suggest that cardiac disease (particularly low cardiac output and left ventricular diastolic dysfunction) in the absence of cardiac surgery is associated with cognitive impairments [105]. PERIPHERAL NEUROPATHY Upper extremity Upper extremity peripheral nerve injury follows cardiac operations in 2 to 15 percent of patients [8,48,106-108]. Putative mechanisms of injury include brachial plexus traction, brachial plexus compression between the clavicle and the first rib during sternal retraction, and nerve injury during internal mammary artery dissection, hypothermia, and hemodynamic changes during cardiopulmonary bypass (CPB). In one case series, hypertension, tobacco use, and diabetes were risk factors for nerve injuries [108]. Peripheral neuropathy typically presents with numbness, weakness, pain, diminished reflexes, and discoordination of one upper extremity. The presence of pain suggests a peripheral rather than central injury, while confusion, cranial nerve involvement, or hemiparesis suggests a central injury. Sensory symptoms are most frequent in the fourth and fifth fingers. Although this distribution is expected with ulnar nerve injury at the elbow, similar symptoms are associated with injury to the https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 12/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate lower (medial) brachial plexus elements. Overall, brachial plexus injury is more common than isolated ulnar nerve deficits after cardiac surgery. Weakness in muscles supplied by the lower cervical nerve roots but not the ulnar nerve, such as the extensor indicis and abductor pollicis brevis, indicates a plexopathy. Following intraaortic balloon pump insertion, femoral nerve injury may occur due to local trauma, vascular occlusion, pseudoaneurysm formation, or emboli. In most neuropathies related to cardiac surgery, symptoms improve or resolve within three weeks, suggesting a neurapraxic injury caused by disruption of the myelin sheath. Given this good prognosis, conservative treatment, consisting of physical therapy to improve strength and flexibility in the affected muscles, is indicated. Axonal injury is much less common and is associated with neurologic symptoms lasting for an extended period. Thus, failure to improve within three weeks following cardiac surgery should prompt electromyography and nerve conduction studies to confirm the diagnosis, delineate the site of injury and the extent of nerve disruption, and provide an accurate prognosis for recovery. Phrenic nerve Phrenic nerve injury occurs with cooling of the heart by iced slush. The reported frequency with which it occurs has varied widely from 1 to 30 percent, depending in part upon whether it is diagnosed by radiographic evidence of diaphragmatic dysfunction, which is not always due to phrenic nerve dysfunction [109], or phrenic nerve conduction studies [107,109-111]. Most patients have unilateral phrenic nerve injury, typically on the same side as the internal mammary graft with coronary artery bypass graft surgery (CABG) [110,111]. Patients with bilateral phrenic nerve dysfunction generally require prolonged mechanical ventilation [111]. Most affected patients recover fully within one year, but recovery may be delayed for two years or more [110,112]. The frequency of phrenic nerve injury has declined dramatically with changes in surgical technique. These include a reduction in the use of iced slush and an increase in the use of foam insulation [111]. Intercostal nerve Harvesting of the internal thoracic artery may be associated with injury to the anterior intercostal nerves. This nerve injury can present with numbness, tenderness, light- touch evoked pain, or constant burning pain over the sternum and left anterolateral chest wall. In one study of 37 patients, for example, 81 percent reported protracted postoperative symptoms; although this usually subsided by four months, 15 percent had symptoms that persisted for 5 to 28 months after surgery [113]. https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 13/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate OTHERS A dyskinetic movement disorder, so-called post-pump chorea may complicate cardiac surgery in a small number of children with congenital heart disease. This has also been described in a single case series of five adult patients who underwent pulmonary endarterectomy with coronary artery bypass graft surgery (CABG) and hypothermic circulatory arrest [114]. Symptoms presented between one and three days postoperatively and subsequently remitted over several weeks to months. Two patients had persistent mild symptoms. (See "Hyperkinetic movement disorders in children", section on 'Post-pump chorea'.) SUMMARY AND RECOMMENDATIONS Neurologic complications of cardiac surgery are not rare; there is an estimated 6 percent incidence of combined central nervous system complications (stroke, encephalopathy). Cerebrovascular disease Most strokes that occur in the setting of cardiac surgery are clinically apparent within 24 to 48 hours. The incidence is uncertain; surgical databases may substantially underestimate the incidence of stroke when compared with data collected