Evaluating neurological outcomes in children undergoing cardiac surgery in the middle east: a retrospective study

Introduction

Background

Congenital heart disease (CHD) is a widespread birth defect that impacts approximately one in three patients, leading to major congenital abnormalities (1,2). The majority of these anomalies necessitate immediate surgical intervention (1,2). Despite advancements in congenital heart surgery, pediatric patients continue to experience various complications (3). One of the most severe complications involves neurological manifestations, which can present as long-term and short-term neurological deficits, including impairments in cognitive, behavioral, language, and motor skills (4-9).

Previous research indicates that children undergoing cardiac surgery are at risk for a range of neurological complications, such as stroke, seizures, and cognitive impairment (10,11). In high-income countries, improvements in surgical techniques, postoperative monitoring, and early rehabilitation programs have contributed to a reduction in neurological morbidity (12-14). However, there is limited representation of Middle Eastern populations in the existing literature. The region faces unique demographic and healthcare challenges, including higher birth rates, a greater prevalence of congenital disorders linked to consanguinity, and variable access to specialized pediatric cardiac and neurodevelopmental (ND) care compared to Western settings. These factors may influence both the prevalence and outcomes of CHD and its complications.

A retrospective study in the United States, which evaluated the incidence of acute neurological manifestations following cardiac surgery, showed that while neurological morbidity has decreased, seizures remain the most commonly observed complication (12). Similarly, researchers from Pakistan analyzed ND outcome frequencies in patients with CHD and found that seizures were the most frequent finding (2). A Swiss study assessed the long-term ND effects in school-aged children who had undergone CHD surgery, observing delays in cognitive, neurological, and motor function compared to their peers (13). A Japanese study also found that infants with CHD had more ND complications than healthy infants (14). A cross-sectional study in Saudi Arabia highlighted the impact of cardiac surgery on the ND functions of these children, showing significant differences when compared to their healthy counterparts (15).

Rationale and knowledge gap

Despite growing global awareness, data from the Middle East are scarce, particularly concerning the short- and long-term neurological outcomes in children who have undergone cardiac surgery. Additionally, there is a lack of standardized regional guidelines to inform educational and rehabilitation strategies for affected children.

Objective

This study aimed to evaluate the neurological outcomes of children who had cardiac surgery at a tertiary center in Jeddah, Saudi Arabia. We assessed the prevalence of acute and chronic neurological complications and examined their relationship with specific cardiac procedures. The findings of this study offer valuable information for healthcare providers and policymakers in the Middle East as they develop programs to improve the care of children with CHD. We present this article in accordance with the STROBE reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-12/rc).

Methods

Study design and setting

This retrospective study was conducted in the pediatric department of a tertiary healthcare center in Jeddah, Saudi Arabia. The hospital’s extensive patient records and specialized facilities provided a comprehensive setting for this study on pediatric surgical outcomes.

Study population and sampling

The study focused on a computed target population of 1,169 pediatric patients (Figure 1). These individuals were selected based on specific criteria to ensure the reliability and validity of the study outcomes. Inclusion Criteria: We included patients who had undergone cardiac surgery. All patients were 14 years of age or younger at the time of their surgery. Both male and female patients were considered to ensure a balanced representation. Exclusion criteria included patients with any syndromes or baseline neurological disabilities, to maintain the integrity of the neurological assessments post-surgery. Those who had repeated cardiac surgeries were included only if they exhibited no neurological symptoms prior to the subsequent procedure, allowing for a clearer analysis of surgery-related neurological impacts. These criteria were applied to focus the study on neurological outcomes related specifically to the surgical procedures and to minimize the influence of pre-existing conditions.

Figure 1 Participant selection flowchart for the study cohort.

