Review of Temperature Regimens and Neuroprotection
During Cardiopulmonary Bypass: Does Rewarming Rate Matter?.
Anesthesia & Analgesia 109:6, 1741-1751CrossRef 29. 29Christian
Werner. (2009) Anesthetic drugs and sustained neuroprotection in
acute cerebral ischemia: can we alter clinical outcomes?. Canadian
Journal of Anesthesia/Journal canadien d'anesthsie 56:12,
883-888CrossRef 30. 30Don Poldermans, Jeroen J. Bax, Eric Boersma,
Stefan de Hert, Erik Eeckhout, Gerry Fowkes, Bulent Gorenek,
Michael G. Hennerici, Bernard Iung, Malte Kelm, Keld Per Kjeldsen,
Steen Dalby Kristensen, Jos Lpez-Sendn, Paolo Pelosi, Franois
Philippe, Luc Pierard, Piotr Ponikowski, Jean-Paul Schmid, Olav
F.M. Sellevold, Rosa Sicari, Greet Van den Berghe, Frank Vermassen.
(2009) Gua de prctica clnica para la valoracin del riesgo cardiaco
preoperatorio y el manejo cardiaco perioperatorio en la ciruga no
cardiaca. Revista Espaola de Cardiologa 62:12,
1467.e1-1467.e56CrossRef 31. 31Salman Ansari, Jennifer Y Tan,
George S Larcos, Hugh Paterson. (2009) LOW PREVALENCE OF
SIGNIFICANT CAROTID ARTERY DISEASE ON ULTRASOUND IN PATIENTS
PROCEEDING TO CORONARY ARTERY BYPASS SURGERY. Internal Medicine
JournalCrossRef 32. 32Juan-Carlos Murciano, Abd Al-Roof Higazi,
Douglas B. Cines, Vladimir R. Muzykantov. (2009) Soluble urokinase
receptor conjugated to carrier red blood cells binds latent
pro-urokinase and alters its functional profile. Journal of
Controlled Release 139:3, 190-196CrossRef 33. 33, D. Poldermans, J.
J. Bax, E. Boersma, S. De Hert, E. Eeckhout, G. Fowkes, B. Gorenek,
M. G. Hennerici, B. Iung, M. Kelm, K. P. Kjeldsen, S. D.
Kristensen, J. Lopez-Sendon, P. Pelosi, F. Philippe, L. Pierard, P.
Ponikowski, J.-P. Schmid, O. F.M. Sellevold, R. Sicari, G. Van den
Berghe, F. Vermassen, , S. E. Hoeks, I. Vanhorebeek, , A. Vahanian,
A. Auricchio, J. J. Bax, C. Ceconi, V. Dean, G. Filippatos, C.
Funck-Brentano, R. Hobbs, P. Kearney, T. McDonagh, K. McGregor, B.
A. Popescu, Z. Reiner, U. Sechtem, P. A. Sirnes, M. Tendera, P.
Vardas, P. Widimsky, , R. De Caterina, S. Agewall, N. Al Attar, F.
Andreotti, S. D. Anker, G. Baron-Esquivias, G. Berkenboom, L.
Chapoutot, R. Cifkova, P. Faggiano, S. Gibbs, H. S. Hansen, L.
Iserin, C. W. Israel, R. Kornowski, N. M. Eizagaechevarria, M.
Pepi, M. Piepoli, H. J. Priebe, M. Scherer, J. Stepinska, D.
Taggart, M. Tubaro. (2009) Guidelines for pre-operative cardiac
risk assessment and perioperative cardiac management in non-cardiac
surgery: The Task Force for Preoperative Cardiac Risk Assessment
and Perioperative Cardiac Management in Non-cardiac Surgery of the
European Society of Cardiology (ESC) and endorsed by the European
Society of Anaesthesiology (ESA). European Heart Journal 30:22,
2769-2812CrossRef 34. 34Don Poldermans, Olaf Schouten, Felix van
Lier, Sanne E. Hoeks, Louis van de Ven, Robert Jan Stolker, Lee A.
Fleisher. (2009) Perioperative Strokes and -Blockade.
Anesthesiology 111:5, 940-945CrossRef 35. 35Timothy E Miller,
Anthony M Roche, Tong J Gan. (2009) Definitions and epidemiology.
