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Morimoto T, Kobayashi T, Hirata H, Tsukamoto M, Yoshihara T, Toda Y, Ito H, Otani K, Mawatari M. Perioperative Cerebrovascular Accidents in Spine Surgery: A Retrospective Descriptive Study and A Systematic Review with Meta-Analysis. Spine Surg Relat Res 2024; 8:171-179. [PMID: 38618211 PMCID: PMC11007245 DOI: 10.22603/ssrr.2023-0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/09/2023] [Indexed: 04/16/2024] Open
Abstract
Introduction Perioperative cerebrovascular accidents (CVAs) related to spine surgery, although rare, can lead to significant disabilities. More studies on spine surgeries are required to identify those at risk of perioperative CVAs. The characteristics and outcomes of patients that experienced CVAs during spine surgery were assessed through a retrospective descriptive study and meta-analysis. Methods Patients aged ≥18 years who underwent spine surgery under general anesthesia at a hospital between April 2011 and March 2023 were examined. Of the 2,391 initially identified patients, 2,346 were included after excluding 45 who underwent debridement for surgical site infections. Subsequently, a meta-analysis including the present retrospective descriptive study was conducted. Databases such as PubMed and Google Scholar were searched for original peer-reviewed articles written in English. Results Of the 2,346 patients, 4 (0.17%) (three men, one woman) exhibited perioperative CVAs associated with spine surgery. The CVAs were diverse in nature: one case of cerebral hemorrhage resulting from dural injury during posterior occipitocervical fusion, two cases of cerebral infarctions after lumbar laminectomy and anterior thoracic fusion due to anticoagulant discontinuation, and one case of posterior reversible encephalopathy syndrome following microscopic lumbar discectomy due to gestational hypertension. The subsequent meta-analysis included three studies (n=186,860). It showed several risk factors for perioperative CVAs, including cervical level (pooled odds ratio [OR]=1.33), hypertension (pooled OR=2.27), atrial fibrillation (pooled OR=8.78), history of heart disease (pooled OR=2.47), and diabetes (pooled OR=2.13). Conclusions It was speculated that the potential risk factors for the four perioperative CVA cases of spine surgery in this retrospective descriptive study were intraoperative dural injury, preoperative anticoagulant discontinuation, and gestational hypertension history. The meta-analysis revealed that cervical spine surgery, hypertension, atrial fibrillation, heart disease, and diabetes increased the CVA risk. This highlights the need for risk assessment, preoperative optimization, and postoperative care to reduce spine surgery-associated perioperative CVAs.
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Affiliation(s)
- Tadatsugu Morimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takaomi Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hirohito Hirata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masatsugu Tsukamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomohito Yoshihara
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yu Toda
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hayato Ito
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Koji Otani
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
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Risk of Dementia According to Surgery Type: A Nationwide Cohort Study. J Pers Med 2022; 12:jpm12030468. [PMID: 35330467 PMCID: PMC8955036 DOI: 10.3390/jpm12030468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 12/19/2022] Open
Abstract
The relationship between dementia and surgery remains unclear. Research to elucidate the relationship between them is scarce, and conducting epidemiological research is complicated. This study aimed to investigate the incidence and risk of dementia according to the surgery type. We performed a retrospective propensity score-matched cohort study using nationwide representative cohort sample data from the Korean National Health Insurance Service in South Korea between 2003 and 2004. Incidence rates for dementia were obtained by dividing the number of patients with dementia by person-years at risk. To identify the risk of dementia according to the type of surgery, we investigated the hazard ratio by each surgery type. The incidence rates of dementia in control, musculoskeletal, and two or more surgeries groups were 9.66, 13.47, and 13.36 cases per 1000 person-years, respectively. The risk of dementia in the musculoskeletal and two or more surgeries groups was 1.44-fold higher (95% confidence interval (95% CI), 1.22–1.70) and 1.42-fold higher (95% CI, 1.17–1.72) than that in the control group, respectively. Patients who underwent musculoskeletal surgery and two or more surgeries had a higher risk of dementia; however, there was no association with the type of anesthesia administered.
