Top Things to Know: Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery
Prepared by Anne Leonard MPH, BSN, RN – Senior Science and Medicine Advisor - Lead
- Perioperative stroke is a complication in patients who undergo non-cardiac and non-neurologic surgery.
- The incidence of perioperative stroke in patients undergoing non-cardiac, non-neurologic surgery is between 0.1 – 1.0% in two large retrospective studies; in a large prospective international study of over 40,000 patients undergoing non-cardiac surgery, the rate of perioperative stroke was 0.3% overall, with higher risk associated with vascular and neurosurgical operations.
- Perioperative stroke can be defined as any embolic, thrombotic, or hemorrhagic cerebrovascular event with motor, sensory, or cognitive dysfunction lasting at least 24 hours, occurring intra-operatively or within 30 days following surgery.
- This paper summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for post-operative assessments, and treatment approaches for minimizing permanent neurologic dysfunction in patients who experience a perioperative stroke.
- This paper discusses silent cerebral ischemia, the impact of perioperative stroke, the pathophysiology of perioperative stroke, and preoperative risk stratification.
- Considerations for preoperative stroke prevention strategies include: the timing of surgery following stroke, presence of extracranial carotid artery stenosis, presence of intracranial stenosis, and whether or not the patient has patent foramen ovale.
- Suggestions for the management of antithrombotic medications using risk stratification for prevention of thromboembolism are included.
- All patients undergoing evaluation prior to surgery need to be assessed for perioperative stroke risk factors (age, renal disease, and history of prior TIA/stroke) with additional emphasis on timing of surgery relative to prior stroke, overall cardiovascular risk, and type of surgery planned.
- Use or adjustment of medications such as beta blockers, statins, and antithrombotic agents should follow existing guidelines but also tailor to individual patient characteristics.
- Perioperative stroke is a complication in patients who undergo non-cardiac and non-neurologic surgery with the need for awareness of higher risk patients and ways to mitigate perioperative complications.
Citation
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