Perspective:

The following are 10 points to remember about this article:

1. Despite the increasing prevalence of atherosclerotic disease in patients undergoing coronary artery bypass grafting (CABG), the incidence of stroke after CABG has declined over the past decade, with recent studies reporting an overall rate of stroke of 1.6% after isolated CABG.

2. The traditionally invoked mechanism of brain infarction occurring during cardiac surgery is that of macroembolization or microembolization. More recent data suggest, however, that hypoperfusion and the systemic inflammatory response may also be presumed sources of neurologic injury.

3. Older age, history of stroke, and history of hypertension and diabetes are each predictors of postoperative neurologic complications, including stroke.

4. Although off-pump CABG was developed in part with the goal of reducing neurologic complications, multiple randomized trials have not shown decreased rates of postoperative stroke with this procedure.

5. The strategy for treating patients who have both carotid artery and coronary artery disease should depend on the characteristics of the individual patient and the degree of urgency of CABG.

6. Although the pathogenesis of adverse neurologic events after CABG is probably multifactorial, there is growing evidence that patient-related risk factors, such as the extent of pre-existing cerebrovascular and systemic vascular disease, have a greater effect on both short- and long-term neurologic sequelae than do procedural variables, such as on-pump versus off-pump surgery.

7. The risk of postoperative stroke or cognitive decline should not be a factor in the choice of surgical therapy for coronary artery disease.

8. Strategies to minimize the incidence of postoperative stroke and cognitive decline should focus on careful preoperative assessment of known risk factors, such as a history of preoperative anemia or pre-existing cerebrovascular disease or infarctions.

9. Although some degree of short-term cognitive decline may occur days to weeks after CABG, these changes are generally minor and temporary. Late cognitive decline is most likely related to progression of underlying cardiovascular and cerebrovascular disease rather than to the use of cardiopulmonary bypass.

10. Strategies for minimizing the risk of late cognitive decline after CABG should include strict postoperative control of modifiable risk factors for cerebrovascular disease, including diet, exercise, blood pressure, and cholesterol.