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Yu J, Park JY, Hong JH, Hwang JH, Kim YK. Effect of pneumoperitoneum and Trendelenburg position on internal carotid artery blood flow measured by ultrasound during robotic prostatectomy. Clin Physiol Funct Imaging 2022; 42:139-145. [PMID: 35018713 DOI: 10.1111/cpf.12742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy. METHODS Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point. RESULTS A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3±44.7 [T2] vs. 188.0±49.6 mL/min [T1], P=0.002; 163.1±39.9 [T3] vs. 188.0±49.6 mL/min [T1], P=0.009). The ICA blood flow also differed significantly between Ta and T1 (236.8±58.3 vs. 188.0±49.6 mL/min, P<0.001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points. CONCLUSION Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Poon YY, Liu YW, Huang YH, Chan SHH, Tsai CY. Postoperative Stroke after Spinal Anesthesia and Responses of Carotid or Cerebral Blood Flow and Baroreflex Functionality to Spinal Bupivacaine in Rats. BIOLOGY 2021; 10:biology10070617. [PMID: 34356472 PMCID: PMC8301092 DOI: 10.3390/biology10070617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 07/01/2021] [Indexed: 11/16/2022]
Abstract
Spinal anesthesia is generally accepted as an effective and safe practice. Three rare incidents of postoperative cerebral infarction after surgery under spinal anesthesia prompted us to assess whether spinal bupivacaine may compromise carotid or cerebral blood flow. Postoperative examination after the stroke incident revealed that all three patients shared a common pathology of stenosis or atheromatosis in the carotid or middle cerebral artery. In a companion study using 69 Sprague-Dawley rats, subarachnoid application of bupivacaine elicited an initial (Phase I) reduction in the mean arterial pressure, carotid blood flow (CBF) and baroreflex-mediated sympathetic vasomotor tone, all of which subsequently returned to baseline (Phase II). Whereas heart rate (HR) exhibited sustained reduction, cardiac vagal baroreflex, baroreflex efficiency index (BEI) and tissue perfusion and oxygen in the cerebral cortex remained unaltered. However, in one-third of the rats studied, Phase II gave way to Phase III characterized by secondary hypotension and depressed baroreflex-mediated sympathetic vasomotor tone, along with declined HR, sustained cardiac vagal baroreflex, decreased BEI, reduced CBF and waning tissue perfusion or oxygen in the cerebral cortex. We concluded that carotid and cerebral blood flow can indeed be compromised after spinal anesthesia, and an impaired baroreflex-mediated sympathetic vasomotor tone, which leads to hypotension, plays a contributory role.
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Affiliation(s)
- Yan-Yuen Poon
- Department of Anesthesiology, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
- Institute for Translational Research in Biomedicine, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | - Yueh-Wei Liu
- Department of General Surgery, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | - Ya-Hui Huang
- Institute for Translational Research in Biomedicine, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | - Samuel H. H. Chan
- Institute for Translational Research in Biomedicine, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
- Correspondence: (S.H.H.C.); (C.-Y.T.)
| | - Ching-Yi Tsai
- Institute for Translational Research in Biomedicine, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
- Correspondence: (S.H.H.C.); (C.-Y.T.)
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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Dantas F, Vieira Caires AC, Cariri GA, Rolemberg Dantas FL. Perioperative Ischemic and Hemorrhagic Stroke in Spine Surgery: A Series of 5 Cases. World Neurosurg 2020; 146:e175-e183. [PMID: 33091642 DOI: 10.1016/j.wneu.2020.10.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stroke is a potentially life-threatening condition that can lead to disability and prolonged hospital stay. Perioperative stroke is a rare complication of spine surgery, especially in elective procedures. The prevalence of this complication varies in the literature, and the physiopathology is uncertain in many cases. Our objective was to describe 5 cases of patients who underwent spine surgery complicated by perioperative stroke and to analyze their characteristics and clinical outcomes. METHODS We retrospectively analyzed data from spine surgeries performed at a single institution from January 2016 to December 2019. Patients who presented with perioperative stroke were included. Data related to patient demographics, postoperative status, hospital stay, type of surgery, American Society of Anesthesiologists (ASA) score, neurologic status at discharge, and mortality were registered. RESULTS Five of 1002 consecutive patients (0.49%) had complication of stroke during surgery. The surgeries included occipitocervical fusion, anterior cervical fusion, lumbar fusion, lumbosacral fusion, and thoracolumbar fusion. The mean age of patients was 52.2 ± 15.73 years (range, 39-78 years), and the mean time of hospitalization was 20 ± 26.93 days (range, 6-68 days). The majority of patients were women (80%). Three patients (60%) presented with ischemic stroke, and 2 patients (40%) had hemorrhagic stroke. Two patients were severely disabled, and 3 showed good neurologic outcomes; no in-hospital deaths were observed. The etiology of stroke remained uncertain in the majority of cases. CONCLUSIONS Despite the rarity of this complication, perioperative stroke in spine surgery can lead to considerable morbidity. Precocious diagnosis and treatment may improve patient outcomes.
