Update in the Evaluation and Management of Perioperative Stroke
- 31 Downloads
Purpose of review
This review will review the current knowledge and gaps in the literature on the relationship between surgery and ischemic stroke.
Surgery and ischemic stroke are interrelated phenomena as surgery is an independent risk factor for stroke and perioperative stroke increases morbidity and mortality leading to poor outcomes after surgery. This relationship and the risk of adverse outcome apply not only the clinically apparent stroke in the perioperative period but also clinically silent brain infarction detected only on radiological studies. The risk of perioperative stroke depends on several factors including (i) patient-related factors (age, history of prior stroke, and other comorbidities), (ii) procedure-related factors (type of surgery/procedure, use of cardiopulmonary bypass, antiplatelet/antithrombotic interruption, and metabolic derangement), and (iii) perioperative atrial fibrillation.
With observation and retrospective data, the literature is limited to prevention and management of perioperative stroke.
KeywordsPerioperative stroke Ischemic stroke Risk prevention Atrial fibrillation
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.Mashour GA, Moore LE, Lele AV, Robicsek SA, Gelb AW. Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care*. J Neurosurg Anesthesiol. 2014;26(4):273–85.PubMedCrossRefGoogle Scholar
- 11.•• Powers WJ, et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020–35. This focussed update added mechanical throbectomy to the standard of care and changed the span of management for patients with large-vessel occlusion. This is of particular importance to patients with postoperative stroke because many of these patients may be ineligible for IV thrombolysis.PubMedCrossRefGoogle Scholar
- 12.•• Powers WJ, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110. Change in the stroke guidelines and liberalization of tPA contraindication.CrossRefGoogle Scholar
- 17.Brown JM, O’Brien SM, Wu C, Sikora JAH, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg. 2009;137(1):82–90.PubMedCrossRefGoogle Scholar
- 23.•Echahidi N, et al. Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol. 2008;51(8):793–801. Describe factors contributing to the development of perioperative atrial fibrillation and its clinical importance.Google Scholar
- 31.Wolman RL, Nussmeier NA, Aggarwal A, Kanchuger MS, Roach GW, Newman MF, et al. Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter Study of Perioperative Ischemia Research Group (McSPI) and the Ischemia Research Education Foundation (IREF) Investigators. Stroke. 1999;30(3):514–22.PubMedCrossRefGoogle Scholar
- 35.de Waard DD, de Borst GJ, Bulbulia R, Huibers A, Halliday A, Asymptomatic Carotid Surgery Trial-1 Collaborative Group. Diastolic blood pressure is a risk factor for peri-procedural stroke following carotid endarterectomy in asymptomatic patients. Eur J Vasc Endovasc Surg. 2017;53(5):626–31.PubMedPubMedCentralCrossRefGoogle Scholar
- 39.Puskas JD, Williams WH, O’Donnell R, Patterson RE, Sigman SR, Smith AS, et al. Off-pump and on-pump coronary artery bypass grafting are associated with similar graft patency, myocardial ischemia, and freedom from reintervention: long-term follow-up of a randomized trial. Ann Thorac Surg. 2011;91(6):1836–42 discussion 1842-3.PubMedCrossRefGoogle Scholar
- 43.Kapadia S, et al. Insights into timing, risk factors, and outcomes of stroke and transient ischemic attack after transcatheter aortic valve replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves). Circ Cardiovasc Interv. 2016;9(9).Google Scholar
- 44.Blackstone EH, Suri RM, Rajeswaran J, Babaliaros V, Douglas PS, Fearon WF, et al. Propensity-matched comparisons of clinical outcomes after transapical or transfemoral transcatheter aortic valve replacement: a placement of aortic transcatheter valves (PARTNER)-I trial substudy. Circulation. 2015;131(22):1989–2000.PubMedCrossRefGoogle Scholar
- 48.Knipp SC, Matatko N, Schlamann M, Wilhelm H, Thielmann M, Forsting M, et al. Small ischemic brain lesions after cardiac valve replacement detected by diffusion-weighted magnetic resonance imaging: relation to neurocognitive function. Eur J Cardiothorac Surg. 2005;28(1):88–96.PubMedCrossRefGoogle Scholar
- 51.• Hillis LD, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58(24):e123–210. Cardiology guidelines on presurgical carotid disease screening.PubMedCrossRefGoogle Scholar
- 53.Weimar C, Bilbilis K, Rekowski J, Holst T, Beyersdorf F, Breuer M, et al. Safety of simultaneous coronary artery bypass grafting and carotid endarterectomy versus isolated coronary artery bypass grafting: a randomized clinical trial. Stroke. 2017;48(10):2769–75.PubMedPubMedCentralCrossRefGoogle Scholar
- 54.• Kramer J, Abraham J, Jones PA. Carotid artery stenting before CABG: a better alternative to treat concomitant coronary and carotid artery disease. Stroke. 2006;37(6):1359; author reply 1360. Case series from single center showing benefit of carotid stenting prior to CABG.PubMedCrossRefGoogle Scholar
- 57.Christiansen MN, Andersson C, Gislason GH, Torp-Pedersen C, Sanders RD, Føge 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(1):9–19.PubMedCrossRefGoogle Scholar
- 63.Omran H, Bauersachs R, Rübenacker S, Goss F, Hammerstingl C. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online bRiDging REgistRy (BORDER). Thromb Haemost. 2012;108(1):65–73.PubMedCrossRefPubMedCentralGoogle Scholar
- 64.Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S–50S.PubMedPubMedCentralCrossRefGoogle Scholar
- 68.Giustino G, Mehran R, Veltkamp R, Faggioni M, Baber U, Dangas GD. Neurological outcomes with embolic protection devices in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2016;9(20):2124–33.PubMedCrossRefPubMedCentralGoogle Scholar
- 70.January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1–76.PubMedCrossRefGoogle Scholar
- 71.• Kirchhof P, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Kardiol Pol. 2016;74(12):1359–469. The importance of atrial fibrillation duration when considering oral anticoagulation for perioperative atrial fibrillation.PubMedCrossRefGoogle Scholar
- 74.Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947.PubMedCrossRefGoogle Scholar
- 77.• Fountain RB, et al. The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) trial. Am Heart J. 2006;151(5):956–61. Shows advancement in stroke prevention and left atrial appendage occluder is now an option for patients with atrial fibrillation ineligible for oral aticoagulation.PubMedCrossRefGoogle Scholar
- 78.Reddy VY, Doshi SK, Sievert H, Buchbinder M, Neuzil P, Huber K, et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial. Circulation. 2013;127(6):720–9.PubMedCrossRefGoogle Scholar