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Perioperative Stroke in Noncardiac, Nonneurosurgical Surgery

Perioperative Stroke in Noncardiac, Nonneurosurgical Surgery. Ng et al, Anesthesiology 2011; 115:879-90 Presented by Paul Larsen. Stroke Definitions. Stroke - Focal or global neurologic deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours

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Perioperative Stroke in Noncardiac, Nonneurosurgical Surgery

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  1. Perioperative Stroke in Noncardiac, Nonneurosurgical Surgery • Ng et al, Anesthesiology 2011; 115:879-90 • Presented by Paul Larsen

  2. Stroke Definitions • Stroke - Focal or global neurologic deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours • TIA - <24 hours • Covert Stroke - Asymptomatic ischemic event detected with imaging

  3. Stroke Incidence • In cardiac, neurologic, and carotid surgery, the incidence is 2.2-5.2% • Other procedures have a range of 0.05-4.4% • Differences in patient population, changing clinical practice over 40 year study design, diagnostic tests, and duration of follow up may account for the large variance in reported stroke rates

  4. Outcomes • 12.6% mortality rate in non-surgical strokes • Perioperative stroke mortality ranges from 26% in general surgery to 87% in patients with a previous stroke

  5. Pathophys

  6. Pathophys • The majority of perioperative strokes occur after the second postoperative day • Only 5.8% of strokes are thought to have occured during surgery • Cardiothoracic surgery related strokes are 60% embolic • Other surgeries have a 68% thrombotic etiology of the stroke

  7. Why Thrombosis? • Post-op endothelial dysfunction? • General anesthetics impair endothelial function • Withholding antiplatelet/anticoagulant agents may aggrevate surgically induced hypercoaguability

  8. Who is at risk? • Comorbidities: • Age, history of stroke, atrial fibrillation are among the most important risk factors • Others include COPD, PVD, DM

  9. Who is at risk? • Type of Surgery • Hip arthoplasty, peripheral vascular surgery have a higher incidence of stroke than knee arthroplasty or general surgery • Head and neck surgery increases risk by 0.2-5%

  10. Who is at risk? • B-blockers - increase in non-fatal stroke, hypotension, and bradycardia in patients undergoing noncardiac surgery • It is unclear if there is causation, and no temporal relationship between the stroke and hypotension has been defined.

  11. Risk modification • Timing elective surgery after a recent stroke • Acute stroke impairs cerebral autoregulation so blood flow becomes passively dependent on perfusion pressure • Occurs within 8 hours of a stroke, can last 2-6 months • Recommend delaying nonurgent surgery for at least 1-3 months

  12. Risk modification • A fib: • If pre-existing, continue antiarrhythmic or rate-controling agent perioperatively • Correct post-op electrolyte imbalances and fluid volume

  13. Risk modification • Anticoagulants:

  14. Perioperative stroke management • ID at risk patients and make an early diagnosis • Non-contrast CT within 25 minutes, consider thrombolysis, correct hypotension, fever • ASA is the only oral antiplatelet agent found to be beneficial

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