Data collection

The data from patient files were collected in July 2020 by medical students, which included the following: Age, sex, height, weight, nationality, diagnosis, procedure type, date, number of procedures, anesthesia duration, and pediatric cardiac intensive care unit (PCICU) admission. Neurological complications were categorized as acute (seizure and stroke) and chronic (cognitive impairment, chronic weakness secondary to stroke, and epilepsy). Chronic weakness was defined as persistent motor weakness lasting beyond the immediate postoperative period. Imaging data were collected from patient records and included electroencephalograms (EEG), computed tomography (CT) scans, and magnetic resonance imaging (MRI). CT and MRI findings were assessed for evidence of structural brain abnormalities such as ischemic infarcts, intracranial hemorrhage, cerebral atrophy, hydrocephalus, encephalomalacia, or white matter changes. Radiological reports were reviewed and categorized by board-certified pediatric neuroradiologists at the time of imaging. Imaging abnormalities were classified based on predefined diagnostic criteria aligned with current pediatric neuroimaging guidelines. The treatment history, which included seizure and cardiac medications, and occupational, behavioral, speech, and physiological therapy, was also documented.

Data analysis

Data analysis was done using Microsoft Excel 2020 and IBM Statistical Package for the Social Sciences (SPSS) version 26. Continuous variables are presented as central tendency and standard deviation, while categorical variables are presented as frequencies and percentages. Bivariate relationships were analyzed using the independent t-test and Chi-squared tests. Cases with missing outcome data were excluded from outcome-specific statistical analyses but retained for demographic summaries when applicable. Missing data from the files was obtained by directly contacting the parents or legal guardians of patients. The correlational analysis examined relationships between key variables in the dataset. Continuous variables (age, weight, height, head circumference, anesthesia duration, number of operations) and binary clinical outcomes (acute/chronic complications, treatments) were included. Pearson’s (r) assessed linear relationships between continuous variables, while point-biserial correlations evaluated links between continuous and binary variables. Pairwise deletion addressed missing data, ensuring each correlation used all available cases for the variable pair. Significance was tested at α=0.05, with Bonferroni correction applied for multiple comparisons (adjusted α=0.001). Analyses excluded non-numerical entries (e.g., “min” annotations) after data cleaning. All computations used Python (SciPy v1.10.1), with |(r)| >0.3 considered practically significant. All statistical tests were two-sided, and a P value of <0.05 was considered statistically significant.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional ethics committee of King Abdulaziz University, Faculty of Medicine (No. 81-20) and individual consent for this retrospective analysis was waived.

Results

In total, 560 patients met the inclusion criteria. Male patients predominated [320 (57.1%) vs. females 240 (42.9%)]. The median age at surgery was 4.1 years (IQR, 1.8–8.3 years), with median height of 80.0 cm (IQR, 60.0–100.0 cm) and weight of 10.0 kg (IQR, 5.5–15.2 kg) (Table 1). Cardiac procedures were significantly associated with seizures and hemiplegic stroke (P=0.01 and P=0.02, respectively; Tables 2,3). The results indicate that there was no statistically significant difference between admission to the PCICU and neurological outcomes.

Diagnoses and outcomes

Of the observed cases, tetralogy of Fallot was the most frequent diagnosis documented (19.3%, 108 cases), followed by ventricular septal defect (VSD) (15.7%, 88 cases), and transposition of the great arteries (TGA) (13%, 73 cases). Patients who experienced acute neurological outcomes following different types of cardiac surgeries showed a significant difference in the incidence of seizure (P=0.01) and hemiplegic stroke (P=0.02). These statistically significant differences suggest a potential link between the surgical procedure and these specific outcomes as described in Table 2. However, the data did not show a statistically significant difference in the incidence of stroke (P=0.20) across the different surgical types. The table also indicates other factors that differed significantly, such as the number of procedures and anesthesia duration, which were both longer in patients who had acute and chronic neurological outcomes compared to those who did not (Table 3). For instance, the mean anesthesia duration was significantly longer for patients with seizures (173.56 vs. 140.99 minutes; P=0.002) and hemiplegic stroke (183.33 vs. 141.13 minutes; P=0.01). Other data for acute and chronic neurological outcomes are reported in Tables 2,3.

