British Journal of Anaesthesia, Vol 84, Issue 3 378-393, Copyright © 2000 by Oxford University Press
JE Arrowsmith, HP Grocott, JG Reves and MF Newman
The neurological complications of cardiac surgery are associated with
significantly increased mortality, morbidity and resource utilization. The
use of new surgical techniques, introduction of wider indications for
surgery and increased public expectation has led to an increase in the
average age of cardiac surgical patients and an increased incidence of
repeat procedures. With these changes has come an increased risk of
neurological complications. The likelihood of perioperative stroke varies
between 1% and 5% in most published series and is dependent on a multitude
of risk factors. Of these, patient age, aortic atheroma, symptomatic
cerebrovascular disease, diabetes mellitus and the type of surgery appear
to be most important. Cognitive deterioration after cardiac surgery is far
more common, affecting as many as 80% of patients a few days after surgery
and persisting in one-third. Despite an increase in the age of the cardiac
surgical population, the reported incidence of cognitive dysfunction after
cardiac surgery seems to have fallen in recent years. Whether this is a
real phenomenon or the result of changes in the use of psychometric testing
and the definition of cognitive decline remains unclear. Recognition that
certain equipment, surgical practices and patient factors contribute to
neurological morbidity has prompted 'neuroprotective' interventions. Some
of these (e.g. arterial line filtration and alpha-stat management) have
been shown to improve outcome. Despite these measures, a small number of
patients will inevitably sustain cerebral injury during otherwise
successful cardiac surgery. Although pharmacological neuroprotection may,
in the future, offer some of these patients an improved outcome, it is
unlikely that any single agent will prevent neurological injury. In the
meantime, the CNS complications of cardiac surgery remain a fertile area of
research.
ARTICLES
Central nervous system complications of cardiac surgery
Department of Anaesthesia, Papworth Hospital, Papworth Everard, Cambridge, UK.
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