Anesthesia Considerations 

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.