Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis

PURPOSE OF REVIEW

To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting.

RECENT FINDINGS

Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued.

SUMMARY

In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.

Cerebrovascular Events During Treatment for Systemic Malignant Tumors in Patients with Moyamoya Disease

OBJECTIVE

With the increasing incidence of malignancies, the importance of cancer-associated stroke is emphasized. Although moyamoya disease is a leading cause of stroke, no reports have documented cancer-associated stroke in patients with this condition. We aimed to investigate cerebrovascular events during malignancy treatments in patients with moyamoya disease.

METHODS

A total of 405 patients with moyamoya disease who visited our hospital between January 2000 and March 2022 were retrospectively examined. We evaluated the management of moyamoya disease, presence of the ring finger protein 213 p.Arg4810Lys variant, treatments for malignant tumors, presence of cerebrovascular events during treatment, and follow-up periods and outcomes.

RESULTS

Among the 405 patients, 17 patients with moyamoya disease (4.2%) were diagnosed with malignancies. Among patients aged 60 years and over, 7 out of 67 (10.4%) had malignancies. Of the 17 patients, 11 (64.7%) were symptomatic, and 7 (41.2%) had revascularization surgery. 9 patients were treated with oral antiplatelet drugs. There was no significant difference between the groups with and without malignancy regarding the presence of the ring finger protein 213 p.Arg4810Lys variant (80.0% vs. 62.7%, P = 0.33). All patients underwent surgical treatment, and 7 (41.2%) received chemotherapy. One death due to tumor progression was reported. No cerebrovascular event was observed during malignancy treatments and follow-up periods, which had a mean duration of 6 years.

CONCLUSIONS

In our cohort, malignancy treatments in patients with moyamoya disease were safely conducted without cerebrovascular events. However, it is advisable to avoid hypotension, dehydration, hyperventilation, and long-term discontinuation of antiplatelet drugs during the treatment of malignant tumors.

Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study)

OBJECTIVE

To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium.

BACKGROUND

Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years.

METHODS

Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes.

RESULTS

Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days].

CONCLUSIONS

One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.

Carbon Dioxide, Blood Pressure, and Perioperative Stroke: A Retrospective Case-Control Study

BACKGROUND

The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke.

METHODS

We conducted a retrospective, case-control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmHg or less, 35 mmHg or less, 45 mmHg or greater) were calculated based on total area under the curve. The association between stroke and total area under the curve values was then tested while adjusting for relevant confounders.

RESULTS

In total, 1,244,881 cases were analyzed. Among the cases that screened positive for stroke (n = 1,702), 126 were confirmed and successfully matched with 500 corresponding controls. Total area under the curve was significantly associated with stroke for all thresholds tested, with the strongest combination observed with mean arterial pressure less than 55 mmHg (adjusted odds ratio per 10 mmHg-min, 1.17 [95% CI, 1.10 to 1.23], P < 0.0001) and end-tidal carbon dioxide 45 mmHg or greater (adjusted odds ratio per 10 mmHg-min, 1.11 [95% CI, 1.10 to 1.11], P < 0.0001). There was no interaction effect observed between blood pressure and carbon dioxide.

CONCLUSIONS

Intraoperative hypotension and carbon dioxide dysregulation may each independently increase postoperative stroke risk.

EDITOR’S PERSPECTIVE

Perioperative stroke in patients undergoing spinal surgery: a retrospective cohort study

BACKGROUND

The incidence of perioperative stroke following spinal surgery, including ischemic and hemorrhagic stroke, has not been fully investigated in the Chinese population. Whether specific spinal or emergency/elective procedures are associated with perioperative stroke remains controversial. This study aimed to investigate the incidence of perioperative stroke, health economic burden, clinical outcomes, and associated risk factors.

