Pub Date: Thursday, Apr 08, 2021
Author: Seemant Chaturvedi, MD, and Prachi Mehndiratta, MBBS
Affiliation: Department of Neurology & Stroke Program, University of Maryland School of Medicine
Perioperative stroke is a significant cause of morbidity and mortality and an increased risk for such a life altering event can limit patient willingness to undergo a necessary procedure.
Perioperative strokes occur in ~ 25,000 patients per year over the age of 45 who are undergoing non-cardiac surgery in the United States. Thirty-day mortality rates in patients who suffer a stroke attributable to perioperative causes, are as high as 26%. Recent studies have demonstrated a slightly upward trend in rate of perioperative stroke from 2004 to 20131,2. Infarcts that occur intra-operatively or within 30 days following non-cardiac and non-neurologic surgery can be clinically silent initially in 10% of patients, only to later result in cognitive impairment or be uncovered during a delayed neurological evaluation3. Patients with silent infarcts are twice as likely to develop cognitive impairment in prior studies2. Advanced age, renal disease and prior stroke independently increase the risk for a perioperative ischemic stroke with hemorrhagic infarcts being much less common. Mechanisms of ischemia in these patients are not clearly established; often linked to hypoxia, hypotension or undiagnosed underlying vessel stenosis or risk factors4.
A practicing cardiologist and neurologist are often called upon to provide recommendations and perioperative risk assessment for a patient undergoing surgery. This highly nuanced, and much needed scientific statement by Benesch et al5 provides elegant guidance to neurologists and cardiologists alike to evaluate pre-operative neurologic risk, to implement intraoperative strategies to decrease stroke risk, and to adequately manage those who unfortunately experience a perioperative stroke. This guideline has simplified our approach in risk prediction and management and has clearly answered the following questions by analyzing current evidence.
- How should we estimate the perioperative risk for stroke in our patients? The authors recommend using the American College of Surgeons surgical risk calculator that comprehensively incorporates underlying risk factors and disease states to provide a detailed risk percentage for various surgical complications including perioperative stroke6. In patients with prior stroke or TIA, another important consideration is the timing of surgery. Review of prior data suggests that non-elective surgeries be deferred at least 6-9 months while elective surgeries that lead to a quality-of-life benefit can be considered at the 6-month mark7.
- How do underlying stroke risk factors contribute to stroke risk? The authors specifically evaluated data pertaining to patients with carotid stenosis, patent foramen ovale (PFO) and intracranial stenosis. As expected, existing literature demonstrates that high grade symptomatic carotid stenosis should be addressed surgically prior to any procedure while management of asymptomatic carotid stenosis is an ongoing area of research. With the evolution of intensive medical management strategies and the ongoing CREST-2 study, further guidance on managing asymptomatic carotid stenosis is awaited. The risk for perioperative stroke in patient with intracranial stenosis is unclear and can likely be ameliorated with intensive medical therapy. Patients with a PFO carry an increased perioperative risk but it is unclear if this risk is conferred due to an underlying cardiac risk. There is no clear data that high risk PFO’s as established by recent clinical trial criteria require closure prior to surgery 8,9.
- What about medications? It is recommended to continue beta blockers and statins; however, the discontinuation and re-initiation of antithrombotic therapy may vary by procedure-risk and thromboembolism-risk. The authors provide comprehensive guidance on when to stop and restart anticoagulation in patients based on these criteria 10-12
- What intra-operative strategies can help mitigate stroke risk? Hypotension and decreased cerebral perfusion are the most important risk predictors and it is recommended that the MAP be >=70mm Hg for patients at moderate to high risk. With surgery within one month of a stroke, hypotension should be avoided to prevent downregulation of cerebral blood flow. In cases of blood loss and patients with known vascular stenosis and occlusion, blood transfusion is recommended for Hemoglobin <8g/dl 13-15.
All primary and comprehensive stroke centers employ a dedicated “stroke alert” process to activate teams of neurologists, radiologists and interventional specialists to rapidly evaluate and treat patients with all stroke types. The approach to perioperative stroke is no different and these patients need to be expeditiously evaluated for IV thrombolysis and endovascular thrombectomy (EVT). Bleeding risk at the surgical site needs to be discussed with the surgical team prior to administration of thrombolytics. Some patients with post-surgical strokes and large vessel occlusion will benefit from EVT without the bleeding risk of thrombolytics.
