Acute Ischemic Stroke in the Cardiothoracic Surgery Patient: Thrombolytic Therapy or Mechanical Thrombectomy?

  • Masoom DesaiEmail author
  • Deborah M. Stein
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


  • Purpose: To review and outline evidence-based guidance of acute ischemic stroke (AIS) in post-operative cardiac surgery patients.

  • Background: Stroke is a devastating complication after cardiac surgery and accounts for substantially high post-surgical mortality and morbidity. Peri-surgical stroke leads to longer hospital stay and increased economic burden in the management of post cardiovascular surgery patients. Management of AIS in patients with recent cardiac surgery is challenging and needs careful consideration of both, risks and benefits of different interventions. Addressing the risk factors and timely secondary prevention for neurologic complications is crucial in improving outcomes post cardiac surgery.

  • Method: Evidence-based review of management of stroke post cardiac surgery and important steps of secondary prevention post cardiac surgery are depicted in this chapter. This chapter illustrates recommendations on difficult decisions in managing stroke in post cardiac surgery patients using GRADE classification.

  • Conclusion: Intravenous t-PA (tissue plasminogen activator) is contraindicated in treatment of stroke in patients post cardiothoracic surgery. Available options include intra-arterial t-PA and mechanical thrombectomy. Interventional procedures have emerged as a promising option for management of stroke post cardiac surgery. Timely detection of neurological complications is challenging but crucial to improve outcomes in patients post cardiac surgery. Medical management of AIS post cardiac surgery presents several challenging questions reviewed in this chapter along with gaps which need to be addressed in the future.


Cardiothoracic surgery Acute ischemic stroke Mechanical thrombectomy Contraindication to t-PA Secondary prevention of stroke Mechanical thrombectomy and outcomes 


