Perioperative stroke: prevention

and treatment

Alexander Zlotnik MD PhD

Professor and Chairman,

Department of Anesthesiology and Critical Care,
Soroka University Medical Center
Ben Gurion University of the Negev Beer Sheva,
Israel
 Plan of discussion

• Definition
• Incidence and significance
• Preoperative identification of high risk patients
• Preoperative considerations to mitigate the risk
• Intraoperative management to mitigate the risk
• Identification and treatment of stroke in postoperative period
Definition:
Perioperative stroke is
defined as a brain infarction
of ischemic or hemorrhagic
ethiology that occurs during
surgery or within 30 days
after surgery
Incidence:
The incidence of
perioperative stroke is 1-6 per
1000 cases depending on
kind of the surgery
Importance:
Stroke is associated with an
adjusted 8-fould increase in
mortality in patients after non-
cardiac and non-neurologic
surgery
Neurovision Trial:
In noncardiac surgery patients
the incidence of covert stroke
(without obvious deficit) is 10%
as identified by MRI
 Incidence of perioperative stroke
Mashour et al, 2011; American College of Surgeons/National Surgical Quality Improvement Program

Kind of surgery N Stroke all age (%) Stroke Age>65 (%)

Perianal abscess 2,508 0 0
Anorectal resection 2,103 0 0
Arthroscopy 4,255 0 0
Bariatric surgery 23,766 0 0
Brest excision 36,793 0 0.1
Head & Neck tumor 20.057 0 0.1
Minor vascular procedures 5,883 0 0.1
Esophagogastric surgery 4,653 0 0.1
Hernioplasty 26,448 0.1 0.1
Biliary tree 43,289 0.1 0.2
Hysterectomy 4,454 0.1 0.2
Total Knee Replacement 2,970 0.1 0.2
Biopsy of soft tissues 2,014 0.1 0.2
Skeletal fractures, spine 5,223 0.1 0.3
Colorectal resections 2,293 0.2 0.2
 Incidence of perioperative stroke
Mashour et al, 2011; American College of Surgeons/National Surgical Quality Improvement Program

Kind of surgery N Stroke all age (%) Stroke Age>65 (%)

Abdomenoperianeal resection 3,169 0.2 0.5
Pancreatic surgery 4,832 0.3 0.5
Hip Arthroplasty 1,568 0.4 0.5
Lung resection 1,484 0.3 0.7
Gastric surgery 4,749 0.3 0.7
Adhesiolysis 5,863 0.3 0.7
Colectomy 33,426 0.4 0.7
Liver surgery 2,144 0.3 0.8
Small intestine resection 5,860 0.5 0.6
Explorative laparotomy 5,760 0.5 0.9
Amputation 4,800 0.8 1.1
 Risk factors

Three of the most consistent risk factors for POS are:

1. Advanced age (>62y)
2. Renal failure
3. A history of stroke or TIA
Sharifpour et al. A&A; 2013.
Popa et al. Jhosp Med; 2009
Bateman et al. Anesthesiology; 2009.

Recommendations:
Screen for risk factors
Identify susceptible patients
Discuss such risk with patient and health providers.
 Timing of surgery after stroke

Patients with acute or recent stroke have Brain perfusion is

impaired cerebrovascular passive and depends
autoregulation & chemoregulation. on systemic BP
(for months!)

To prevent POS in patients with a history

of recent CVA, it is beneficial to identify Typically, anesthesia is
the cause of the initial stroke: associated with blood
1. Duplex carotid pressure fluctuations
2. MRI Angio & anemia
3. TTE/TEE

Ultimately, the decision to proceed Elective surgery should

with surgery should be balanced be delayed for 1-3 m
between the risk of CVA and the risk of after stroke
delaying surgery further.
 Timing of surgery after stroke

However, observational studies to date found no relationship

between timing of stroke history and incidence of POS.

Landercasper et al. Arch Surg; 1990

Sanders et al. Ann Surg; 2012
Bottle et al. Anesthesiology; 2013
 Timing of surgery after stroke:
recommendations

• Discuss surgical timing with neurologist

• Identify the cause of the initial stroke

• Delay elective surgery for 1-3 month after recent stroke

(All opinion based evidence Category A)

Management of anticoagulants

Clinical dilemma:
 Management of anticoagulants
Recommendations
Replace coumadin therapy for LMWH in perioperative setting

Stop LMWH 12-24h before surgery

Low/moderate bleeding risk:

Resume therapeutic dose of LMWH 24h after surgery

High bleeding risk:

Resume therapeutic dose of LMWH 48-72h after surgery when there is adequate
hemostasis.
(All opinion based evidence Category A)

There is no evidence to suggest that continuation of aspirin in patients at risk

reduces the risk of stroke after non-cardiac surgery (category A).
 Role of perioperative β-blockers and statins in
preventing of perioperative stroke
• Continue β-blockers and statins perioperatively in patients who are
already taking them.

• High doses of β-blockers were associated with increased risk of

perioperative stroke.
POISE Trial, Devereaux et al. Lancet; 2008
Mashour et al. Anesthesiology; 2013

• In β-blockers naïve patients, high doses should not be administrated

without careful titration.
Fleischmann et al. J Am Coll Cardiol 2009

• Discontinuation of statins in the perioperative period have adverse

consequences (stroke and cognitive dysfunction).
Heyer et a. Stroke; 2013

• There is no data to suggest that starting statins in the perioperative

period can prevent stoke.
Intraoperative recommendations
 Anesthetic technique
• Neuroaxial anesthesia has been associated with lower risk of POS
compared to GA (0.07%vs.0.13%) (n>290,000! In TKT, THR)
Neuroaxial anesthesia has lower overall 30-day mortality compared
to GA (0.1%vs.0.18%).
Memtosoudis et al. Anesthesiology; 2013
• No difference in POS rate between GA and regional anesthesia after
carotid endarterectomy
GALA Trial Lewis et al. Lancet; 2008

• No data exists for other surgical populations

• No association between Nitrous Oxide administration and POS.

