Risks of Cardiovascular Adverse Events and Death in Patients with Previous Stroke Undergoing Emergency Noncardiac, Nonintracranial Surgery

Stroke History and Time Elapsed are Predictors of Complications in Total Knee Arthroplasty

BACKGROUND

A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors.

METHODS

A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI).

RESULTS

The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067).

CONCLUSIONS

Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk.

Risk of Mortality Following Surgery in Patients With a Previous Cardiovascular Event

Importance

There is a lack of consensus regarding the interval of time-dependent postoperative mortality risk following acute coronary syndrome or stroke.

Objective

To determine the magnitude and duration of risk associated with the time interval between a preoperative cardiovascular event and 30-day postoperative mortality.

Design, Setting, and Participants

This is a longitudinal retrospective population-based cohort study. This study linked data from the Hospital Episode Statistics for National Health Service England, Myocardial Ischaemia National Audit Project and the Office for National Statistics mortality registry. All adults undergoing a National Health Service-funded noncardiac, nonneurologic surgery in England between April 1, 2007, and March 31, 2018, registered in Hospital Episode Statistics Admitted Patient Care were included. Data were analyzed from July 2021 to July 2022.

Exposure

The time interval between a previous cardiovascular event (acute coronary syndrome or stroke) and surgery.

Main Outcomes and Measures

The primary outcome was 30-day all-cause mortality. Secondary outcomes were postoperative mortality at 60, 90, and 365 days. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios.

Results

There were 877 430 patients with and 20 582 717 without a prior cardiovascular event (overall mean [SD] age, 53.4 [19.4] years; 11 577 157 [54%] female). Among patients with a previous cardiovascular event, the time interval associated with increased risk of postoperative mortality was surgery within 11.3 months (95% CI, 10.8-11.7), with subgroup risks of 14.2 months before elective surgery (95% CI, 13.3-15.3) and 7.3 months for emergency surgery (95% CI, 6.8-7.8). Heterogeneity in these timings was noted across many surgical specialties. The time-dependent risk intervals following stroke and myocardial infarction were similar, but the absolute risk was greater following a stroke. Regarding surgical urgency, the risk of 30-day mortality was higher in those with a prior cardiovascular event for emergency surgery (adjusted hazard ratio, 1.35; 95% CI, 1.34-1.37) and an elective procedure (adjusted hazard ratio, 1.83; 95% CI, 1.78-1.89) than those without a prior cardiovascular event.

Conclusions and Relevance

In this study, surgery within 1 year of an acute coronary syndrome or stroke was associated with increased postoperative mortality before reaching a new baseline, particularly for elective surgery. This information may help clinicians and patients balance deferring the potential benefits of the surgery against the desire to avoid increased mortality from overly expeditious surgery after a recent cardiovascular event.

Perioperative stroke

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

Hypotension during transsphenoidal pituitary surgery associated with increase in plasma levels of brain injury markers

BACKGROUND

Patients undergoing pituitary surgery may experience short- and long-term postoperative morbidity. Intraoperative factors such as hypotension might be a contributing factor. Our aim was to investigate the association between intraoperative hypotension and postoperative plasma levels of tau, neurofilament light (NfL), and glial fibrillary acidic protein (GFAP) as markers of perioperative brain injury.

METHODS

Between June 2016 and October 2017, 35 patients from the Gothenburg Pituitary Tumor Study were included. For tau, NfL, and GFAP, concentrations were measured in plasma samples collected before and immediately following surgery, and on postoperative days 1 and 5. The difference between the highest postoperative value and the value before surgery was used for analysis (∆taupeak , ∆NfLpeak , ∆GFAPpeak ). Intraoperative hypotension was defined as the area under the curve of an absolute threshold below 70 mmHg (AUC70) and a relative threshold below 20% (AUC20%) of the baseline mean arterial blood pressure.

RESULTS

Plasma tau and GFAP were highest immediately following surgery and on day 1, while NfL was highest on day 5. There was a positive correlation between AUC20% and both ∆taupeak (r2  = .20, p < .001) and ∆NfLpeak (r2  = .26, p < .001). No association was found between AUC20% and GFAP or between AUC70 and ∆taupeak , ∆NfLpeak or ∆GFAPpeak .

CONCLUSION

Intraoperative relative, but not absolute, hypotension was associated with increased postoperative plasma tau and NfL concentrations. Patients undergoing pituitary surgery may be vulnerable to relative hypotension, but this needs to be validated in future prospective studies.

Global trends in perioperative stroke research from 2003 to 2022: a web of science-based bibliometric and visual analysis

Background

Perioperative stroke is a potentially devastating complication in surgical patients, which has attracted global attention. This retrospective bibliometric and visual analysis evaluates the status and global trends in perioperative stroke research.

