Incidence and predictors of silent embolic cerebral infarction following diagnostic coronary angiography

https://doi.org/10.1016/j.ijcard.2009.10.053Get rights and content

Abstract

Background

Coronary angiography (CAG) is an invasive diagnostic procedure, which could lead to procedure related complications. One of the well known post-procedural complications is cerebral embolic infarction with or without symptoms. Silent embolic cerebral infarction (SECI) has clinical significance because it can progress to a decline in cognitive function and increase the risk of dementia in the long term. The aim of this study was to detect the incidence and predictors of SECI after diagnostic CAG using diffusion-weighted magnetic resonance imaging (DW-MRI).

Methods

A total of 197 patients with coronary artery disease who underwent DW-MRI for evaluation of intracranial vasculopathy before coronary artery bypass graft surgery were retrospectively enrolled in the present study. DW-MRI was performed within 48 h after diagnostic CAG. SECI was diagnosed as presence of focal bright high signal intensity in DW-MRI. Patients were divided into groups according to presence/absence of SECI (+ SECI vs. − SECI, respectively). The clinical and angiographic characteristics were analyzed and independent predictors were evaluated.

Results

Of the 197 patients, SECI occurred in 20 patients (10.2%) after diagnostic CAG. Age, female gender, frequency of underlying atrial fibrillation, extent of coronary disease, and fluoroscopic time during diagnostic CAG were not different between the + SECI and − SECI groups. Left ventricular ejection fraction was significantly lower in the + SECI group than in the − SECI group (45.9 ± 8.5% vs. 51.4 ± 13.1%, p = 0.014) and performance rate of internal mammary artery (IMA) angiography was significantly higher in the + SECI group compared with the − SECI group (85% vs. 37.2%, p < 0.001). By multivariate analysis, performing IMA angiography was the only predictor of SECI (OR = 14.642; 95% CI = 3.201 to 66.980, p = 0.001).

Conclusions

The incidence of SECI after diagnostic CAG was not infrequent. Diagnostic CAG with IMA angiography may increase the risk of SECI.

Introduction

Coronary angiography (CAG) is an invasive diagnostic procedure, which could induce post-procedural complications such as myocardial infarction, cerebrovascular accident, arrhythmia, vascular complications, dye allergy, hemodynamic derangements, and heart chamber perforation [1], [2]. One of the well known post-procedural complications is asymptomatic and symptomatic cerebral embolic infarction. Retrospective data analysis showed that 0.11 to 0.38% of patients undergoing diagnostic CAG showed clinically apparent cerebral infarction [3], [4], [5], whereas the incidence of asymptomatic cerebral infarction was 13 to 22% [3], [6], [7].

Silent embolic cerebral infarction (SECI) is defined as an embolic-origin brain lesion which is the result of vascular occlusion diagnosed incidentally by magnetic resonance imaging (MRI) or computed tomography (CT) in otherwise healthy subjects or during autopsy [8]. Symptomatic embolic cerebral infarction is a brain lesion that produces clinical symptoms such as motor or sensory weakness, loss of consciousness, inadequate pupillary response, and dysarthria [8], [9]. SECI is considered a precursor of symptomatic stroke and progressive brain damage that may be associated with vascular dementia. Therefore, SECI has clinical significance because it can progress to a decline in cognitive function and increase the risk of dementia in the long term [10].

Diffusion-weighted magnetic resonance imaging (DW-MRI) has been known to be the most sensitive imaging technique in detecting acute cerebral infarction that appeared as high signal intensity within 2 weeks [11], [12]. DW-MRI can also provide an improved estimate of acute embolic-origin cerebral ischemic events associated with cardiovascular catheter procedures [3], [6]. To date, only limited data were available regarding SECI after diagnostic CAG procedure. The aim of the study was to evaluate the incidence and predictors of SECI after diagnostic CAG using DW-MRI.

Section snippets

Study population

From December 2002 to June 2007, 197 patients with coronary artery disease who underwent diagnostic CAG were retrospectively enrolled in the study. Because of the severity of their coronary artery disease, all patients had been scheduled to undergo coronary artery bypass grafting (CABG) surgery. DW-MRI examination was performed in all patients within 48 h after diagnostic CAG for evaluation of intracranial vasculopathy. The patients with a history of recent cerebral infarction (i.e., within 3 

Baseline clinical and angiographic characteristics

Baseline patient demographics and coronary angiographic results are shown in Table 1. Age, gender, history of cerebral infarction and frequency of coronary risk factors such as smoking, diabetes, hypertension, and hyperlipidemia were not different between the two groups. Frequencies of combined valvular heart disease and arrhythmia were similar in both groups (Table 1). Left ventricular ejection fraction in the + SECI group was significantly lower than that of the − SECI group (45.9 ± 8.5% vs.

Discussion

CAG is an invasive diagnostic procedure and it can lead to several post-procedural complications including cerebrovascular accident [1], [2]. Cerebrovascular accident that is induced by cerebral embolism has clinical significance because it can progress to a decline in cognitive function and increase the risk of dementia in the long term. DW-MRI provides an image contrast that is dependent on the molecular motion of water, which is substantially altered by acute cerebral ischemia. It even

Conclusion

SECI was not infrequent after diagnostic CAG in patients with coronary artery disease scheduled for CABG. CAG with IMA angiography may increase the risk of SECI. These findings suggest that careful catheter manipulation should be required in the case of combined diagnostic CAG with IMA angiography procedures. Furthermore, when visualization of IMA is needed, computed tomography angiography or MRI angiography might be a good option for reducing the risk of SECI.

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [16].

References (16)

  • H. Omran et al.

    Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomized study

    Lancet

    (2003)
  • A.J. Coats

    Ethical authorship and publishing

    Int J Cardiol

    (2009)
  • N. Sabri

    Complications of cardiac catheterization, coronary angiography, and coronary interventions

    J Invasive Cardiol

    (1994)
  • P.J. Scanlon et al.

    ACC/AHA guidelines for coronary angiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography)

    J Am Coll Cardiol

    (1999)
  • K.A. Busing et al.

    Cerebral infarction incidence and risk factors after diagnostic and interventional cardiac catheterization — prospective evaluation at diffusion-weighted MR imaging

    Radiology

    (2005)
  • A.Z. Segal et al.

    Stroke as a complication of cardiac catheterization: risk factors and clinical features

    Neurology

    (2001)
  • S. Fuchs et al.

    Stroke complicating percutaneous coronary interventions: incidence, predictors, and prognostic implications

    Circulation

    (2002)
  • C. Lund et al.

    Cerebral emboli during left heart catheterization may cause acute brain injury

    Eur Heart J

    (2005)
There are more references available in the full text version of this article.

Cited by (0)

View full text
Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.