METHOD

A retrospective cohort study using an electronic hospital information system database was conducted from Jan 1, 2015, to Jan 1, 2021, in a tertiary hospital in China. Patients aged ≥18 years who had undergone spinal surgery were included in the study. We recorded patient demographics, comorbidities, and health economics data. Clinical outcomes included perioperative stroke during hospitalization and associated risk factors. The patients' operative data, anesthetic data, and clinical manifestations were recorded.

RESULT

A total of 17,408 patients who had undergone spinal surgery were included in this study. Twelve patients had perioperative stroke, including seven ischemic stroke (58.3%) and five hemorrhagic stroke (41.7%). The incidence of perioperative stroke was 0.07% (12/17,408). In total, 12 stroke patients underwent spinal fusion. Patients with perioperative stroke were associated with longer hospital stay (38.33 days vs. 9.78 days, p < 0.001) and higher hospital expenses (RMB 175,642 vs. RMB 81,114, p < 0.001). On discharge, 50% of perioperative patients had severe outcomes. The average onset time of perioperative stroke was 1.3 days after surgery. Stroke history (OR 146.046, 95% CI: 28.102-759.006, p < 0.001) and hyperlipidemia (OR 4.490, 95% CI: 1.182-17.060, p = 0.027) were associated with perioperative stroke.

CONCLUSION

The incidence of perioperative stroke of spinal surgery in a tertiary hospital in China was 0.07%, with a high proportion of hemorrhagic stroke. Perioperative stroke patients experienced a heavy financial burden and severe outcomes. A previous stroke history and hyperlipidemia were associated with perioperative stroke.

Protective effects on acute hypoxic-ischemic brain damage in mfat-1 transgenic mice by alleviating neuroinflammation

Acute hypoxic-ischemic brain damage (HIBD) mainly occurs in adults as a result of perioperative cardiac arrest and asphyxia. The benefits of n-3 polyunsaturated fatty acids (n-3 PUFAs) in maintaining brain growth and development are well documented. However, possible protective targets and underlying mechanisms of mfat-1 mice on HIBD require further investigation. The mfat-1 transgenic mice exhibited protective effects on HIBD, as indicated by reduced infarct range and improved neurobehavioral defects. RNA-seq analysis showed that multiple pathways and targets were involved in this process, with the anti-inflammatory pathway as the most significant. This study has shown for the first time that mfat-1 has protective effects on HIBD in mice. Activation of a G protein-coupled receptor 120 (GPR120)-related anti-inflammatory pathway may be associated with perioperative and postoperative complications, thus innovating clinical intervention strategy may potentially benefit patients with HIBD.

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.

Stroke in Surgical Patients

Stroke is associated with substantial morbidity and mortality. The aim of this review is to provide an evidence-based synthesis of the literature related to perioperative stroke, including its etiology, common risk factors, and potential risk reduction strategies. In addition, the authors will discuss screening methods for the detection of postoperative cerebral ischemia and how multidisciplinary collaborations, including endovascular interventions, should be considered to improve patient outcomes. Lastly, the authors will discuss the clinical and scientific knowledge gaps that need to be addressed to reduce the incidence and improve outcomes after perioperative stroke.

Patent foramen ovale and long-term risk of ischaemic stroke after surgery

AIMS

Pre-operatively diagnosed patent foramen ovale (PFO) is associated with an increased risk of ischaemic stroke within 30 days after surgery. This study aimed to assess the PFO-attributable ischaemic stroke risk beyond the perioperative period.

