(Kiosk 3) Left PCA Infarct Following off Pump CABG: A Case Report

Case Diagnosis: 71-year-old female with history of end-stage renal disease (ESRD) on peritoneal dialysis who underwent off-pump coronary artery bypass graft (CABG) complicated by new left posterior cerebral artery (PCA) stroke.

Case Description or Program Description: Patient presented with chest pain and dyspnea on exertion. Cardiac work-up showed coronary artery disease of left anterior descending artery (LAD). She underwent successful off-pump CABG from left internal mammary artery (LIMA) to LAD. She was discharged to inpatient rehab and during her course, she became increasingly lethargic and was transferred back to the hospital.

Setting: Acute Inpatient Rehab

Assessment/Results: Brain imaging revealed new left PCA infarct and encephalomalacia in right temporal lobe. Neurology initiated aspirin and ticagrelor with clearance to resume rehabilitation. Patient subsequently, had an episode of unresponsiveness accompanied with nystagmus. Neurological work-up was unremarkable, but patient was started on levetiracetam for concern of post-stroke seizure with resolution of symptoms.

Discussion (relevance): An off-pump CABG is chosen for high-risk patients with contraindications to traditional CABG. This approach is thought to have decreased risk of stroke, however, neurologic dysfunction remains a common complication in all CABG patients. Underlying heart disease is an important risk factor for post-operative stroke and use of dual anti-platelet therapy has been proven safe and effective in decreasing neurologic sequela. Additionally, post-stroke seizures are a rare but known complication and typically treated with anti-epileptics.

Conclusions: Patients who have a neuro-cognitive dysfunctions after cardiac surgery typically have more functional deficits making discharge to home challenging. Patient who undergo CABG have several complications including stroke and it is important to be aware of these complications. In this case, early recognition and work-up led to appropriate treatment with dual anti platelet therapy. Management of subsequent sequelae including post-stroke seizures was also identified and treated. Optimal medical management stabilized the patient, allowing full participation in inpatient rehabilitation, and ultimately a safe discharge to her home.