Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery

Abstract

It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of noncardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery.

Anesthesia for Patients with Prior Stroke

“…14,15 Main factors that affect the level of recovery are severity of stroke, time elapsed after stroke, care given in acute phase, motivation, environment, and post-stroke rehabilitative training. A recurrent stroke in these patients is associated with poor outcome, and measures for secondary prevention should be employed [5][6][7]16,17 (►Table1).…”

“…Anesthesia and surgery may cause perturbations in cardiac output, cerebral metabolism, and oxygenation leading to precipitation of perioperative recurrent stroke. 5,19 A hypercoagulable state caused by surgical trauma and postoperative immobility and withdrawal of antiplatelet agents further make a patient with a prior stroke potentially "at higher risk" of recurring ischemic brain injury after surgery. 5,16,17,20 The risk of postoperative stroke or transient ischemic attack (TIA) is maximum at 1 to 3 days after surgery (risk ratio: 34.0) but remains increased till 90 days after the surgery.…”

“…Stroke-related diagnostic tests such as carotid Doppler and magnetic resonance angiography, are important in cases of recent, symptomatic strokes to evaluate and discuss with surgeons and neurologists the plan of optimization before elective surgery. 3,5 In patients with recent history of TIA, magnetic resonance imaging may detect silent infarcts.…”

“…51 Overall the evidence suggests that it would be safer to consider delaying an elective surgery for 3 to 9 months after an acute ischemic stroke to reduce the risk of secondary perioperative cerebrovascular event. 5,16,18,19,32,52 Treatment received during acute phase: Medical and surgical interventions received during acute phase should be noted. A patient who has been thrombolyzed or undergone mechanical thrombectomy immediately after stroke is likely to have a patent vessel with smaller infarct along with good functional recovery.…”

“…Aggravation of the neurological disability and occurrence of a secondary stroke in the perioperative period are 6 to 12 times more common in stroke patients than in general population. 4,5 Perioperative complications can be reduced by carefully planning anesthesia according to the cerebrovascular reserve of the patient and the risks associated with the proposed surgery.…”