Methods

Papers published between 2003 and 2022 were retrieved from the Web of Science core collection. Extracted data were summarized and analyzed using Microsoft Excel and further bibliometric and co-occurrence analyses were conducted using VOSviewer and CiteSpace software.

Results

Publications on perioperative stroke have increased over the years. The USA topped the list of countries with the highest number of publications and citations, while Canada had the highest mean citation frequency. The Journal of Vascular Surgery and Annals of Thoracic Surgery had the highest number of publications and citation frequency for perioperative stroke. Regarding authors, Malas, Mahmoud B. contributed the most publications to the field, and Harvard University had the highest number of publications (409 papers). Based on an overlay visualization map, timeline view, and the strongest strength burst of keywords, "antiplatelet therapy," "antithrombotic therapy," "carotid revascularization," "bleeding complications," "postoperative cognitive dysfunction," "intraoperative hypotension," "thrombectomy," "cerebral revascularization," "valve surgery," "tranexamic acid," and "frozen elephant trunk" were trending topics in perioperative stroke research.

Conclusion

Publications regarding perioperative stroke have experienced rapid growth in the past 20 years and are likely to continuously increase. Research on perioperative antiplatelet and antithrombotic, cardiovascular surgery, postoperative cognitive dysfunction, thrombectomy, tranexamic acid, and frozen elephant trunk has attracted increasing attention, and these topics are emerging hotspots of present research and possible candidates for future research.

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BACKGROUND

For patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.

METHODS

Our total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).

RESULTS

For CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.

CONCLUSION

Complications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.

Higher rates of mortality and perioperative complications in patients undergoing primary shoulder arthroplasty and a history of previous stroke

BACKGROUND

Cerebrovascular accidents (CVAs), or strokes, are the second most common cause of mortality and third most common cause of disability worldwide. Although advances in the treatment of strokes have improved survivorship following these events, there remains a limited understanding of the effect of a prior stroke and sequelae on patients undergoing shoulder arthroplasty (SA). This study aimed to determine the outcomes of patients with a history of stroke with sequela undergoing primary SA.

METHODS

Over a 30-year time period (1990-2020), 205 primary SAs (32 hemiarthroplasties [HAs], 56 anatomic total shoulder arthroplasties [aTSAs], and 117 reverse shoulder arthroplasties [RSAs]) were performed in patients who sustained a previous stroke with sequela and were followed for a minimum of 2 years. This cohort was matched (1:2) according to age, sex, body mass index, implant, and year of surgery with patients who had undergone HA or aTSA for osteoarthritis or RSA for cuff tear arthropathy. Mortality after primary SA was individually calculated through a cumulative incidence analysis. Implant survivorship was analyzed with a competing risk model selecting death as the competing risk.

RESULTS

The stroke cohort sustained 38 (18.5%) surgical and 42 (20.5%) medical perioperative complications. Compared with the control group, the stroke cohort demonstrated higher rates of any surgical complication (18.5% vs 10.7%; P = .007), instability (6.3 % vs 1.7%; P = .002), venous thromboembolism (3.4% vs 0.5%; P = .004), pulmonary embolus (2.0% vs 0%; P = .005), postoperative stroke (2.4% vs 0%; P = .004), respiratory failure (1.0% vs 0%; P = .045), any medical complication (20.5% vs 7.3%; P < .001), and 90-day readmission (16.6% vs 4.9%; P < .001). Additionally, RSA in the stroke cohort was associated with higher reoperation (8.5% vs 2.6%; P = .011) and revision rates (6.8% vs 1.7%; P = .013) compared with the matched cohort. Subsequent cumulative incidences of death at 1, 2, 5, 10, 15, and 20 years were 4.4% vs 3.4%, 10.7% vs 5.1%, 25.6% vs 14.7%, 51.6% vs 39.3%, 74.3% vs 58.6%, and 92.6% vs 58.6% between the stroke and matched cohorts, respectively (P < .001).

CONCLUSIONS

A preoperative diagnosis of a stroke in patients undergoing primary SA is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. This information should be considered to counsel patients and surgeons to optimize care and help mitigate risks associated with the perioperative period.

Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery

Importance

Perioperative strokes are a major cause of death and disability. There is limited information on which to base decisions for how long to delay elective nonneurologic, noncardiac surgery in patients with a history of stroke.

Objective

To examine whether an association exists between the time elapsed since an ischemic stroke and the risk of recurrent stroke in older patients undergoing elective nonneurologic, noncardiac surgery.

Design, Setting, and Participants

This cohort study used data from the 100% Medicare Provider Analysis and Review files, including the Master Beneficiary Summary File, between 2011 and 2018 and included elective nonneurologic, noncardiac surgeries in patients 66 years or older. Patients were excluded if they had more than 1 procedure during a 30-day period, were transferred from another hospital or facility, were missing information on race and ethnicity, were admitted in December 2018, or had tracheostomies or gastrostomies. Data were analyzed May 7 to October 23, 2021.

