Introduction
Acute ischaemic stroke occurs in approximately 1-10% of patients undergoing cardiac
surgery and can markedly impair recovery (1). Thrombolysis carries an unacceptably
high risk of haemorrhage in the early postoperative period after heart surgery. Mechanical
thrombectomy is becoming an increasingly preferred alternative to treat ischaemic
strokes, and unlike thrombolysis, is not contraindicated in the early postoperative
period. We report a patient who had witnessed onset of ischaemic stroke in the early
postoperative period after aortic valve replacement (AVR) and coronary artery bypass
grafting (CABG) surgery and was treated with mechanical thrombectomy.
Discussion
An 81-year-old male patient underwent elective tissue AVR and CABG (internal mammary
to left anterior descending coronary artery) surgery. Surgery was uncomplicated and
following weaning from mechanical ventilation, the patient's trachea was extubated
on the evening of surgery. His recovery progressed uneventfully and on the day after
surgery, he was moved to a high dependency unit. On the morning of the second post-operative
day, the patient had a witnessed rapid deterioration in conscious level, becoming
unresponsive with a divergent gaze. Urgent plain CT scan of the brain showed hyperattenuation
of the left middle cerebral artery (MCA) territory consistent with acute thrombosis.
The patient was granted emergency funding for a mechanical thrombectomy and was transported
to the regional neurology hospital. A mechanical thrombectomy was performed successfully,
with digital subtraction angiography (DSA) confirming complete occlusion of the left
MCA with poor collateral cross flow. The patient failed to recover neurological function
and died approximately 24 hours later.
Mechanical thrombectomy is now a well-established treatment for acute ischaemic stroke.
There are clear advantages with regard to functional outcome for patients undergoing
mechanical thrombectomy versus best available medical therapies such as thrombolysis
(2). A recent systematic review of acute ischaemic stroke post cardiac surgery showed
that 50% of patients who underwent endovascular mechanical thrombectomy had a full
or good neurological recovery, 36% had moderate recovery and 14% had little improvement
(1). Factors that may have led to a poor outcome in this patient's case included the
delay in hospital transfer, the poor cerebral cross blood flow noted on DSA and extensive
comorbidities.
In conclusion, although there are many reports of mechanical thrombectomy being associated
with a good neurological outcome from acute ischaemic stroke associated with cardiac
surgery, outcome may not be improved if there is underlying cerebrovascular disease
and intervention is delayed.
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© 2021 Published by Elsevier Inc.
