Perioperative stroke

Abstract

Purpose Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. In this review, we examine the significance, pathophysiology, risk factors, and evidence-based recommendations for prevention and management of perioperative stroke. Source This is a narrative review based on literature from the PubMed Database regarding perioperative stroke across a broad surgical population. The Society for Neuroscience in Anesthesiology and Critical Care recently published evidence-based recommendations for perioperative management of patients at high risk for stroke; these recommendations were analyzed and incorporated into this review. Principal Findings The incidence of overt perioperative stroke is highest in patients presenting for cardiac and major vascular surgery, although preliminary data suggest that the incidence of covert stroke may be as high as 10% in non-cardiac surgery patients. The pathophysiology of perioperative stroke involves different pathways. Thrombotic stroke can result from increased inflammation and hypercoagulability, cardioembolic stroke can result from disease states such as atrial fibrillation, and tissue hypoxia from anemia can result from the combination of anemia and beta-blockade. Across large-scale database studies, common risk factors for perioperative stroke include advanced age, history of cerebrovascular disease, ischemic heart disease, congestive heart failure, atrial fibrillation, and renal disease. Recommendations for prevention and management of perioperative stroke are evolving, though further work is needed to clarify the role of proposed modifiable risk factors such as perioperative anticoagulation, anti-platelet therapy, appropriate transfusion thresholds, and perioperative beta-blockade. Conclusions Perioperative stroke carries a significant clinical burden. The incidence of perioperative stroke may be higher than previously recognized, and there are diverse pathophysiologic mechanisms. There are many opportunities for further investigation of perioperative stroke pathophysiology, prevention, and management.

Can Haste in Pre-Anaesthetic Check-up Increase the Chances of Post-Operative Stroke: A Case Report

“…Currently, the incidence of perioperative ischemic stroke in non-cardiac, non-neurologic, and non-major vascular surgery is in the range of approximately 0.1-1.9% depending on associated risk factor [11]. Stroke presenting immediately after extubation is rare and suggests intraoperative etiology.…”

Ischemic Stroke Mechanisms, Prevention, and Treatment: The Anesthesiologist’s Perspective

“…Surgical intervention is a significant and predict- (85). Ischemic stroke risk is a function of surgical procedure, and thus, suspicion for perioperative stroke should be based on procedure-specific incidences (85).…”

“…Ischemic stroke risk is a function of surgical procedure, and thus, suspicion for perioperative stroke should be based on procedure-specific incidences (85). Anti-coagulants and anti-platelets should be continued for patients with low risk of blood loss and discontinued for those with high risk of bleeding; bridging strategies should be implemented and therapy resumed between 1-3 days after surgery, depending on bleeding risk (4).…”

“…Anti-coagulants and anti-platelets should be continued for patients with low risk of blood loss and discontinued for those with high risk of bleeding; bridging strategies should be implemented and therapy resumed between 1-3 days after surgery, depending on bleeding risk (4). Beta blockers and statins can be continued in patients already taking them (85). Outside of these guidelines, it has been theorized that pharmacological or ischemic preconditioning may enhance the brain's tolerance to ischemia thereby improving stroke outcomes (86).…”

“…Intraoperative use of metoprolol may increase stroke risk, and the authors of the Consensus Statement suggest using short-acting beta blockers such as esmolol instead. There are currently no data to make recommendations on intraoperative ventilation techniques, however, it seems logical to avoid hypocapnia which causes reduction in cerebral blood flow (4,85). Intraoperative hemorrhage is a risk factor for postoperative stroke, and as such, hemoglobin should be maintained >9.0 mg/dL for those already taking beta blockers.…”