Exposures

Time interval between a previous hospital admission for acute ischemic stroke and surgery.

Main Outcomes and Measures

Acute ischemic stroke during the index surgical admission or rehospitalization for stroke within 30 days of surgery, 30-day all-cause mortality, composite of stroke and mortality, and discharge to a nursing home or skilled nursing facility. Multivariable logistic regression models were used to estimate adjusted odds ratios (AORs) to quantify the association between outcome and time since ischemic stroke.

Results

The final cohort included 5 841 539 patients who underwent elective nonneurologic, noncardiac surgeries (mean [SD] age, 74.1 [6.1] years; 3 371 329 [57.7%] women), of which 54 033 (0.9%) had a previous stroke. Patients with a stroke within 30 days before surgery had higher adjusted odds of perioperative stroke (AOR, 8.02; 95% CI, 6.37-10.10; P < .001) compared with patients without a previous stroke. The adjusted odds of stroke were not significantly different at an interval of 61 to 90 days between previous stroke and surgery (AOR, 5.01; 95% CI, 4.00-6.29; P < .001) compared with 181 to 360 days (AOR, 4.76; 95% CI, 4.26-5.32; P < .001). The adjusted odds of 30-day all-cause mortality were higher in patients who underwent surgery within 30 days of a previous stroke (AOR, 2.51; 95% CI, 1.99-3.16; P < .001) compared with those without a history of stroke, and the AOR decreased to 1.49 (95% CI, 1.15-1.92; P < .001) at 61 to 90 days from previous stroke to surgery but did not decline significantly, even after an interval of 360 or more days.

Conclusions and Relevance

The findings of this cohort study suggest that, among patients undergoing nonneurologic, noncardiac surgery, the risk of stroke and death leveled off when more than 90 days elapsed between a previous stroke and elective surgery. These findings suggest that the recent scientific statement by the American Heart Association to delay elective nonneurologic, noncardiac surgery for at least 6 months after a recent stroke may be too conservative.

Complications and Mortality after Surgeries in Patients with Prior Stroke Who Received General and Neuraxial Anesthesia: A Propensity-Score Matched Study

Patients who previously suffered a stroke have increased risks of mortality and complications after surgeries, but the optimal anesthesia method is not fully understood. We aimed to compare the outcomes after surgeries for stroke patients who received general anesthesia (GA) and neuraxial anesthesia (NA). Using health insurance research data, we identified 36,149 stroke patients who underwent surgeries from 1 January 2008 to 31 December 2013. For balancing baseline covariates, the propensity-score-matching procedure was used to select adequate surgical patients who received GA and NA at a case–control ratio of 1:1. Multiple logistic regressions were applied to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative mortality and complications between surgical patients with prior stroke who received GA and NA. Among the 4903 matched pairs with prior stroke, patients with GA had higher risks of pneumonia (OR 2.00, 95% CI 1.62–2.46), pulmonary embolism (OR 3.30, 95% CI 1.07–10.2), acute renal failure (OR 3.51, 95% CI 1.13–2.10), intensive care unit stay (OR 3.74, 95% CI 3.17–4.41), and in-hospital mortality (OR 2.02, 95% CI 1.16–3.51) than those who received NA. Postoperative adverse events were associated with GA in patients aged more than 60 years and those who received digestive surgery (OR 3.11, 95% CI 2.08–4.66). We found that stroke patients undergoing GA had increased postoperative complications and mortality after surgery compared with those who received NA. However, these findings need more validation and evaluation by clinical trials.

The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery

BACKGROUND

The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this.

OBJECTIVES

Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery.

SEARCH METHODS

We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period.

SELECTION CRITERIA

We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews.

MAIN RESULTS

We screened 3960 records and included 107 articles.   Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations.  Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI  Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of  BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI   Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS₂, CHA₂DS₂-VASc, R₂CHADS₂, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively.

AUTHORS' CONCLUSIONS

Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.

Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Cerebrovascular accident and acute coronary syndrome and perioperative outcomes (CAPO) study protocol: a 10-year database linkage between Hospital Episode Statistics Admitted Patient Care, Myocardial Infarction National Audit Project and Office for National Statistics registries for time-dependent risk analysis of perioperative outcomes in English NHS hospitals

INTRODUCTION

An increasing number of people who have a history of acute coronary syndrome or cerebrovascular accident (termed cardiovascular events) are being considered for surgery. Up-to-date evidence of the impact of these prior events is needed to inform person-centred decision making. While perioperative risk for major adverse cardiac events immediately after a cardiovascular event is known to be elevated, the duration of time after the event for which the perioperative risk is increased is not clear.

