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Perioperative Stroke

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Background​

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  • Defn: brain infarct (ischemic or hemorrhagic) which occurs during surgery or  < 30d post-op

  • Two types:

    • Overt: acute infarct, classic signs/sx, last > 24h, easily diagnosed

    • Covert: diagnosis made via brain imaging only, too subtle to be dx clinically at the time

  • Incidence = 0.1-1.9% after non-cardiac, non-neurosx

  • ↑ disability / mortality compared to non-surgical related stroke

  • Etiology:

    • More common: cardioembolic

    • Less common: hypotension → hypoperfusion

  • Timing:

    • Peak POD 1-2

  • May contribute to Post-operative Neurocognitive Decline

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Considerations for High Risk Patients 

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  • Consider EEG / Cerebral oximetry monitoring

  • Regional or GA are both OK

  • Maintain normotension → Avoid prolonged periods of hypotension

  • Signs/symptoms of covert stroke are sublte:

  • mental status changes only

  • no other deficits

  • diagnosis is made via CT/imaging only

  • Risk factors:

  • Old age, Hx of prior stroke/TIA

  • HTN, Afib, Valve dz, CAD, CHF, PFO

  • CKD, DM, Smoker/COPD

  • Migraines

  • Type of surgery: vascular, thoracic, transplant, endocrine, burn, ENT, hemicolectomy

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Prevention

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  • Identify ↑ risk pts, discuss risk/benefit profile

  • In pts with hx of stroke:

    • Delay elective surgery for 9 months post-stroke

    • Proceed with urgent surgery

  • No interventions are yet known to ↓ risk of perioperative stroke

  • Not recommended:

    • Routine bridging of anti-coagulation for afib 

    • Perioperative ASA for stroke prevention

    • Treating asymptomatic carotid artery disease

    • Starting new beta-blocker therapy

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Management

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  • Requires ↑ degree of suspicion as mental status change may be only sign of covert stroke

  • Consider use of scoring tool to detect covert stroke (e.g. mNIHSS)

  • Perform routine investigations to rule out other causes:

    • Blood pressure / SpO2 / ABG / Blood glucose

    • CBC / electrolytes / Creatinine

  • If stroke is suspected:

    • perform neurologic assessment

    • immediate non-contrast CT or MRI

  • Once confirmed with imaging:

    • Consult stroke team / neurology service for further management

    • Consider endovascular thrombectomy

 

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References​

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  • Lindberg AP, Flexman AM. Perioperative stroke after non-cardiac, non-neurological surgery. BJA Educ. 2021 Feb;21(2):59-65. doi: 10.1016/j.bjae.2020.09.003. Epub 2020 Nov 5. PMID: 33889431; PMCID: PMC7810781.

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