Skip to main content
SpringerLink
Log in

Neurologische Komplikationen nach herzchirurgischen Operationen

Neurological complications after cardiothoracic surgery

  • Nachbardisziplinen
  • Published:
Zeitschrift für Herz-,Thorax- und Gefäßchirurgie Aims and scope

Zusammenfassung

Herzchirurgische Eingriffe gehören zu den häufigsten chirurgischen Operationen überhaupt und sind oft lebensrettend. Angesichts der steigenden Lebenserwartung der alternden Bevölkerungen werden in Zukunft immer mehr Operationen an immer älteren Patienten durchgeführt, die ihrerseits zudem eine hohe Komorbidität aufweisen. Herzchirurgische Operationen sind für den Herzchirurgen ebenso wie für den Anästhesiologen aufgrund deren Komplexität eine Herausforderung; sie bedeuten für den Patienten neben der Chance einer Lebensrettung und Heilung gleichzeitig das Risiko einer sekundären Organschädigung. Das Gehirn als sauerstoffempfindlichstes und metabolisch aktivstes Organ ist am häufigsten davon betroffen. Im Zusammenhang mit einer herzchirurgischen Operation sind die häufigsten neurologischen Komplikationen eine akute Enzephalopathie, ischämische und hämorrhagische Insulte sowie eine chronische kognitive Beeinträchtigung. Der vorliegende Beitrag soll Ätiologie und Inzidenz dieser Komplikationen näher beleuchten und Strategien zu deren Prävention aufzeigen.

Abstract

Cardiothoracic surgery is one of the most frequently performed interventions and often saves lives. The increased life expectancy in the aging populations will require more surgical procedures in the elderly with their higher operative risk and higher comorbidity. Due to its complexity, cardiothoracic surgery is still a challenge for both the cardiothoracic surgeon and anesthesiologist, because the patient is at risk for neuronal damage and chronic dysfunction. The three most frequent neurological complications of cardiothoracic surgery are acute postoperative encephalopathy, ischemic and hemorrhagic strokes, and persistent cognitive impairment. The following report will provide detailed information about etiology and incidence of these complications and will also highlight prevention strategies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Leary MC, Caplan LR (2007) Technology insight: brain MRI and cardiac surgery – detection of postoperative brain ischemia. Nat Clin Pract Cardiovasc Med 4:379–388

    Article  PubMed  Google Scholar 

  2. Nassau K, Kasel K, Kilger E, Zwiβler B (2008) Die Intensivmedizin. 10. Aufl. Kapitel XII, In: Burchardi H, Larsen R, Kuhlen R, (Hrsg) Springer-Verlag, S 969–985

  3. Roach GW, Kanchuger M, Mangano CM et al (1996) Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 335:1857–1863

    Article  PubMed  CAS  Google Scholar 

  4. Wolman RL, Nussmeier NA, Aggarwal A et al (1999) Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter Study of Perioperative Ischemia Research Group (McSPI) and the Ischemia Research Education Foundation (IREF) Investigators. Stroke 30:514–522

    PubMed  CAS  Google Scholar 

  5. Gottesman RF, Sherman PM, Grega MA et al (2006) Watershed strokes after cardiac surgery: diagnosis, etiology, and outcome. Stroke 37:2306–2311

    Article  PubMed  Google Scholar 

  6. Samuels M (2006) Can Cognition Survive Heart Surgery? Circulation 113:2784–2786

    Article  PubMed  Google Scholar 

  7. Rolfson DB, McElhaney JE, Rockwood K et al (1999) Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Can J Cardiol 15:771–776

    PubMed  CAS  Google Scholar 

  8. Eriksson M, Samuelsson E, Gustafson Y et al (2002) Delirium after coronary bypass surgery evaluated by the organic brain syndrome protocol. Scand Cardiovasc J 36:250–255

    Article  PubMed  Google Scholar 

  9. Bucerius J, Gummert JF, Borger MA et al (2004) Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery. J Thorac Cardiovasc Surg 127:57–64

    Article  PubMed  Google Scholar 

  10. Gottesman RF, Grega MA, Bailey MM et al (2010) Delirium after coronary artery bypass graft surgery and late mortality. Ann Neurol 67:338–344

    PubMed  CAS  Google Scholar 

  11. McKhann GM, Grega MA, Borowicz LM Jr et al (2002) Encephalopathy and stroke after coronary artery bypass grafting: incidence, consequences, and prediction. Arch Neurol 59:1422–1428

    Article  PubMed  Google Scholar 

  12. McKhann GM, Grega MA, Borowicz LM Jr et al (2006) Stroke and encephalopathy after cardiac surgery: an update. Stroke 37:562–571