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Affiliation(s)
- François Dantas
- Department of Neurosurgery-Biocor Instituto, Nova Lima, Minas Gerais, Brazil; Faculdade de Ciências Médicas de Minas Gerais-Feluma Post-Graduation, Belo Horizonte, Minas Gerais, Brazil
| | | | - Gustavo Agra Cariri
- Department of Neurosurgery-Biocor Instituto, Nova Lima, Minas Gerais, Brazil
| | - Fernando Luiz Rolemberg Dantas
- Department of Neurosurgery-Biocor Instituto, Nova Lima, Minas Gerais, Brazil; Pontifícia Universidade Católica de Minas Gerais-Belo Horizonte, Minas Gerais, Brazil.
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Kurnutala LN, Anand S. Perioperative Stroke in a Patient Undergoing Noncardiac, Non-Neurosurgical Procedure: A Case Report. Cureus 2020; 12:e9570. [PMID: 32913687 PMCID: PMC7474566 DOI: 10.7759/cureus.9570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Perioperative stroke is a focal or global neurological deficit lasting more than 24 hours, which occurs during the surgery or within 30 days following surgery. Medications administered during anesthesia mask the symptoms of stroke in the perioperative period and make the early diagnosis of stroke difficult. Postoperative endothelial dysfunction and surgery-induced hypercoagulable state are some of the factors contributing to perioperative stroke. This report describes a case of perioperative stroke in a patient with an unremarkable intraoperative course following otolaryngology surgery. Vigilance, early diagnosis, and prompt treatment with the help of the acute stroke team are pivotal in improving patient outcomes.
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Affiliation(s)
| | - Suwarna Anand
- Anesthesiology, University of Mississippi Medical Center, Jackson, USA
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8
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Kummer BR, Hazan R, Merkler AE, Kamel H, Willey JZ, Middlesworth W, Yaghi S, Marshall RS, Elkind MSV, Boehme AK. A Multilevel Analysis of Surgical Category and Individual Patient-Level Risk Factors for Postoperative Stroke. Neurohospitalist 2019; 10:22-28. [PMID: 31839861 DOI: 10.1177/1941874419848590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Purpose Many studies supporting the association between specific surgical procedure categories and postoperative stroke (POS) do not account for differences in patient-level characteristics between and within surgical categories. The risk of POS after high-risk procedure categories remains unknown after adjusting for such differences in patient-level characteristics. Methods Using inpatients in the American College of Surgeons National Surgical Quality Initiative Program database, we conducted a retrospective cohort study between January 1, 2000, and December 31, 2010. Our primary outcome was POS within 30 days of surgery. We characterized the relationship between surgical- and individual patient-level factors and POS by using multivariable, multilevel logistic regression that accounted for clustering of patient-level factors with surgical categories. Results We identified 729 886 patients, 2703 (0.3%) of whom developed POS. Dependent functional status (odds ratio [OR]: 4.11, 95% confidence interval [95% CI]: 3.60-4.69), history of stroke (OR: 2.35, 95%CI: 2.06-2.69) or transient ischemic attack (OR: 2.49 95%CI: 2.19-2.83), active smoking (OR: 1.20, 95%CI: 1.08-1.32), hypertension (OR: 2.11, 95%CI: 2.19-2.82), chronic obstructive pulmonary disease (OR: 1.39 95%CI: 1.21-1.59), and acute renal failure (OR: 2.35, 95%CI: 1.85-2.99) were significantly associated with POS. After adjusting for clustering, patients who underwent cardiac (OR: 11.25, 95%CI: 8.52-14.87), vascular (OR: 4.75, 95%CI: 3.88-5.82), neurological (OR: 4.60, 95%CI: 3.48-6.08), and general surgery (OR: 1.40, 95%CI: 1.15-1.70) had significantly greater odds of POS compared to patients undergoing other types of surgical procedures. Conclusions Vascular, cardiac, and neurological surgery remained strongly associated with POS in an analysis accounting for the association between patient-level factors and surgical categories.