in rigorous clinical or imaging-based studies. (See 'Incidence' above.) Valvular repairs and combined coronary artery bypass graft surgery (CABG) and valvular repairs, particularly those involving the mitral valve, appear to have a significantly higher risk of stroke than CABG alone. Mechanisms of intraoperative and postoperative ischemic stroke include cerebral hypoperfusion, artery-to-artery embolism, and cardiogenic embolism. (See 'Mechanisms of cerebral infarction' above.) Traditional atherosclerosis risk factors, prior cerebrovascular disease, and atherosclerotic disease affecting the coronary or peripheral arteries are among the risk factors for perioperative ischemic stroke. (See 'Risk factors' above.) Management of perioperative ischemic stroke in the setting of cardiac surgery is similar to that in other settings except that use of intravenous tissue plasminogen activator is contraindicated in patients after cardiac surgery. (See 'Diagnosis and treatment' above and "Initial assessment and management of acute stroke".) Encephalopathy More diffuse cerebral involvement after cardiac surgery may manifest as a delirium, seizures, and sometimes even coma. The mechanisms underlying this https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 14/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate complication are likely multifactorial. A minority of patients will have persistent neurocognitive dysfunction. Evaluation in these patients focuses on excluding a cerebrovascular event and reversible toxic and metabolic conditions. (See 'Encephalopathy' above.) Peripheral nerve complications Peripheral nerve injury is an uncommon complication. 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Topic 1660 Version 14.0 https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 23/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate GRAPHICS Neurologic complications of cardiac operations Complication Incidence Preventive measures Brachial plexus 2-15 percent Minimize sternal retraction injury Attention to patient position Padding arms Stroke 0.4-6 percent Conduct of cardiopulmonary bypass Minimize duration Hypothermia Alpha-stat pH management (?) Minimally invasive procedures (?) Avoid perioperative hypotension Preoperative screening If significant carotid stenosis consider: Preoperative stent Combined CEA/CABG Avoidance of emboli De-airing maneuvers Minimize aortic trauma in patients with severely calcified aortas Monitoring TEE EEG/EP (?) TCD (?) Ophthalmologic Clinical 0.1-25 Same as stroke percent Angiography 100 percent https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 24/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate Delirium 3-32 percent Minimize: Sensory deprivation Benzodiazepine/narcotic use postoperatively Disruption of sleep-wake cycles Watch for metabolic encephalopathies Electrolytes Renal dysfunction Hepatic dysfunction Watch for withdrawal syndromes Subtle neuropsychological 10-79 percent Same as stroke Intracranial <0.1 percent Wait 2-4 weeks after new stroke before surgery if possible hemorrhage Seizures 0.6 percent Avoid: Hyponatremia Hypocalcemia Hypomagnesemia Avoid withdrawal of: Benzodiazepines Barbiturates Avoid toxic doses of: Lidocaine CEA: carotid endarterectomy; EEG: electroencephalography; CABG: coronary artery bypass grafting; EP: evoked potentials; TEE: transesophageal echocardiography; TCD: transcranial Doppler. Graphic 68206 Version 3.0 https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 25/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate Impact of age on adverse cerebral outcomes after coronary bypass surgery The incidence of adverse cerebral events after coronary artery bypass surgery is 6.1 percent, of which half are type I (focal injury, coma, or stupor at discharge) and half are type II (deterioration in intellectual function, memory defect, or seizures). The incidence of both type I and II events increase with age. Data from Roach GW, Kanchuger M, Mangano M, et al, and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996; 335:1857. Graphic 68686 Version 4.0 https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 26/27 7/5/23, 12:06 PM Neurologic complications of cardiac surgery - UpToDate Contributor Disclosures Michael L McGarvey, MD No relevant financial relationship(s) with ineligible companies to disclose. Albert T Cheung, MD No relevant financial relationship(s) with ineligible companies to disclose. Mark M Stecker, MD, PhD, FAAN, FACNS, FASNM Employment: Fresno Institute of Neuroscience [Neuroscience]. Equity Ownership/Stock Options: Fresno Institute of Neuroscience [Neuroscience]. Consultant/Advisory Boards: Legal case reviews [Intraoperative monitoring]. All of the relevant financial relationships listed have been mitigated. Michael J Aminoff, MD, DSc Consultant/Advisory Boards: Brain Neurotherapy Bio [Parkinson disease]. All of the relevant financial relationships listed have been mitigated. Gabriel S Aldea, MD No relevant financial relationship(s) with ineligible companies to disclose. Janet L Wilterdink, MD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/neurologic-complications-of-cardiac-surgery/print 27/27