    Article  PubMed  Google Scholar 

  13. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM (2003) Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 49:516–522

    Article  Google Scholar 

  14. Wijeysundera DN, Naik JS, Beattie WS (2003) Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: A meta-analysis. Am J Med 114:742–752

    Article  PubMed  CAS  Google Scholar 

  15. Prakanrattana U, Prapaitrakool S (2007) Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care 35:714–719

    PubMed  CAS  Google Scholar 

  16. Caplan LR, Hennerici M (1998) Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 55:1475–1482

    Article  PubMed  CAS  Google Scholar 

  17. Gootjes EC, Wijdicks EF, McClelland RL (2005) Postoperative stupor and coma. Mayo Clin Proc 80:350–354

    Article  PubMed  Google Scholar 

  18. Wityk RJ, Goldsborough MA, Hillis AE et al (2001) Diffusion- and perfusion-weighted brain magnetic resonance imaging in patients with neurologic complications after cardiac surgery. Arch Neurol 58:571–576

    Article  PubMed  CAS  Google Scholar 

  19. Rankin JM, Silbert PL, Yadava OP et al (1994) Mechanism of stroke complicating cardiopulmonary bypass surgery. Aust N Z J Med 24:154–160

    PubMed  CAS  Google Scholar 

  20. Dittrich R, Ringelstein EB (2008) Occurrence and clinical impact of microembolic signals during or after cardiosurgical procedures. Stroke 39:503–511

    Article  PubMed  Google Scholar 

  21. Ringelstein EB, Koschorke S, Holling A et al (1989) Computed tomographic patterns of proven embolic brain infarctions. Ann Neurol 26:759–765

    Article  PubMed  CAS  Google Scholar 

  22. Pepi M, Evangelista A, Nihoyannopoulos P et al (2010) European Association of Echocardiography. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 11:461–476

    Article  PubMed  Google Scholar 

  23. Gottesman RF, McKhann GM, Hogue CW (2008) Neurological complications of cardiac surgery. Semin Neurol 28:703–715

    Article  PubMed  Google Scholar 

  24. Wareing TH, Davila-Roman VG, Barzilai B et al (1992) Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment. J Thorac Cardiovasc Surg 103:453–462

    PubMed  CAS  Google Scholar 

  25. Mathew JP, Fontes ML, Tudor IC et al (2004) Investigators of the Ischemia Research and Education Foundation; Multicenter Study of Perioperative Ischemia Research Group. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 291:1720–1729

    Article  PubMed  CAS  Google Scholar 

  26. McKhann GM, Goldsborough MA, Borowicz LM Jr et al (1997) Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg 63:516–521

    Article  PubMed  CAS  Google Scholar 

  27. Stamou SC, Hill PC, Dangas G et al (2001) Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 32:1508–1513

    PubMed  CAS  Google Scholar 

  28. Dacey LJ, Likosky DS, Leavitt BJ et al (2005) Perioperative stroke and long-term survival after coronary bypass graft surgery. Ann Thorac Surg 79:532–536

    Article  PubMed  Google Scholar 

  29. Salazar JD, Wityk RJ, Grega MA et al (2001) Stroke after cardiac surgery: short- and long-term outcomes. Ann Thorac Surg 72:1195–1201

    Article  PubMed  CAS  Google Scholar 

  30. Diener HC, Putzki N (Hrsg) (2008) Akuttherapie des ischämischen Schlaganfalls. In: Leitlinien für Diagnostik und Therapie in der Neurologie. 4., überarb. Aufl. Thieme Verlag (http://www.dgn.org)

  31. Knipp SC, Matatko N, Wilhelm H et al (2004) Evaluation of brain injury after coronary artery bypass grafting. A prospective study using neuropsychological assessment and diffusion-weighted magnetic resonance imaging. Eur J Cardiothorac Surg 25:791–800

    Article  PubMed  Google Scholar 

  32. Koenig MA, Grega MA, Bailey MM et al (2009) Statin use and neurologic morbidity after coronary artery bypass grafting: A cohort study. Neurology 73:2099–2106

    Article  PubMed  CAS  Google Scholar 

  33. Linden J van der, Bergman P, Hadjinikolaou L (2007) The topography of aortic atherosclerosis enhances its precision as a predictor of stroke. Ann Thorac Surg 83:2087–2092

    Article  PubMed  Google Scholar 

  34. Bergman P, Linden J van der (2005) Atherosclerosis of the ascending aorta as a major determinant of the outcome of cardiac surgery. Nat Clin Pract Cardiovasc Med 2:246–251