For clinicians who are often called upon to provide “surgical clearance”, this guideline can be used as a practical framework and can help us keep pace with the advancing complexity of stroke care; not only can we provide evidence-based recommendations to those getting tooth extractions but also to those who are undergoing more high risk non-cardiac, non-neurological procedures.
Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messe SR, Mijalski C, Nelson MT, Power M, Welch BG; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Epidemiology and Prevention. Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print April 8, 2021]. Circulation. doi: 10.1161/CIR.0000000000000968
- Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology. 2011 Jun;114(6):1289-96. doi: 10.1097/ALN.0b013e318216e7f4. PMID: 21478735.
- NeuroVISION Investigators. Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study. Lancet. 2019 Sep 21;394(10203):1022-1029. doi: 10.1016/S0140-6736(19)31795-7. Epub 2019 Aug 15. PMID: 31422895.
- Mrkobrada M, Hill MD, Chan MT, Sigamani A, Cowan D, Kurz A, Sessler DI, Jacka M, Graham M, Dasgupta M, Dunlop V, Emery DJ, Gulka I, Guyatt G, Heels-Ansdell D, Murkin J, Pettit S, Sahlas DJ, Sharma M, Sharma M, Srinathan S, St John P, Tsai S, Gelb AW, O'Donnell M, Siu D, Chiu PW, Sharath V, George A, Devereaux PJ. Covert stroke after non-cardiac surgery: a prospective cohort study. Br J Anaesth. 2016 Aug;117(2):191-7. doi: 10.1093/bja/aew179. PMID: 27440630.
- Vermeer SE, Prins ND, den Heijer T, Hofman A, Koudstaal PJ, Breteler MM. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med. 2003 Mar 27;348(13):1215-22. doi: 10.1056/NEJMoa022066. PMID: 12660385.
- Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messe SR, Mijalski C, Nelson MT, Power M, Welch BG; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Epidemiology and Prevention. Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print April 8, 2021]. Circulation. doi: 10.1161/CIR.0000000000000968
- Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, Cohen ME. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013 Nov;217(5):833-42. e1-3. doi: 10.1016/j.jamcollsurg.2013.07.385. Epub 2013 Sep 18. PMID: 24055383; PMCID: PMC3805776.
- Christiansen MN, Andersson C, Gislason GH, Torp-Pedersen C, Sanders RD, Foge Jensen P, et al. Risks of Cardiovascular Adverse Events and Death in Patients with Previous Stroke Undergoing Emergency Noncardiac, Nonintracranial Surgery: The Importance of Operative Timing. Anesthesiology. 2017; 127:9-19.
- Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MS, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Dec;45(12):3754-832. doi: 10.1161/STR.0000000000000046. Epub 2014 Oct 28. PMID: 25355838; PMCID: PMC5020564.
- Kasner SE, Messe SR. Is Patent Foramen Ovale a Risk Factor for Perioperative Stroke? JAMA. 2018; 319:446-447.
- POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008; 371:1839-1847.
- Berwanger O, Le Manach Y, Suzumura EA, Biccard B, Srinathan SK, Szczeklik W, et al. Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. Eur Heart J. 2016; 37:177-185
- Hornor MA, Duane TM, Ehlers AP, Jensen EH, Brown PS, J., Pohl D, et al. American College of Surgeons' Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg. 2018; 227:521-536 e1
- Sessler DI, Bloomstone JA, Aronson S, Berry C, Gan TJ, Kellum JA, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019; 122:563-574
- Calvo-Vecino JM, Ripolles-Melchor J, Mythen MG, et al. Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: amulticentre randomised controlled trial (FEDORA trial). Br J Anaesth. 2018; 120:734-744.
- Kellert L, Martin E, Sykora M, Bauer H, Gussmann P, Diedler J, et al. Cerebral oxygen transport failure? decreasing hemoglobin and hematocrit levels after ischemic stroke predict poor outcome and mortality: STroke: RelevAnt Impact of hemoGlobin, Hematocrit and Transfusion (STRAIGHT)--an observational study. Stroke. 2011; 42:2832-2837.
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