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Affiliation(s)
- Benjamin R Kummer
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca Hazan
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Alexander E Merkler
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Joshua Z Willey
- Department of Neurology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - William Middlesworth
- Department of Surgery, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Randolph S Marshall
- Department of Neurology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Amelia K Boehme
- Department of Neurology, College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Meng L, Li J, Flexman AM, Tong C, Zhou X, Gelb AW, Wang T, McDonagh DL. Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication. Anesth Analg 2019; 128:191-196. [PMID: 30044292 DOI: 10.1213/ane.0000000000003677] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Jianjun Li
- Department of Anesthesiology, Shandong University Qilu Hospital, Qingdao, Shandong, China
| | - Alana M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chuanyao Tong
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Xiangyong Zhou
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Adrian W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management.,Neurological Surgery.,Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
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Al-Hader R, Al-Robaidi K, Jovin T, Jadhav A, Wechsler LR, Thirumala PD. The Incidence of Perioperative Stroke: Estimate Using State and National Databases and Systematic Review. J Stroke 2019; 21:290-301. [PMID: 31590473 PMCID: PMC6780011 DOI: 10.5853/jos.2019.00304] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022] Open
Abstract
Background and Purpose Perioperative stroke remains a devastating complication after surgical procedures, due to hemodynamic and inflammatory changes that increase the risk of strokes within 30 days following surgery. We aimed to assess the incidence of perioperative strokes in patients undergoing various surgical procedures and reach a national estimate.
Methods A retrospective cohort study was conducted using California State Inpatient Databases, State Emergency Department Databases, State Ambulatory Surgery and Services Databases, and the National Inpatient Sample (NIS) during the period 2008 to 2011 from the Healthcare Cost and Utilization Project. A systematic review was conducted using PubMed, Embase, and Web of Science databases to obtain published articles that reported the incidence of perioperative stroke in various surgical procedures.
Results Analysis of 3,694,410 surgical encounters from the state of California (mean±standard deviation age: 52.4±21.1 years) yielded an overall rate of perioperative stroke of 0.32% (n=11,759). The incidence of perioperative strokes was highest following neurological (1.25%), vascular (1.07%), and cardiac (0.98%) surgeries. The NIS database contained a total of 48,672,974 weighted hospitalizations and yielded a rate of perioperative stroke of 0.42% (n=204,549). The systematic review completed yielded 187 articles, which had an overall sample size of 184,922 and an incidence of perioperative stroke ranging from 0% to 13.86%. It is estimated that in any given year, there would be approximately 40,000 to 55,000 (0.33% to 0.46%) perioperative strokes nationally.
Conclusions Our findings support further strategies to identify and stratify patients undergoing surgical procedures with a high incidence of perioperative strokes to improve patient counseling and a future potential treatment plan.
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Affiliation(s)
- Rami Al-Hader
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Khalid Al-Robaidi
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tudor Jovin
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashutosh Jadhav
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lawrence R Wechsler
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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Mrkobrada M, Chan MTV, Cowan D, Spence J, Campbell D, Wang CY, Torres D, Malaga G, Sanders RD, Brown C, Sigamani A, Szczeklik W, Dmytriw AA, Agid R, Smith EE, Hill MD, Sharma M, Sharma M, Tsai S, Mensinkai A, Sahlas DJ, Guyatt G, Pettit S, Copland I, Wu WKK, Yu SCH, Gin T, Loh PS, Ramli N, Siow YL, Short TG, Waymouth E, Kumar J, Dasgupta M, Murkin JM, Fuentes M, Ortiz-Soriano V, Lindroth H, Simpson S, Sessler D, Devereaux PJ. Rationale and design for the detection and neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study: a prospective international cohort study. BMJ Open 2018; 8:e021521. [PMID: 29982215 PMCID: PMC6042543 DOI: 10.1136/bmjopen-2018-021521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Covert stroke after non-cardiac surgery may have substantial impact on duration and quality of life. In non-surgical patients, covert stroke is more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac surgery.NeuroVISION is a multicentre, international, prospective cohort study that will characterise the association between perioperative acute covert stroke and postoperative cognitive function. SETTING AND PARTICIPANTS We are recruiting study participants from 12 tertiary care hospitals in 10 countries on 5 continents. PARTICIPANTS We are enrolling patients ≥65 years of age, requiring hospital admission after non-cardiac surgery, who have an anticipated length of hospital stay of at least 2 days after elective non-cardiac surgery that occurs under general or neuraxial anaesthesia. PRIMARY AND SECONDARY OUTCOME MEASURES Patients are recruited before elective non-cardiac surgery, and their cognitive function is measured using the Montreal Cognitive Assessment (MoCA) instrument. After surgery, a brain MRI study is performed between postoperative days 2 and 9 to determine the presence of acute brain infarction. One year after surgery, the MoCA is used to assess postoperative cognitive function. Physicians and patients are blinded to the MRI study results until after the last patient follow-up visit to reduce outcome ascertainment bias.We will undertake a multivariable logistic regression analysis in which the dependent variable is the change in cognitive function 1 year after surgery, and the independent variables are acute perioperative covert stroke as well as other clinical variables that are associated with cognitive dysfunction. CONCLUSIONS The NeuroVISION study will characterise the epidemiology of covert stroke and its clinical consequences. This will be the largest and the most comprehensive study of perioperative stroke after non-cardiac surgery. TRIAL REGISTRATION NUMBER NCT01980511; Pre-results.