Treatment assessment

Physiotherapy emerged as a key intervention, showing a significant association with both acute and chronic neurological outcomes. Acute seizures, epilepsy, stroke, and weakness were significantly correlated with seizure treatment. Speech therapy was strongly associated with hemiplegic stroke, weakness, and cognitive impairment (P=0.001). Notably, weakness was the only outcome that was significantly associated with cardiac treatment (P=0.04). Occupational and behavioral therapies did not show statistically significant differences (Table 4).

Investigative correlations

CT scan findings showed statistically significant associations with all reported neurological outcomes, including acute seizures, stroke, epilepsy, chronic weakness, and cognitive impairment. The most commonly identified abnormalities on CT included ischemic infarcts (notably in the middle cerebral artery territory), hemorrhagic lesions, and diffuse cerebral atrophy. Similarly, MRI findings were significantly associated with all outcomes except cognitive impairment (P=0.001). MRI revealed detailed abnormalities such as periventricular leukomalacia, delayed myelination, gliotic changes, and localized cortical volume loss. These imaging abnormalities corresponded with the clinical neurological deficits, suggesting a direct link between radiologic findings and postoperative neurological morbidity. Strong positive correlations emerged between anthropometric measures: weight correlated with height (r=0.92, P<0.001) and head circumference (r=0.78, P<0.001), confirming expected physiological scaling. Surgical complexity showed clinically relevant patterns: anesthesia duration positively correlated with operation number (r=0.65, P<0.001) and acute stroke (r=0.41, P=0.002), indicating prolonged procedures may heighten neurological risks. Operation number was also linked to acute seizures (r=0.38, P=0.007). Weight weakly predicted cardiac treatment (r=0.35, P=0.01), suggesting that larger patients receive more interventions. Crucially, no significant correlations emerged between complications and rehabilitation therapies (e.g., physiotherapy) (P=0.45), highlighting potential care gaps. These patterns underscore the interplay between surgical complexity, anthropometry, and acute neurological outcomes in CHD management. Furthermore, significant associations were observed between specific surgical procedures and acute neurological complications. Norwood procedures had the strongest link to acute seizures (r=0.41, P<0.001), while TGA corrections also showed a significant seizure correlation (r=0.38, P<0.001). Fontan operations were uniquely associated with acute strokes (r=0.35, P=0.001). Also, hemiplegic strokes correlated with VSD closures (r=0.28, P=0.01). These findings suggest that high-risk procedures like Norwood, TGA correction, and Fontan operations may warrant intensified intraoperative neuromonitoring and postoperative seizure prophylaxis due to substantial risks of seizures and strokes (Table 5). Moreover, procedure-specific patterns emerged for chronic neurological complications (Table 6). Fontan procedures showed the strongest link to cognitive impairment (r=0.42, P<0.001), while Norwood operations correlated with chronic seizures (r=0.38, P<0.001). Arterial switch operations predicted chronic weakness (r=0.33, P=0.002), and VSD closures demonstrated associations with cognitive impairment (r=0.29, P=0.008). These results indicate that chronic complications follow procedure-specific patterns, supporting the need for tailored ND surveillance, such as cognitive screening after Fontan procedures and seizure monitoring after Norwood operations (Table 6).

Discussion

Key findings

Early cardiac surgery, while lifesaving, can increase the postoperative susceptibility of pediatric patients to neurological complications (15). This study aimed to assess the outcomes in children who underwent corrective surgery at KAUH between 2015 and 2019. Male predominance (55.2%) aligns with findings of other studies (2,3,12), possibly reflecting sex-specific differences in cardiac development and susceptibility to complications. The mean height (76.51 cm) and weight (10.28 kg) were lower than those reported in a Japanese study, wherein cognitive, language, and motor deficits were observed (16), which suggests a potential interaction between the preoperative growth status and neurological vulnerability of patients. VSD was the most frequent diagnosis (15.7%), consistent with its position as the most common congenital heart anomaly (17). VSD closure was also the most frequent procedure performed (27.6%). Notably, not all patients with VSD required surgery, suggesting a potential selection bias in our sample. Future studies should explore factors influencing the surgical decisions of patients with VSDs. The duration of anesthesia varied widely (351 min), exceeding the range reported in another study (120–240 minutes) (15). Prolonged anesthesia increases the risk of neurological complications (18); hence, analyzing the association between the duration of anesthesia and specific neurological outcomes could provide valuable insights.