METHODS AND ANALYSIS

This is an individual patient-level database linkage study of all patients in England with at least one operation between 2007 and 2017 in the Hospital Episode Statistics Admitted Patient Care database. Data will be linked to mortality data from the Office for National Statistics up to 2018, for 30-day, 90-day and 1-year mortality and to the Myocardial Ischaemia National Audit Project, a UK registry of acute coronary syndromes. The primary outcome will be the association between time from cardiovascular event to index surgery and 30-day all-cause mortality. Additional associations we will report are all unplanned readmissions, prolonged length of stay, 30-day hospital free survival and incidence of new cardiovascular events within one postoperative year. Important subgroups will be surgery specific (invasiveness, urgency and subspecialty), type of acute coronary syndrome (ST or non-ST elevation myocardial infarction) and type of cerebrovascular accident (ischaemic or haemorrhagic stroke).

ETHICS AND DISSEMINATION

Ethical approval for this observational study has been obtained from East Midlands-Nottingham 1 Research Ethics Committee; REC reference: 18/EM0403. The results of the study will be made available through peer-reviewed publications and via the Health Services Research Centre of the Royal College of Anaesthetists, London.

[Perioperative stroke]

Perioperative stroke is defined as an ischemic cerebrovascular event that occurs during or within 30 days after surgery and is associated with an increased perioperative risk of morbidity and mortality. Depending on the type of surgery stroke is diagnosed in up to 11% of all patients in the perioperative period. Patients with a history of ischemic stroke or transitory ischemic attack have an increased risk for perioperative stroke. Therefore, a critical assessment of indications and the timing of surgery are crucial to prevent recurring stroke in this patient population. Importantly, individualized blood pressure management is essential for optimization of cerebral perfusion during the perioperative period.This article provides a summary of the epidemiology, risk factors, and etiology of perioperative stroke. Moreover, possible preventive strategies relevant for the anesthesiologist are reviewed.

Pathophysiological and clinical considerations in the perioperative care of patients with a previous ischaemic stroke: a multidisciplinary narrative review

With an ageing population and increasing incidence of cerebrovascular disease, an increasing number of patients presenting for routine and emergency surgery have a prior history of stroke. This presents a challenge for pre-, intra-, and postoperative management as the neurological risk is considerably higher. Evidence is lacking around anaesthetic practice for patients with vascular neurological vulnerability. Through understanding the pathophysiological changes that occur after stroke, insight into the susceptibilities of the cerebral vasculature to intrinsic and extrinsic factors can be developed. Increasing understanding of post-stroke systemic and cerebral haemodynamics has provided improved outcomes from stroke and more robust secondary prevention, although this knowledge has yet to be applied to our delivery of anaesthesia in those with prior stroke. This review describes the key pathophysiological and clinical considerations that inform clinicians providing perioperative care for patients with a prior diagnosis of stroke.

Incidence and Risk Factors for Stroke in Fast-Track Hip and Knee Arthroplasty-A Clinical Registry Study of 24,862 Procedures

BACKGROUND

Postoperative stroke is a severe complication with a reported 30-day incidence of 0.4%-0.6% after total hip (THA) and knee arthroplasty (TKA). However, most data are based on diagnostic codes and with limited details on perioperative care, including the use of fast-track protocols. We investigated the incidence of and preoperative and postoperative factors for stroke after fast-track THA/TKA.

METHODS

We used an observational study design of elective fast-track THA/TKA patients with prospective collection of comorbidity and complete 90-day follow-up. Medical records were evaluated for events potentially disposing to stroke. Identification of relevant preoperative risk factors was done by multivariable logistic regression. Incidence of stroke was compared with a Danish background population.

RESULTS

Of 24,862 procedures with a median length of stay of 2 (interquartile range, 2-3) days, we found 27 (0.11%; 95% confidence interval [CI], 0.08%-0.16%) and 43 strokes (0.17%, 95% CI, 0.13%-0.23%) ≤30 and ≤90 days after surgery, respectively. Preoperative risk factors for stroke ≤30 days were age ≥ 85 years (odds ratio [OR], 4.3; 95% CI, 1.1-16.3) and anticoagulant treatment (OR, 3.1; 95% CI, 1.2-7.9). Preoperative anemia was near significant (OR, 2.1; 95% CI, 0.98-4.6, P = .055). Eight strokes ≤30 days were preceded by a cardiovascular event within the second postoperative day. Incidence of stroke after postoperative day 30 was similar to a Danish background population.

CONCLUSION

Risk of postoperative stroke in fast-track THA and TKA was low but may be further reduced with increased focus on avoiding perioperative cardiovascular events and in patients with preoperative anticoagulants or anemia.

Neuroanesthesiology Update

We provide a synopsis of innovative research, recurring themes, and novel experimental findings pertinent to the care of neurosurgical patients and critically ill patients with neurological diseases. We cover the following broad topics: general neurosurgery, spine surgery, stroke, traumatic brain injury, monitoring, and anesthetic neurotoxicity.