METHODS AND RESULTS

This observational study of adult patients without history of stroke undergoing non-cardiac surgery with general anaesthesia examined the association of PFO with ischaemic stroke 1 and 2 years after surgery using multivariable logistic regression. Of the 144 563 patients included, a total of 1642 (1.1%) and 2376 (1.6%) ischaemic strokes occurred within 1 and 2 years after surgery, 54 (4.7%) and 76 (6.6%) among patients with PFO, and 1588 (1.1%) and 2300 (1.6%) among patients without PFO, respectively. The odds of ischaemic stroke within 1 and 2 years after surgery were increased in patients with PFO: adjusted odds ratio (aOR) 2.01, 95% confidence interval (CI) 1.51-2.69; P < 0.001 and aOR 2.10, 95% CI 1.64-2.68; P < 0.001, respectively. Among patients who underwent contrast transoesophageal echocardiography, the frequency of PFO was 27%, and the increased stroke risk in patients with PFO was robust (aOR 3.80, 95% CI 1.76-8.23; P = 0.001 for year 1). The PFO-attributable risk was mitigated by post-operative prescription of combination antithrombotic therapy (odds ratio 0.41, 95% CI 0.22-0.75; P for interaction = 0.004).

CONCLUSION

Patients with PFO are vulnerable to ischaemic stroke for an extended period of time after surgery. Physicians should consider implementing PFO screening protocols in patients scheduled for major non-cardiac surgery.

Perioperative Stroke

PURPOSE OF REVIEW

This review overviews perioperative stroke as it pertains to specific surgical procedures.

RECENT FINDINGS

As awareness of perioperative stroke increases, so does the opportunity to potentially improve outcomes for these patients by early stroke recognition and intervention. Perioperative stroke is defined to be any stroke that occurs within 30 days of the initial surgical procedure. The incidence of perioperative stroke varies and is dependent on the specific type of surgery performed. This chapter overviews the risks, mechanisms, and acute evaluation and management of perioperative stroke in four surgical populations: cardiac surgery, carotid endarterectomy, neurosurgery, and non-cardiac/non-carotid/non-neurological surgeries.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider

BACKGROUND

Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management.

AIM

To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF.

METHODS

The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality.

RESULTS

New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059).

CONCLUSION

Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Clinical Implications of Preoperative Nonvalvular Atrial Fibrillation with Respect to Postoperative Cardiovascular Outcomes in Patients Undergoing Non-Cardiac Surgery

BACKGROUND AND OBJECTIVES

Atrial fibrillation (AF) is associated with a higher long-term risk of major cardiovascular events. However, its clinical implications with respect to peri-operative cardiovascular outcomes in patients undergoing non-cardiac surgery is unclear. We tried to examine the association between pre-operative AF and peri-operative cardiovascular outcomes.

METHODS

We retrospectively analyzed data from 26,501 consecutive patients who underwent comprehensive preoperative cardiac evaluations for risk stratification prior to receiving non-cardiac surgery at our center. Preoperative AF was diagnosed in 1,098 patients (4.1%), and their cardiovascular outcomes were compared with those of patients without AF. The primary outcome was the rate of major adverse cardiac and cerebrovascular events (MACCE) during immediate post-surgery period (<30 days).

RESULTS

Patients with AF were older and had higher proportion of male sex, higher rate of extra-cardiac comorbidities, higher CHA₂DS2-VASc score, and higher revised cardiac risk index (RCRI) compared with those without AF. The rate of MACCE was significantly higher in AF patients compared to non-AF patients (4.6% vs. 1.2%, p<0.001). Preoperative AF was associated with higher risk of MACCE, even after multivariable adjustment (odds ratio, 2.97; 95% confidence interval, 2.13-4.07, p<0.001). The relative contribution of AF to MACCE was larger in patients with lower RCRI (p for interaction=0.010). The discriminating performance of RCRI was significantly enhanced by addition of AF.

CONCLUSIONS

In patients undergoing non-cardiac surgery, preoperative AF was associated with a higher risk of peri-operative cardiovascular outcomes.

Wall shear stress can improve prediction accuracy for transient ischemic attack

BACKGROUND

Early prediction of transient ischemic attack (TIA) has important clinical value. To date, systematic studies on clinical, biochemical, and imaging indicators related to carotid atherosclerosis have been carried out to predict the occurrence of TIA. However, their prediction accuracy is limited.

AIM

To explore the role of combining wall shear stress (WSS) with conventional predictive indicators in improving the accuracy of TIA prediction.