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Affiliation(s)
| | | | - David Cowan
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - David Torres
- Clinica Santa Maria, Universidad de Los Andes, Santiago, Chile
| | | | | | - Carl Brown
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Ronit Agid
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Manas Sharma
- University of Western Ontario, London, Ontario, Canada
| | | | - Scott Tsai
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | - Shirley Pettit
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ingrid Copland
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Simon C H Yu
- Chinese University of Hong Kong, Hong Kong, China
| | - Tony Gin
- Chinese University of Hong Kong, Hong Kong, China
| | | | | | | | | | | | | | | | - John M Murkin
- University of Western Ontario, London, Ontario, Canada
| | - Maite Fuentes
- Clinica Santa Maria, Universidad de Los Andes, Santiago, Chile
| | | | | | - Sara Simpson
- University of British Columbia, Vancouver, British Columbia, Canada
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Fujikawa T, Kawamoto H, Kawamura Y, Emoto N, Sakamoto Y, Tanaka A. Impact of laparoscopic liver resection on bleeding complications in patients receiving antithrombotics. World J Gastrointest Endosc 2017; 9:396-404. [PMID: 28874960 PMCID: PMC5565505 DOI: 10.4253/wjge.v9.i8.396] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 05/15/2017] [Accepted: 05/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the impact of laparoscopic liver resection (LLR) on surgical blood loss (SBL), especially in patients with antithrombotics for thromboembolic risks.
METHODS Consecutive 258 patients receiving liver resection at our institution between 2010 and 2016 were retrospectively reviewed. Preoperative antithrombotic therapy (ATT; antiplatelets and/or anticoagulation) was regularly used in 100 patients (ATT group, 38.8%) whereas not used in 158 (non-ATT group, 61.2%). Our perioperative management of high thromboembolic risk patients included maintenance of preoperative aspirin monotherapy for patients with antiplatelet therapy and bridging heparin for patients with anticoagulation. In both ATT and non-ATT groups, outcome variables of patients undergoing LLR were compared with those of patients receiving open liver resection (OLR), and the independent risk factors for increased SBL were determined by multivariate analysis.
RESULTS This series included 77 LLR and 181 OLR. There were 3 thromboembolic events (1.2%) in a whole cohort, whereas increased SBL (≥ 500 mL) and postoperative bleeding complications (BCs) occurred in 66 patients (25.6%) and 8 (3.1%), respectively. Both in the ATT and non-ATT groups, LLR was significantly related to reduced SBL and low incidence of BCs, although LLR was less performed as anatomical resection. Multivariate analysis showed that anatomical liver resection was the most significant risk factor for increased SBL [risk ratio (RR) = 6.54, P < 0.001] in the whole cohort, and LLR also had the significant negative impact (RR = 1/10.0, P < 0.001). The same effects of anatomical resection (RR = 15.77, P < 0.001) and LLR (RR = 1/5.88, P = 0.019) were observed when analyzing the patients in the ATT group.
CONCLUSION LLR using the two-surgeon technique is feasible and safely performed even in the ATT-burdened patients with thromboembolic risks. Independent from the extent of liver resection, LLR is significantly associated with reduced SBL, both in the ATT and non-ATT groups.
