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review article
Current Concepts
Perioperative Stroke
Magdy Selim, M.D., Ph.D.
S
From the Department of Neurology, Divi- troke is one of the most feared complications of surgery. to pro-
sion of Cerebrovascular Diseases, Beth vide adequate preventive and therapeutic measures, physicians need to be
Israel Deaconess Medical Center, Boston.
Address reprint requests to Dr. Selim at knowledgeable about the risk factors for stroke during the perioperative peri-
the Department of Neurology, Division od. In this article, I review the pathophysiology of perioperative stroke and pro-
of Cerebrovascular Diseases, Beth Israel vide recommendations for the stratification of risk and the management of risk
Deaconess Medical Center, 330 Brookline
Ave., Palmer 127, Boston, MA 02215, or at factors.
mselim@bidmc.harvard.edu.
Pathophysiology
Radiologic and postmortem studies indicate that perioperative strokes are pre-
dominantly ischemic and embolic.8-10 In a study of 388 patients with stroke after
coronary-artery bypass grafting (CABG), hemorrhage was reported in only 1% of
patients; 62% had embolic infarcts11 (Fig. 1). The timing of embolic strokes after
surgery has a bimodal distribution. Approximately 45% of perioperative strokes are
identified within the first day after surgery.1,11 The remaining 55% occur after un-
eventful recovery from anesthesia, from the second postoperative day onward.1,11
Early embolism results especially from manipulations of the heart and aorta or
release of particulate matter from the cardiopulmonary-bypass pump.1,7,13 Delayed
embolism is often attributed to postoperative atrial fibrillation, myocardial infarc-
tion resulting from an imbalance between myocardial oxygen supply and demand,
and coagulopathy.13 Surgical trauma and associated tissue injury result in hyperco-
agulability. Several studies have shown activation of the hemostatic system and
reduced fibrinolysis after surgery, as evidenced by decreased tissue plasminogen
activator (t-PA) and increased plasminogen activator inhibitor type 1 activity and
increased levels of fibrinogen-degradation products, thrombinantithrombin com-
plex, thrombus precursor protein, and d-dimer immediately after surgery and up to
* Age itself does not predict the risk of stroke, and the 70-year cutoff is arbitrary. However, advanced age is a marker
of decreased cerebrovascular reserve and multiple coexisting conditions.
The effect of systolic dysfunction on the risk of perioperative stroke is particularly pronounced among patients under-
going left-main-stem revascularization and those with atrial fibrillation.
risk of stroke.6,19,20 However, some patients with and cost-effectiveness of hemodynamic testing
hemodynamically significant, high-grade, asymp- before surgery are debatable, and further devel-
tomatic carotid stenosis in particular those opment and validation of these tests are required
with bilateral stenoses may benefit from ca- before their routine preoperative use in patients
rotid revascularization before elective surgery. with carotid stenosis can be advocated.
Therefore, the extent of the preoperative evalua- Aortic atherosclerosis is an independent pre-
tion of patients with asymptomatic carotid dis- dictor of the risk of perioperative stroke, particu-
ease should be individualized. At a minimum, larly among patients undergoing cardiac surgery
the evaluation should include a detailed neuro- and revascularization of the left main-stem ar-
logic examination, a history taking designed to tery.1,13 Identifying the extent and location of
elicit unreported symptoms of transient ischemic aortic atherosclerosis before or at the time of sur-
attack, and brain computed tomographic (CT) or gery by means of transesophageal echocardiog-
magnetic resonance imaging (MRI) studies to rule raphy or intraoperative epiaortic ultrasound is
out silent ipsilateral infarcts. Additional tests important to modify the surgical technique and
such as transcranial Doppler ultrasonography change the site of aortic cannulation or clamp-
and intracranial CT or magnetic resonance angi- ing to avoid calcified plaques. The use of echo-
ography to determine the microembolic signal cardiography-guided aortic cannulation27 and in-
load, intracranial blood flow, and hemodynamic traaortic filtration28 during CABG can reduce the
significance of the carotid stenosis25,26 may pro- risk of perioperative stroke.
vide incremental information to identify patients Systolic dysfunction increases the risk of peri-
who could benefit from carotid revascularization operative stroke, particularly among patients with
before surgery. However, the clinical usefulness atrial fibrillation.13 Preoperative echocardiogra-
carotid surgeries reduces the incidence of post- thrombectomy or embolectomy in patients with
operative stroke without increasing the odds of perioperative stroke. However, these techniques
bleeding complications.49,50 There is also evidence may be useful in the postoperative setting, espe-
that supports the preoperative use of statins, ir- cially when the use of intraarterial thrombolysis
respective of the patients lipid profile, to reduce is contraindicated. The limited window for imple-
the risk of perioperative stroke in patients under- menting these interventions highlights the impor-
going cardiovascular surgery.51 tance of rapid recognition of perioperative stroke
and immediate neurologic consultation.
Management
In patients who have recently undergone major F u t ur e Dir ec t ions
surgery, treatment with intravenous t-PA is con-
traindicated because of an increased risk of bleed- Preoperative prophylaxis against perioperative
ing. However, intraarterial administration of t-PA stroke is an appealing concept. A few random-
and endovascular mechanical clot disruption are ized trials have assessed the effect of neuropro-
alternative options. A few case series suggest that tective drugs on the risk of stroke and cognitive
the use of intraarterial thrombolysis within 6 hours decline among patients undergoing CABG.54-56
after the onset of a perioperative stroke is rela- Preoperative administration of statins51 or beta-
tively safe.52,53 In a study of 36 patients who re- blockers30 does appear to reduce the incidence of
ceived intraarterial t-PA after a perioperative stroke, stroke and cognitive decline after CABG. There is
partial to complete recanalization was achieved also some evidence, albeit controversial, that the
in 80% of the patients, 38% had no symptoms or antifibrinolytic agent aprotinin may have similar
only slight disability after discharge, and the mor- effects.56 These results indicate that neuropro-
tality rate was similar to that reported in nonsur- tection may be successful in the perioperative set-
gical patients treated with intraarterial throm- ting and that it merits further investigation. Ran-
bolysis.53 Bleeding at the surgical site occurred in domized, controlled clinical trials are also needed
17% of the patients. Most of this bleeding was to identify the best preventive and management
minor. Intracranial hemorrhage occurred in 25% strategies for perioperative stroke.
of the patients; however, only 8% had worsening Dr. Selim reports receiving grant support from Cierra. No
other potential conflict of interest relevant to this article was
symptoms. Intracranial hemorrhage was most reported.
common in patients who underwent a cranioto-
my. There are few data on the use of mechanical
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