METHODS

A total of 250 patients with atherosclerosis who underwent carotid ultrasonography at Naval Military Medical University Affiliated Gongli Hospital were recruited. Plaque location, plaque properties, stenosis rate, peak systolic velocity, and end diastolic velocity were measured and recorded. The WSS distribution map of the proximal and distal ends of the plaque shoulder was drawn using the shear stress quantitative analysis software, and the average values of WSS were recorded. The laboratory indicators of the subjects were recorded. The patients were followed for 4 years. Patients with TIA were included in a TIA group and the remaining patients were included in a control group. The clinical data, laboratory indicators, and ultrasound characteristics of the two groups were analyzed. Survival curves were plotted by the Kaplan-Meier method. Receiver operating characteristic curves were established to evaluate the accuracy of potential indicators in predicting TIA. Logistic regression model was used to establish combined prediction, and the accuracy of combined predictive indicators for TIA was explored.

RESULTS

The intraclass correlation coefficients of the WSS between the proximal and distal ends of the plaque shoulder were 0.976 and 0.993, respectively, which indicated an excellent agreement. At the end of the follow-up, 30 patients suffered TIA (TIA group) and 204 patients did not (control group). Hypertension (P = 0.037), diabetes (P = 0.026), homocysteine (Hcy) (P = 0.022), fasting blood glucose (P = 0.034), plaque properties (P = 0.000), luminal stenosis rate (P = 0.000), and proximal end WSS (P = 0.000) were independent influencing factors for TIA during follow-up. The accuracy of each indicator for predicting TIA individually was not high (area under the curve [AUC] < 0.9). The accuracy of the combined indicator including WSS (AUC = 0.944) was significantly higher than that of the combined indicator without WSS (AUC = 0.856) in predicting TIA (z = 2.177, P = 0.030). The sensitivity and specificity of the combined indicator including WSS were 86.67% and 92.16%, respectively.

CONCLUSION

WSS at plaque surface combined with hypertension, diabetes, Hcy, blood glucose, plaque properties, and stenosis rate can significantly improve the accuracy of predicting TIA.

Risk of ischemic stroke after discharge from inpatient surgery: Does the type of surgery matter?

OBJECTIVE

Stroke is a well-known and devastating complication during the perioperative period. However, detailed stroke risk profiles within 90 days in patients discharged without stroke after inpatient surgery are not fully understood. Using the case-crossover design, we aimed to evaluate the risk of ischemic stroke in these patients.

METHODS

We included adult patients with the first hospitalization for ischemic stroke between 2011 and 2012 from 23 million enrollees in the National Health Insurance Research Database. Admission date of the hospitalization was defined as the case day and exactly 365 days before the admission date as the control day. The exposure was the last hospitalization for surgery within 1-30, 31-60, or 61-90 days (case period) before the case day or similar time intervals (control period) before the control day. Surgical types were grouped based on the International Classification of Diseases procedure codes. We performed conditional logistic regression adjusting for time-varying variables to determine the relationship between surgery and subsequent stroke, and case-time-control analyses to examine whether the results were confounded by the time-trend in surgery.

RESULTS

A total of 56596 adult patients (41% female, mean age 69 years) comprised the study population. After adjustment was made for confounding variables, an association between stroke and prior inpatient surgery within 30 days was observed (adjusted odds ratio 1.44; 95% confidence interval 1.29-1.61). Cardiothoracic, vascular, digestive surgery, and musculoskeletal surgery within 30 days independently predicted ischemic stroke in the case-crossover analysis. In the case-time-control analysis, inpatient surgery remained an independent risk factor for ischemic stroke, whereas only cardiothoracic, vascular, and digestive surgery independently predicted ischemic stroke.

CONCLUSIONS

Surgery as a whole independently increased the risk of ischemic stroke within 30 days. Among various types of surgery, cardiothoracic, vascular, and digestive surgery significantly increased the risk of ischemic stroke.