    Article  PubMed  Google Scholar 

  35. Lapar DJ, Bhamidipati CM, Reece TB et al (2010) Is off-pump coronary artery bypass grafting superior to conventional bypass in octogenarians? J Thorac Cardiovasc Surg [Epub ahead of print]

  36. Li Z, Denton T, Yeo KK et al (2010) Off-pump bypass surgery and postoperative stroke: California coronary bypass outcomes reporting program. Ann Thorac Surg 90:753–759

    Article  PubMed  Google Scholar 

  37. Kuss O, Salviati B von, Börgermann J (2010) Off-pump versus on-pump coronary artery bypass grafting: a systematic review and meta-analysis of propensity score analyses. J Thorac Cardiovasc Surg 140:829–835

    Article  PubMed  Google Scholar 

  38. Hilker M, Arlt M, Keyser A et al (2010) Minimizing the risk of perioperative stroke by clampless off-pump bypass surgery: a retrospective observational analysis. J Cardiothorac Surg 5:14

    Article  PubMed  Google Scholar 

  39. Ahlsson A, Fengsrud E, Bodin L, Englund A (2010) Postoperative atrial fibrillation in patients undergoing aortocoronary bypass surgery carries an eightfold risk of future atrial fibrillation and a doubled cardiovascular mortality. Eur J Cardiothorac Surg 37:1353–1359

    Article  PubMed  Google Scholar 

  40. Newman MF, Kirchner JL, Phillips-Bute B et al (2001) Neurological Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors Investigators. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med 344:395–402

    Article  PubMed  CAS  Google Scholar 

  41. Grocott HP, Homi HM, Puskas F (2005) Cognitive dysfunction after cardiac surgery: revisiting etiology. Semin Cardiothorac Vasc Anesth 9:123–129

    Article  PubMed  Google Scholar 

  42. Pugsley W, Klinger L, Paschalis C et al (1994) The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 25:1393–1399

    PubMed  CAS  Google Scholar 

  43. Evered LA, Silbert BS, Scott DA (2010) Postoperative cognitive dysfunction and aortic atheroma. Ann Thorac Surg 89:1091–1097

    Article  PubMed  Google Scholar 

  44. Markus HS, Droste DW, Kaps M et al (2005) Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 111:2233–2240

    Article  PubMed  CAS  Google Scholar 

  45. Markus HS, King A, Shipley M et al (2010) Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 9:663–671

    Article  PubMed  Google Scholar 

  46. Hernandez F Jr, Brown JR, Likosky DS et al (2007) Neurocognitive outcomes of off-pump versus on-pump coronary artery bypass: a prospective randomized controlled trial. Ann Thorac Surg 84:1897–1903

    Article  PubMed  Google Scholar 

  47. Newman MF, Mathew JP, Grocott HP et al (2006) Central nervous system injury associated with cardiac surgery. Lancet 368:694–703

    Article  PubMed  Google Scholar 

  48. McDonagh DL, Mathew JP, White WD et al (2010) Neurologic Outcome Research Group. Cognitive function after major noncardiac surgery, apolipoprotein E4 genotype, and biomarkers of brain injury. Anesthesiology 112:852–859

    Article  PubMed  CAS  Google Scholar 

  49. Mathew JP, Podgoreanu MV, Grocott HP et al (2007) PEGASUS Investigative Team. Genetic variants in P-selectin and C-reactive protein influence susceptibility to cognitive decline after cardiac surgery. J Am Coll Cardiol 49:1934–1942

    Article  PubMed  CAS  Google Scholar 

  50. Selnes OA, Grega MA, Bailey MM et al (2007) Neurocognitive outcomes 3 years after coronary artery bypass graft surgery: a controlled study. Ann Thorac Surg 84:1885–1896

    Article  PubMed  Google Scholar 

  51. Droste DW, Dittrich R, Kemeny V et al (1999) Prevalence and frequency of microembolic signals in 105 patients with extracranial carotid artery occlusive disease. J Neurol Neurosurg Psychiatry 67:525–528

    Article  PubMed  CAS  Google Scholar 

Download references

Interessenkonflikt

Der koorespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Klinik und Poliklinik für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48149, Münster, Deutschland

    R. Dittrich & E.B. Ringelstein

Authors
  1. R. Dittrich
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E.B. Ringelstein
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to R. Dittrich.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dittrich, R., Ringelstein, E. Neurologische Komplikationen nach herzchirurgischen Operationen. Z Herz- Thorax- Gefäßchir 25, 92–98 (2011). https://doi.org/10.1007/s00398-011-0828-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00398-011-0828-z

Schlüsselwörter

Keywords

Search

Navigation