Current Opinion in Critical Care 15:4, 314-319CrossRef 36. 36Felix
van Lier, Olaf Schouten, Ron T. van Domburg, Patrick J. van der
Geest, Eric Boersma, Lee A. Fleisher, Don Poldermans. (2009) Effect
of Chronic Beta-Blocker Use on Stroke After Noncardiac Surgery. The
American Journal of Cardiology 104:3, 429-433CrossRef 37.
37Mustapha Alilou, Ahmed El Hijri, Abderrahim Azzouzi. (2009) Les
accidents vasculaires crbraux ischmiques aprs chirurgie vasculaire.
Canadian Journal of Anesthesia/Journal canadien d'anesthsie 56:6,
469-470CrossRef 38. 38F. Herrle, U. Gller. (2009) Reihe
Evidenzbasierte Chirurgie. Zeitschrift fr Herz-,Thorax- und
Gefchirurgie 23:3, 182-189CrossRef 39. 39H. J. Park, H. J. Cho,
Y.-D. Kim, D. W. Lee, H.-Y. Choi, S. M. Kim, J. H. Heo. (2009)
Comparison of the characteristics for in-hospital and
out-of-hospital ischaemic strokes. European Journal of Neurology
16:5, 582-588CrossRef 40. 40Carsten Bantel, Mervyn Maze, Stefan
Trapp. (2009) Neuronal Preconditioning by Inhalational Anesthetics.
Anesthesiology 110:5, 986-995CrossRef 41. 41Alina S. Popa,
Alejandro A. Rabinstein, Paul M. Huddleston, Dirk R. Larson, Rachel
E. Gullerud, Jeanne M. Huddleston. (2009) Predictors of ischemic
stroke after hip operation: A population-based study. Journal of
Hospital Medicine 4:5, 298-303CrossRef 42. 42Tess, Anjala V.,
Smetana, Gerald W., . (2009) Medical Evaluation of Patients
Undergoing Electroconvulsive Therapy. New England Journal of
Medicine 360:14, 1437-1444Full Text43. 43Janice Marie Poletti.
(2009) Carotid bruit on an orthopaedic preoperative exam. The Nurse
Practitioner 34:3, 8-11CrossRef 44. 44Mutsuhito KIKURA, Yoshiki
ISHIGURO. (2009) Perioperative Management of Hemostasis and
Thrombosis in Cardiovascular Anesthesia. THE JOURNAL OF JAPAN
SOCIETY FOR CLINICAL ANESTHESIA 29:7, 809-814CrossRef 45. 45Steven
R. Mess, Joseph E. Bavaria, Michael Mullen, Albert T. Cheung,
Rebecca Davis, John G. Augoustides, Jacob Gutsche, Edward Y. Woo,
Wilson Y. Szeto, Alberto Pochettino, Y. Joseph Woo, Scott E.
Kasner, Michael McGarvey. (2008) Neurologic Outcomes from High Risk
Descending Thoracic and Thoracoabdominal Aortic Operations in the
Era of Endovascular Repair. Neurocritical Care 9:3, 344-351CrossRef
46. 46Joseph D. Burns, Edward M. Manno, Eelco F. M. Wijdicks.
(2008) An Unusual Cause of Fixed Dilated Pupils After Cardiac
Surgery. Neurocritical Care 9:3, 370-373CrossRef 47. 47Matthias
Bock, Christian J. Wiedermann. (2008) Perioperative Risikoreduktion
eine interdisziplinre Herausforderung. Wiener Medizinische
Wochenschrift 158:21-22, 590-594CrossRef 48. 48Ioannis K.
Toumpoulis, Constantine E. Anagnostopoulos, Themistocles P.
Chamogeorgakis, Dimitrios C. Angouras, Maria A. Kariou, Daniel G.
Swistel, Chris K. Rokkas. (2008) Impact of Early and Delayed Stroke
on In-Hospital and Long-Term Mortality After Isolated Coronary
Artery Bypass Grafting. The American Journal of Cardiology 102:4,
411-417CrossRef 49. 49Christian H Mller, Luit Penninga, Jrn
Wetterslev, Daniel A Steinbrchel, Christian Gluud, Christian H
Mller. 2008. Off-pump versus on-pump coronary artery bypass
grafting for ischaemic heart disease. . CrossRef 50. 50K. Grschel,
S. M. Pilgram, U. Ernemann, S. Schnaudigel, T. Ngele, M. Knauth, A.
Kastrup. (2008) Aortic calcification on plain chest radiography
predicts embolic complications during carotid artery stenting.
