Conclusions
Notwithstanding the remarkable improvement in surgical, anaesthetic and medical management, the risk of stroke after CABG has not significantly declined. Risk stratification is of the utmost importance for identifying vulnerable patients. Specifically, pre-existing cerebrovascular disease and atherosclerosis of the ascending aorta are major determinants of the risk of peri-operative stroke, and should be always carefully scrutinised. RCTs and meta-analysis do not clearly support routine implementation of offpump CABG as a strategy to minimise the risk of stroke. Observational studies have suggested that anaortic approaches might reduce the risk of stroke compared with conventional CABG in patients with severe atherosclerosis of the ascending aorta. Further randomised controlled trials are warranted to confirm this hypothesis.