  1. 1.
    Anyanwu AC, Filsoufi F, Salzberg SP, Bronster DJ, Adams DH. Epidemiology of stroke after cardiac surgery in the current era. J Thorac Cardiovasc Surg. 2007;134(5):1121–7.PubMedGoogle Scholar
  2. 2.
    Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, et al. 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. 1996;335(25):1857–63.PubMedGoogle Scholar
  3. 3.
    Boeken U, Litmathe J, Feindt P, Gams E. Neurological complications after cardiac surgery: risk factors and correlation to the surgical procedure. Thorac Cardiovasc Surg. 2005;53(1):33–6.PubMedGoogle Scholar
  4. 4.
    Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Onnasch JF, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003;75(2):472–8.PubMedGoogle Scholar
  5. 5.
    Tarakji KG, Sabik JF 3rd, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305(4):381–90.PubMedGoogle Scholar
  6. 6.
    Selim M. Perioperative stroke. N Engl J Med. 2007;356(7):706–13.PubMedGoogle Scholar
  7. 7.
    McKhann GM, Grega MA, Borowicz LM, Baumgartner WA, Selnes OA. Stroke and encephalopathy after cardiac surgery. Stroke. 2006;37(2):562–71.PubMedGoogle Scholar
  8. 8.
    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110.PubMedGoogle Scholar
  9. 9.
    Marler JR for the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7.Google Scholar
  10. 10.
    Pexman JHW, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. Am J Neuroradiol. 2001;22(8):1534–42.PubMedGoogle Scholar
  11. 11.
    Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21.Google Scholar
  12. 12.
    Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708–18.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995;274(13):1017–25.PubMedGoogle Scholar
  14. 14.
    Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947.PubMedGoogle Scholar
  15. 15.
    Meretoja A, Putaala J, Tatlisumak T, Atula S, Artto V, Curtze S, et al. Off-label thrombolysis is not associated with poor outcome in patients with stroke. Stroke. 2010;41(7):1450–8.PubMedGoogle Scholar
  16. 16.
    Khatri P, Taylor RA, Palumbo V, Rajajee V, Katz JM, Chalela JA, et al. The safety and efficacy of thrombolysis for strokes after cardiac catheterization. J Am Coll Cardiol. 2008;51(9):906–11.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Voelkel N, Hubert ND, Backhaus R, Haberl RL, Hubert GJ. Thrombolysis in postoperative stroke. Stroke. 2017;48(11):3034–9.PubMedGoogle Scholar
  18. 18.
    Chalela JA, Katzan I, Liebeskind DS, Rasmussen P, Zaidat O, Suarez JI, et al. Safety of intra-arterial thrombolysis in the postoperative period. Stroke. 2001;32(6):1365–9.PubMedGoogle Scholar
  19. 19.
    Moazami N, Smedira NG, McCarthy PM, Katzan I, Sila CA, Lytle BW, et al. Safety and efficacy of intraarterial thrombolysis for perioperative stroke after cardiac operation. Ann Thorac Surg. 2001;72(6):1933–7. discussion 7-9PubMedGoogle Scholar
  20. 20.
    Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA. 1999;282(21):2003–11.PubMedGoogle Scholar
  21. 21.
    Ogawa A, Mori E, Minematsu K, Taki W, Takahashi A, Nemoto S, et al. Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke. Stroke. 2007;38(10):2633–9.PubMedGoogle Scholar
  22. 22.
    Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.PubMedGoogle Scholar
  23. 23.
    Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.PubMedGoogle Scholar
  24. 24.
    Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.PubMedGoogle Scholar
  25. 25.
    Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306.Google Scholar
  26. 26.
    Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.Google Scholar
  27. 27.
    Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.Google Scholar
  28. 28.
    Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Clark W, Davalos A, et al. Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the SWIFT and STAR studies. JAMA Neurol. 2017;74(3):268–74.PubMedGoogle Scholar
  29. 29.
    Madeira M, Martins C, Koukoulis G, Marques M, Reis J, Abecassis M. Mechanical thrombectomy for stroke after cardiac surgery. J Card Surg. 2016;31(8):517–20.PubMedGoogle Scholar
  30. 30.
    Haider AS, Garg P, Watson IT, Leonard D, Khan U, Haque A, et al. Mechanical thrombectomy for acute ischemic stroke after cardiac surgery. Cureus. 2017;9(4):e1150.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Mourand I, Machi P, Milhaud D, Picot M-C, Lobotesis K, Arquizan C, et al. Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion. J Neurointerventional Surg. 2014;6(3):200–4.Google Scholar
  32. 32.
    Mokin M, Sonig A, Sivakanthan S, Ren Z, Elijovich L, Arthur A, et al. Clinical and procedural predictors of outcomes from the endovascular treatment of posterior circulation strokes. Stroke. 2016;47(3):782–8.PubMedGoogle Scholar
  33. 33.
    Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring HP, Trenkler J, et al. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol. 2015;77(3):415–24.PubMedGoogle Scholar
  34. 34.
    Kwak JH, Zhao L, Kim JK, Park S, Lee D-G, Shim JH, et al. The outcome and efficacy of recanalization in patients with acute internal carotid artery occlusion. Am J Neuroradiol. 2014;35(4):747–53.PubMedGoogle Scholar
  35. 35.
    Jovin TG, Gupta R, Uchino K, Jungreis CA, Wechsler LR, Hammer MD, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke. 2005;36(11):2426–30.PubMedGoogle Scholar
  36. 36.
    Blackstone EH, Sabik JFI. Changing the discussion about on-pump versus off-pump CABG. N Engl J Med. 2017;377(7):692–3.PubMedGoogle Scholar
  37. 37.