European Journal of Neurology 15:7, 730-736CrossRef 51. 51M.
KIKURA, F. OIKAWA, K. YAMAMOTO, T. IWAMOTO, K. A. TANAKA, S. SATO,
G. LANDESBERG. (2008) Myocardial infarction and cerebrovascular
accident following non-cardiac surgery: differences in
postoperative temporal distribution and risk factors. Journal of
Thrombosis and Haemostasis 6:5, 742-748CrossRef 52. 52N NEWMAN.
(2008) Perioperative Visual Loss After Nonocular Surgeries.
American Journal of Ophthalmology 145:4, 604-610.e1CrossRef 53.
53Yasuyuki Iguchi, Kazumi Kimura, Junya Aoki, Kazuto Kobayashi,
Yuka Terasawa, Kenichiro Sakai, Kensaku Shibazaki. (2008)
Prevalence of Atrial Fibrillation in Community-Dwelling Japanese
Aged 40 Years or Older in Japan. Circulation Journal 72:6,
909-913CrossRef 54. 54Muhammad U. Farooq, Mathew J. Reeves, Julia
Gargano, Susan Wehner, Susan Hickenbottom, Arshad Majid. (2008)
In-Hospital Stroke in a Statewide Stroke Registry. Cerebrovascular
Diseases 25:1-2, 12-20CrossRef 55. 55C. Dunstan, C. Jerwood. (2007)
Peri-operative stroke: implications of anaesthetic technique.
Anaesthesia 62:8, 853-853CrossRef 56. 56Jean-Louis Mas. (2007)
Revascularizacin de la arteria cartida interna. Revista Espaola de
Cardiologia 60:8, 861-871CrossRef 57. 57Uma Menon, Meghan Kenner,
Roger E Kelley. (2007) Perioperative stroke. Expert Review of
Neurotherapeutics 7:8, 1003-1011CrossRef 58. 58(2007) Perioperative
Stroke. New England Journal of Medicine 356:22, 2325-2327Full
TextTools PDF Print Download Citation Slide Set E-Mail Save Article
Alert Reprints & Permissions Share/BookmarkMore In Review
February 15, 2007Trends: Most Viewed (Last Week) Hepatocellular
Carcinoma September 22, 2011 Breast-Cancer Adjuvant Therapy with
Zoledronic Acid Porphyria Cutanea Tarda September 22, 2011More
Trends
Content:HomeCurrent IssueArticlesIssue IndexSpecialties &
TopicsMultimedia & ImagesArchive 1812-1989Information
For:AuthorsReviewersSubscribersInstitutionsMediaAdvertisersServices:SubscribeRenewPay
BillActivate SubscriptionCreate or Manage AccountAlertsRSS &
PodcastsSubmit a ManuscriptHelpResources:Physician JobsReprints
& PermissionsMedical MeetingsConventionsFAQsJournal
WatchNEJM:AboutProduct InformationEditors & PublishersTerms of
UsePrivacy PolicyCopyrightAdvertising PoliciesContact UsCME:Weekly
CME ProgramBrowse Weekly ExamsYour CME ActivityPurchase Exams
Review CME ProgramFollow us My AccountMy AlertsMy Saved ItemsMy CME
ExamsArticle CategoryResearchReviewsClinical
CasesPerspectiveCommentaryOtherBrowse all articlesMultimediaVideos
in Clinical MedicineImages in Clinical MedicineInteractive Medical
CasesWeekly Audio SummariesBrowse all multimediaThis WeekLast
WeekBrowse full indexSelected
SpecialtiesCardiologyEndocrinologyGastroenterologyGeneticsHematology/OncologyInfectious
DiseaseNephrologyNeurology/NeurosurgeryObstetrics/GynecologyPediatricsPulmonary/Critical
CareSurgeryBrowse all Specialties & TopicsFeatured TopicsHealth
Policy and ReformAuthor CenterSubmit a Manuscript or LetterTrack a
ManuscriptHelp