Leslie et al. Anest Analg; 2011, 2013.
 Intraoperative β-blockers

• Intraoperative metoprolol administration has been associated

with 3-fold increase in POS.
Mashour et al Anesthesiology 2013.

• Short-acting Esmolol may be considered for intraoperative

use.
 Intraoperative Ventilation strategy

• There is no data in the literature regarding ventilation strategy

and incidence of stroke.

• Hyperventilation/hypocapnia probaly should be avoided.

• Non-operative stroke patients who were hypocapnic had

worse outcomes compared to normocapnic pts.
Stringer et al. AJNR; 1993
 Periperative hemorrhage
• Intraoperative hemorrhage, anemia and blood transfusion are
associated with 2-3-fould risk of POS both in cardiac and non-
cardiac surgery patients.

Bahranvalla et al. Ann Thorac Surg; 2011

Kamel et al. Circulation 2012

• For patients already taking β-blockers, a Hb<9 g/dl should be

avoided to minimize risk of stroke.
Ashes et al. Anesthesiology 2013
 Glucose management

A tight intraoperative glucose control with insulin

(goal 80-100 mg/dl) was associated with an increased
risk of stroke and death despite no increase in
hypoglycemic events.

Gandhi et al. Ann Int Med; 2007

In patients at high risk for POS, glucose

monitoring is recommended with target range
of 60-180 mg/dl).
 Blood pressure management

There are data to support an association between

intraoperative hypotension and POS, therefore, hypotension
should be avoided in patients at high risk of POS.
(Category A).
Intraoperative hypotension should be defined as a percent
reduction baseline BP rather than absolute value.
(Category B).
For surgery in “head up” position, consideration should be
given to the BP gradient between brachial artery and brain.
(0.8 mmHg for every 1 cm of the gradient).
(Category A).
Induced hypotension in the “head up” position should
always be approached with caution, especially in
patients with high risk for POS.
(Category A).
Postoperative Recommendations
In the event of acute stroke, achieving optimal outcome is
based on early recognition, communication and management.

Evaluation & treatment of acute POS (typically ischemic) should

be consisted with most resent AHA guidelines for the
management of patients with acute ischemic stroke.

Jauh et al. Stroke; 2013.

An organized protocol for emergency evaluation of surgical

patients with suspected perioperative stroke is recommended.
(Category A).
 Suspicion & assessment for stroke

There is a need to develop simple quick screening tools for

stroke that can be used in perioperative period.

Face Arm Speech Time (FAST)

Los Angeles Prehospital Stroke Screen (LAPSS)
Melbourne Ambulance Stroke Screen (MASS)
Recognition of Stroke in the Emergency Room (ROSIER)

Various physiologic, pharmacologic and pathologic

factors can mask symptoms of POS.

Delayed emergence, altered mental status and presence of focal

neurologic deficit should rise suspicion for stroke.
 Suspicion & assessment for stroke

Clinical evaluation: Possible recurrent drugs effects:

BP measurement Revising of anesthesia records
SpO2
Temperature
Blood glucose
Serum electrolytes Drug reversal:
Complete blood count Naloxon for opiates
Coagulation status Flumazenil for benzodiazepines
Neostigmin or Sugammadex for NMBA

Visualization tools: It is of high importance to determine

Non-contrast CT hemorrhagic or ischemic origin of
MRI stroke and indication for urgent
endovascular intervention
Acute management of ischemic POS
 Trombolysis
Time is brain!
Involve neurologist and
interventional radiologist ASAP IV rtPA is the drug of choice for
thrombotic stroke.
The risk/benefit in perioperative
setting should be discussed.

Importantly, major surgery with the exception

of neurosurgery is a relative rather than
absolute contraindication.

Intraarterial thrombolysis or mechanical

thrombolysis is not superior to IV rtPA.
However, it may be attractive in perioperative
setting.
 General Treatment

Maintain SaO2>94% with

supplemental O2

Indications for intubation:

Inadequate oxygenation
GCS<8
Brainstem dysfunction
Malignant brain edema
Elevated ICP

Cardiac monitoring for at least 24h.

Myocardial ischemia and arrhythmias are
common after stroke.
Any serious arrhythmias should be treated.
 Blood pressure control

Every effort should be made to preserve CPP

In case of hypotension, hypovolemia should be corrected
Elevated blood pressure should be treated
only if it is greater than 220/120

Exceptions from this rule:

The patient is eligible for acute reperfusion intervention
Patients who receive rtPA

In mentioned conditions keep ABP<180/105

Prior to initiation of antihypertensive therapy rule out:

Pain
Nausea
Hypervolemia
Full bladder
Hypoxia
 Blood pressure control

No data are available to guide selection of

medications for the lowering or rising of BP

Both hypovolemia and arrhythmias may lead

to hypotension which is detrimental in setting
of acute stroke

As such, correction of hypovolemia and

restoration of normal sinus rhythm is
beneficial
• Thank you for your time!