Morning hypertension is a risk factor of macrovascular events following cerebral infarction: A retrospective study

This study aimed to investigate risk factors (such as morning hypertension, drug compliance, and biochemical parameters) of macrovascular events after cerebral infarction.This was a retrospective study of patients with cerebral infarction admitted between May 2015 and April 2016 at the Fengxian Branch, 6th People's Hospital of Shanghai. They were divided into the macrovascular events and control groups according to the diagnosis of macrovascular events following cerebral infarction.Among the 702 patients included for analysis, 122 patients were with macrovascular events and 580 were without macrovascular events (controls). Morning hypertension (P = .01), dyslipidemia (P = .007), atrial fibrillation (P = .039), carotid artery plaque (P = .014), inflammatory infection (P = .005), high homocysteine (P = .032), antithrombotic compliance (P < .001), statins compliance (P < .001), morning diastolic blood pressure (P < .001), morning systolic blood pressure (P < .001), and morning heart rate (morHR) (P = .033) were associated with macrovascular events. Multivariable analysis showed that morning hypertension (P = .021, odds ratio [OR] = 1.753, 95% confidence interval [CI] [1.088, 2.826]), dyslipidemia (P = .021, OR = 1.708, 95% CI [1.085, 2.687]), and inflammatory infection (P = .031, OR = 2.263, 95% CI [1.078, 4.752]) were independent risk factors for macrovascular events, while antithrombotic compliance (P < .001, OR = 0.488, 95% CI [0.336, 0.709]), statin compliance (P = .02, OR = 0.64, 95% CI [0.44, 0.931]), and morHR (P = .027, OR = 0.977, 95% CI [0.958, 0.997]) were independent protective factors against macrovascular events. Atrial fibrillation showed a tendency to be associated with macrovascular events (P = .077, OR = 1.531, 95% CI [0.955, 2.454]).Morning hypertension, dyslipidemia, and inflammatory infection may increase the risk of macrovascular events following cerebral infarction. Improving morning blood pressure management and drug compliance (antithrombotic drugs and statins) may reduce the risk of macrovascular events following cerebral infarction.

Mechanical Thrombectomy in Perioperative Strokes: A Case-Control Study

BACKGROUND AND PURPOSE

Perioperative strokes (POS) are rare but serious complications for which mechanical thrombectomy could be beneficial. We aimed to compare the technical results and patients outcomes in a population of POS versus non-POS (nPOS) treated by mechanical thrombectomy.

METHODS

From 2010 to 2017, 25 patients with POS (ie, acute ischemic stroke occurring during or within 30 days after a procedure) who underwent mechanical thrombectomy (POS group) were enrolled and paired with 50 consecutive patients with nPOS (control group), based on the occlusion's site, National Institute of Health Stroke Scale, and age.

RESULTS

Respectively, mean age was 68.3±16.6 versus 67.2±16.6 years (P=0.70), and median National Institute of Health Stroke Scale score at admission was 20 (interquartile range, 15-25) versus 19 (interquartile range, 17-25; P=0.79). Good clinical outcome (modified Rankin Scale score of 0-2 at 3 months) was achieved by 33.3% (POS) versus 56.5% (nPOS) of patients (P=0.055). Successful reperfusion (modified Thrombolysis In Cerebral Infarction score of ≥2b) was obtained in 76% (POS) versus 86% (nPOS) of cases (P=0.22). Mortality at 3 months was 33.3% in the POS group versus 4.2% (nPOS) (P=0.002). The rate of major procedural complications was 4% (POS) versus 6% (nPOS); none were lethal. Average time from symptoms' onset to reperfusion was 4.9 hours (±2.0) in POS versus 5.2 hours (±2.6).

CONCLUSIONS

Successful reperfusion seems accessible in POS within a reasonable amount of time and with a good level of safety. However, favorable outcome was achieved with a lower rate than in nPOS, owing to a higher mortality rate.