Stroke and Delirium prevention in CABG Surgery ‘the Haga Brain Care Strategy’

1. Stroke and Delirium prevention in CABG Surgery‘the Haga Brain Care Strategy’ RWM Keunen, A.Falsafi, W.A.C. Palmbergen Dept. of Neurology, Cardiosurgery and Clinical Neurophysiology The Haga Teaching Hospitals, The Hague, The Netherlands. www.strokeprevention.nl

2. Disclosure R.W.M. Keunen develops medical software in order to prevent cerebral ischemia. The products include an embolus detection system and electronical patient data management systems. These stroke prevention initiatives are promoted on a sponsored website (www.strokeprevention.nl). www.strokeprevention.nl

3. Neurological complications of CABG surgery Delirium 15-40 % Stroke 1-5 % Other www.strokeprevention.nl

4. Risk factors for post CABG delirium • pre-existing mild cognitive impairement • a history of dementia and/or delirium • age > 75 yrs. • use of opiates, tranquilizers, narcotics ect. • > 4 drinks of alcohol each day. Pre-operative Delirium Outcome Scores can reliably predict patients who will experience a post-operative delirium after major surgery www.strokeprevention.nl

5. The concept of the post surgery ‘ischemic delirium’ Ann Thorac Surg 2009;87:36–45 Ref Murkin www.strokeprevention.nl

6. Risk Factors for post CABG strokes • Age > 65 yrs • Carotid bruits • History of a Stroke or TIA • Bilateral carotid artery occlusions/subtotal stenosis • smoking • Peri-operative manipulation/cannulation of the cardiovascular systems • Peri-operative atrial fibrillation Pre-operative Stroke Outcome Score are poor predictors of strokes after major cardiovascular surgery . www.strokeprevention.nl

7. Pre-operative Stroke Risk Analysis(according to ACC & AHA CABG guidelines)- C level of evidence - Screening of the carotid arteries is indicated: 1. > 65 yrs of age, 2. carotid bruits, 3. recent TIA or Stroke, 4. smoking 5. left mainstem coronary artery stenosis. www.strokeprevention.nl

8. Preoperative unilateral high grade carotid artery stenosis! What to do next? Perform an angioplasthy or Surgery in every patient Statement I Increased post-op hemodynamic stroke risk???? Never perform surgery or angioplasthy Statement II Increased risk of myocardial infarcts and/or peri-procedural Embolic strokes ???? www.strokeprevention.nl

9. An index patient with a post CABG Stroke and Delirium • Low pre-operative risk scores • Severe post operative stroke • Post surgery duplex: bilateral subtotal carotid artery stenosis • Post surgery CT: ischemic lesion of right hemisphere • Outcome: poor. www.strokeprevention.nl

10. The Haga Brain Care Strategy • pre-operative evaluation of cerebral hemodynamics by transcranial Doppler (TCD). • Peri- and post operative cerebral oximetry. www.strokeprevention.nl

11. Pre-operative TCD PI of the L/R middle cerebral artery above 0.6 is used as cutt-off value www.strokeprevention.nl

12. Per-operative oximetry Cerebral oximetry is used from the induction of anaesthesia until the patient is awake and hemodynamically stable at the recovery or ICU. www.strokeprevention.nl

13. The Haga Braincare Strategy • Additional features: • Duplex carotid arteries is performed in case of absent temporal windows • Selective angioplasthy in case of either a symptomatic carotid artery stenosis or in case of poor collaterals distally to a high grade carotid artery stenosis. www.strokeprevention.nl

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15. Initial Observations Haga Inclusion: 233 patients in 2009 409 patients in 2010 Male/Female ratio 2 : 1 Age 68 yrs. CABG 43 % CABG + 67 % www.strokeprevention.nl

16. Incidence Post operative Delirium 2009 versus 2010 www.strokeprevention.nl

17. Results • Delirium rate: • 13.3 % (2009) to 7.3 % (2010). • Length of stay at ICU: • 2.1 days (2009) to 1.8 day (2010). • % patients who stayed > 3 days at ICU: • 24.4 % (2009) naar 14.4 % (2010). • Selective carotid angioplasthy: • 1 (2009) and 0 (2010) • Stroke rate • 1.5 % (2009) and 1.3 % (2010). www.strokeprevention.nl

18. Results Post Operative Delirium www.strokeprevention.nl

19. Critical Comments • The present study is not a randomized controlled trial. • Only a subset of patients completed the full strategy. • It is unclear which aspects of the strategy (TCD/NIRS/selective angioplasthy) causes the better outcome. www.strokeprevention.nl

20. Summary • Ischemia is the cause of a postoperative delirium after CABG surgery. • The HBCS increases outcome and patients with CABG + with the lowest pre-operative delirium scores seems to profit most. • Controlled randomized trials are needed to establish the value of the Haga Brain Care Strategy. • The Stroke Prevention Initiative invites neurologists and vascular surgeons to study the frequency of post-operative delirium and stroke at their own hospital through a downloadable internet application that provides a confidential patient electronic database. www.strokeprevention.nl www.strokeprevention.nl

21. Addendum: NIRS and Stroke prevention • There is no definitive evidence that NIRS instruments can prevent strokes during CABG surgery; However: • Patients with bilateral carotid artery stenosis are at risk for hemodynamic strokes. In these patients close monitoring of cerebral oxygenation during surgery might prevent ischemic strokes. 2. All patients might suffer from ongoing embolisation of debris during cardiac surgery. In case of active cerebral embolisation close monitoring of cerebral oxygenation might reduce the ischemic penumbra and therefore increase the outcome of ischemic strokes (see also retrospective data on next slide). www.strokeprevention.nl www.strokeprevention.nl

22. Stroke Incidence & Severity 2007/8 and 2009/10 Incidence of ischemic stroke in percentages; Stroke severity expressed in mean Nat. Inst. of Health Stroke Scales. Retrospective data from the Haga Teaching Hospitals Reference; A. van Sonderen et al. Cerebrovasc Dis 2011 31 (suppl 1): 57. www.strokeprevention.nl