Comparison with similar research

The most common acute neurological outcomes observed were acute seizures (4.6%) and stroke (7.1%). In contrast, two different studies done in Iran and Pakistan showed that seizures were the predominant neurological outcome observed (8.4% and 80%, respectively) (2,3). This difference can be explained by patient and environmental factors, and operative management strategies (4,19). In this study, 1.1% of the patients who underwent repair of aortic coarctation manifested with acute seizures, while 1.1% of the patients who had VSD closure manifested with acute stroke. Other descriptive studies showed that 0.8–5.2% of individuals who underwent coronary artery bypass graft surgery had a stroke postoperatively (20). Of the total number of patients, 5.5% and 14.4% had an MRI and a CT scan, respectively. In our study, CT scans were more frequently performed than MRIs and demonstrated significant associations with neurological outcomes. While MRI offers superior soft tissue detail, CT’s accessibility and speed made it the preferred imaging modality in our clinical setting, particularly for acute postoperative evaluation (11). Of the total, 0.2% of patients received occupational therapy, 0.5% received speech therapy, and 53% received physiotherapy. This finding is different from a previous study that reported 14% of patients received occupational therapy, 35% received speech therapy, and 18.9% received physiotherapy (4). The difference in findings could be explained by the preference for complementary and alternative medicine over other therapies.

This study had some limitations, such as its retrospective nature and potential selection bias. Future research should address these limitations, including prospective studies with larger cohorts and further investigations on the specific mechanisms underlying the observed associations in this study.

This study has several limitations. Its retrospective design may have introduced information and recall bias, particularly in parent-reported outcomes. Being conducted at a single tertiary center with a predominantly non-Saudi patient population limits generalizability. The underuse of MRI and ND assessments may have led to underreporting of subtle complications. Additionally, limited access to rehabilitation therapies could have influenced outcome interpretation. Future prospective multicenter studies with standardized neurological evaluations are needed to validate and expand on these findings.

Conclusions

In conclusion, CHD is a common birth condition that often necessitates corrective surgery early in life. Although these interventions save countless lives, they increase the risk of neurological complications. Our findings suggest a significant association between specific cardiac procedures and the occurrence of hemiplegic stroke and acute seizures. Based on these findings, we recommend the implementation of structured postoperative neurological screening protocols for all pediatric cardiac surgery patients, particularly within the first year following surgery. Incorporating routine MRI and EEG assessments could allow earlier detection of subclinical neurological injury. Also, multidisciplinary rehabilitation programs should be integrated into standard care pathways, including early referrals to physiotherapy, speech-language therapy, and ND specialists. We also suggest developing region-specific clinical guidelines that incorporate neurological outcome tracking and promote standardized documentation across centers in the Middle East. Finally, establishing a national registry for pediatric CHD surgical outcomes would enable long-term follow-up and guide resource allocation for neurorehabilitation services. Further long-term studies with larger populations are essential to elucidate the precise mechanisms underlying these neurological complications. Unraveling these mechanisms will pave the way for developing targeted interventions and optimizing patient care, ultimately helping pediatric patients achieve their full potential and enjoy equal opportunities in life compared to their healthy peers.

Acknowledgments

The study was supervised by Road of Change, a research summer school providing peer teaching.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-12/rc

Data Sharing Statement: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-12/dss

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-12/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-12/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional ethics committee of King Abdulaziz University, Faculty of Medicine (No. 81-20) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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