    Shroyer AL, Hattler B, Wagner TH, Collins JF, Baltz JH, Quin JA, et al. Five-year outcomes after on-pump and off-pump coronary-artery bypass. N Engl J Med. 2017;377(7):623–32.PubMedGoogle Scholar
  38. 38.
    Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z, et al. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med. 2016;375(24):2359–68.PubMedGoogle Scholar
  39. 39.
    Wang J, Gu C, Gao M, Yu W, Li H, Zhang F, et al. Comparison of the incidence of postoperative neurologic complications after on-pump versus off-pump coronary artery bypass grafting in high-risk patients: a meta-analysis of 11 studies. Int J Cardiol. 2015;185:195–7.PubMedGoogle Scholar
  40. 40.
    Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(23):2610–42.PubMedGoogle Scholar
  41. 41.
    Durand DJ, Perler BA, Roseborough GS, Grega MA, Borowicz LM Jr, Baumgartner WA, et al. Mandatory versus selective preoperative carotid screening: a retrospective analysis. Ann Thorac Surg. 2004;78(1):159–66. discussion -66PubMedGoogle Scholar
  42. 42.
    Sheiman RG, Janne d'Othee B. Screening carotid sonography before elective coronary artery bypass graft surgery: who needs it. AJR Am J Roentgenol. 2007;188(5):W475–9.PubMedGoogle Scholar
  43. 43.
    Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, et al. The North American symptomatic carotid endarterectomy trial: surgical results in 1415 patients. Stroke. 1999;30(9):1751–8.PubMedGoogle Scholar
  44. 44.
    Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995;273(18):1421–8.Google Scholar
  45. 45.
    Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010;376(9746):1074–84.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Li Y, Yang JJ, Zhu SH, Xu B, Wang L. Long-term efficacy and safety of carotid artery stenting versus endarterectomy: a meta-analysis of randomized controlled trials. PLoS One. 2017;12(7):e0180804.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Naylor AR. Synchronous cardiac and carotid revascularisation: the devil is in the detail. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg. 2010;40(3):303–8.Google Scholar
  48. 48.
    Kulik A, Ruel M, Jneid H, Ferguson TB, Hiratzka LF, Ikonomidis JS, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927–64.PubMedGoogle Scholar
  49. 49.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159–e95.PubMedGoogle Scholar
  50. 50.
    Sandercock PA, Counsell C, Kane EJ. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev. 2015;3:CD000024.Google Scholar
  51. 51.
    Paciaroni M, Agnelli G, Micheli S, Caso V. Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke. 2007;38(2):423–30.PubMedGoogle Scholar
  52. 52.
    Marsh EB, Llinas RH, Hillis AE, Gottesman RF. Hemorrhagic transformation in patients with acute ischaemic stroke and an indication for anticoagulation. Eur J Neurol: Off J Eur Fed Neurol Soc. 2013;20(6):962–7.Google Scholar
  53. 53.
    Marsh EB, Llinas RH, Schneider ALC, Hillis AE, Lawrence E, Dziedzic P, et al. Predicting hemorrhagic transformation of acute ischemic stroke: prospective validation of the HeRS score. Medicine. 2016;95(2):e2430.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Gold JP, Charlson ME, Williams-Russo P, Szatrowski TP, Peterson JC, Pirraglia PA, et al. Improvement of outcomes after coronary artery bypass. A randomized trial comparing intraoperative high versus low mean arterial pressure. J Thorac Cardiovasc Surg. 1995;110(5):1302–11. discussion 11-4PubMedPubMedCentralGoogle Scholar
  55. 55.
    Charlson 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(5):567–80.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Gold 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(5):1579–85.PubMedGoogle Scholar
  57. 57.
    Mistry EA, Mistry AM, Nakawah MO, Khattar NK, Fortuny EM, Cruz AS, et al. Systolic blood pressure within 24 hours after thrombectomy for acute ischemic stroke correlates with outcome. J Am Heart Assoc. 2017;6(5):e006167.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Ferguson TB Jr, Coombs LP, Peterson ED. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. JAMA. 2002;287(17):2221–7.PubMedGoogle Scholar
  59. 59.
    Brinkman W, Herbert MA, O'Brien S, Filardo G, Prince S, Dewey T, et al. Preoperative beta-blocker use in coronary artery bypass grafting surgery: national database analysis. JAMA Intern Med. 2014;174(8):1320–7.Google Scholar
  60. 60.
    Wiesbauer F, Schlager O, Domanovits H, Wildner B, Maurer G, Muellner M, et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. Anesth Analg. 2007;104(1):27–41.PubMedGoogle Scholar
  61. 61.
    Blessberger H, Kammler J, Domanovits H, Schlager O, Wildner B, Azar D, et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev. 2014;9:Cd004476.Google Scholar
  62. 62.
    Gillinov AM, Bagiella E, Moskowitz AJ, Raiten JM, Groh MA, Bowdish ME, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911–21.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Gibson AJ, Davis FM. Hyperbaric oxygen therapy in the treatment of post cardiac surgical strokes – a case series and review of the literature. Anaesth Intensive Care. 2010;38(1):175–84.PubMedGoogle Scholar
  64. 64.
    Prakkamakul S, Yoo AJ. ASPECTS CT in acute ischemia: review of current data. Top Magn Reson Imaging: TMRI. 2017;26(3):103–12.PubMedGoogle Scholar
  65. 65.
    van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604–7.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.McGaw Medical Center, Division of Epilepsy and Neurophysiology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.R Adams Cowley Shock Trauma Center, Program in TraumaUniversity of Maryland School of MedicineBaltimoreUSA

Personalised recommendations