Perioperative Consultation for Patients with Preexisting Neurologic Disorders

Abstract

As the population ages, the prevalence of many neurologic diseases is increasing. At the same time, older patients are undergoing more surgical procedures. This confluence of events puts neurohospitalists in a unique position to provide both pre- and postoperative guidance to minimize complications, improve clinical outcomes, and decrease health care costs in patients with neurologic comorbidities. Early preoperative consultation is recommended for patients with severe, poorly controlled, or decompensated neurologic disease, a recent stroke, or those undergoing procedures with a high risk of neurologic complications. The neurohospitalist's role includes optimizing management of preexisting diseases, such as epilepsy, neuromuscular disorders, Parkinson's disease, dementia, and cerebrovascular disease, as well as providing guidance for perioperative management and clarification of risks. In the postoperative period, the neurohospitalist will frequently be consulted to mitigate any negative impact of neurologic complications that do occur.

Preoperative Evaluation of Patients with Neurological Disorders

“…These conditions can present at any age but are generally more common in older patients, and symptoms tend to worsen over time [2]. As the population ages, these conditions are expected to increase in prevalence necessitating awareness of the disease and proper perioperative management [2,3]. Additionally, these neurologic impairments are often complicated by additional systemic illnesses, polypharmacy, and the chronicity of the disease itself [4].…”

“…If the stroke was ischemic or due to atrial fibrillation, the patient will often be on antiplatelet or anticoagulation therapy. Perioperative discontinuation of antithrombotic medications increases the risk of stroke, but this must be weighed with risk of bleeding during surgery [3]. Management of these medications will be discussed in later chapters.…”

“…There are no clear guidelines on when an elective surgery can be completed following cerebrovascular accident, but the risk of major adverse cardiac events remains increased for approximately 9 months. Generally, for elective procedures, at least 6 months is recommended following a stroke or TIA to confirm hemodynamic and neurologic stability [1,3]. Following this time period, it is critical to confirm that there has been medical optimization of the patient's risk factors, including management of diabetes and hypertension.…”

“…Perioperatively, the risk of seizures in epileptic patients is estimated at 2-6% [3,13]. In a patient that had a seizure within the preceding month, this risk is as high as 20% [3].…”

“…Perioperatively, the risk of seizures in epileptic patients is estimated at 2-6% [3,13]. In a patient that had a seizure within the preceding month, this risk is as high as 20% [3]. For this reason, it is critical to be knowledgeable about management if an episode does occur.…”