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Canadian Journal of Cardiology

Iatrogenic strokes and covert brain infarcts after percutaneous cardiac procedures: an update

  • William R. Betzner
    Affiliations
    Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada

    Hotchkiss Brain Institute and the Matheson Centre for Mental Health Research
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  • Stephen Wilton
    Affiliations
    Libin Cardiovascular Institute, Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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  • Aravind Ganesh
    Correspondence
    Corresponding Author: Aravind Ganesh, MD DPhil FRCPC, HMRB Room 103, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Telephone: +1 (403) 220-3747,
    Affiliations
    Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada

    Hotchkiss Brain Institute and the Matheson Centre for Mental Health Research

    Department of Community Health Sciences and the O’Brien Institute of Public Health, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
    Search for articles by this author
Published:November 23, 2022DOI:https://doi.org/10.1016/j.cjca.2022.11.008

      Abstract

      Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural, iatrogenic stroke an important concern. These strokes can either occur intraoperatively or within 30 days of a procedure, and can be categorized as either overt or covert, occurring without obvious acute neurological symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing peri-procedural morbidity/mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurological standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include prior stroke, atherosclerotic disease, carotid stenosis, individuals who are female or a Black/African American as well as other patient- and procedural-level factors. While the impact of CBIs is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures =include screening and vascular risk factor control, pre-medicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurological field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.
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