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Dong Y, Cao W, Cheng X, Fang K, Zhang X, Gu Y, Leng B, Dong Q. Risk Factors and Stroke Characteristic in Patients with Postoperative Strokes. J Stroke Cerebrovasc Dis 2017; 26:1635-1640. [PMID: 28478979 DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/29/2016] [Accepted: 12/23/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Intravenous thrombolysis and intra-arterial thrombectomy are now the standard therapies for patients with acute ischemic stroke. In-house strokes have often been overlooked even at stroke centers and there is no consensus on how they should be managed. Perioperative stroke happens rather frequently but treatment protocol is lacking, In China, the issue of in-house strokes has not been explored. The aim of this study is to explore the current management of in-house stroke and identify the common risk factors associated with perioperative strokes. METHOD Altogether, 51,841 patients were admitted to a tertiary hospital in Shanghai and the records of those who had a neurological consult for stroke were reviewed. Their demographics, clinical characteristics, in-hospital complications and operations, and management plans were prospectively studied. Routine laboratory test results and risk factors of these patients were analyzed by multiple logistic regression model. RESULT From January 1, 2015, to December 31, 2015, over 1800 patients had neurological consultations. Among these patients, 37 had an in-house stroke and 20 had more severe stroke during the postoperative period. Compared to in-house stroke patients without a procedure or operation, leukocytosis and elevated fasting glucose levels were more common in perioperative strokes. In multiple logistic regression model, perioperative strokes were more likely related to large vessel occlusion. CONCLUSION Patients with perioperative strokes had different risk factors and severity from other in-house strokes. For these patients, obtaining a neurological consultation prior to surgery may be appropriate in order to evaluate the risk of perioperative stroke.
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Affiliation(s)
- Yi Dong
- Department of Neurology, Fudan University, Huashan Hospital, Shanghai, China; State Key Laboratory of Neurobiology, Fudan University, Shanghai, China.
| | - Wenjie Cao
- Department of Neurology, Fudan University, Huashan Hospital, Shanghai, China; State Key Laboratory of Neurobiology, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Fudan University, Huashan Hospital, Shanghai, China; State Key Laboratory of Neurobiology, Fudan University, Shanghai, China
| | - Kun Fang
- Department of Neurology, Fudan University, Huashan Hospital, Shanghai, China; State Key Laboratory of Neurobiology, Fudan University, Shanghai, China
| | - Xiaolong Zhang
- Department of Radiology, Fudan University, Huashan Hospital, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Fudan University, Huashan Hospital, Shanghai, China
| | - Bing Leng
- Department of Neurosurgery, Fudan University, Huashan Hospital, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Fudan University, Huashan Hospital, Shanghai, China; State Key Laboratory of Neurobiology, Fudan University, Shanghai, China
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Mehdi Z, Birns J, Partridge J, Bhalla A, Dhesi J. Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery. Clin Med (Lond) 2016; 16:535-540. [PMID: 27927817 PMCID: PMC6297334 DOI: 10.7861/clinmedicine.16-6-535] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery.
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Affiliation(s)
- Zehra Mehdi
- Department of Ageing and Health, St Thomas' Hospital, London, UK
| | - Jonathan Birns
- Department of Ageing and Health, St Thomas' Hospital, London, UK
| | - Judith Partridge
- Department of Ageing and Health, St Thomas' Hospital, London, UK
| | - Ajay Bhalla
- Department of Ageing and Health, St Thomas' Hospital, London, UK
| | - Jugdeep Dhesi
- Department of Ageing and Health, St Thomas' Hospital, London, UK
- Division of Health and Social Care Research, Kings College London, London, UK
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Mrkobrada M, Hill M, Chan M, Sigamani A, Cowan D, Kurz A, Sessler D, Jacka M, Graham M, Dasgupta M, Dunlop V, Emery D, Gulka I, Guyatt G, Heels-Ansdell D, Murkin J, Pettit S, Sahlas D, Sharma M, Sharma M, Srinathan S, St John P, Tsai S, Gelb A, O’Donnell M, Siu D, Chiu P, Sharath V, George A, Devereaux P. Covert stroke after non-cardiac surgery: a prospective cohort study. Br J Anaesth 2016; 117:191-7. [DOI: 10.1093/bja/aew179] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2016] [Indexed: 11/13/2022] Open
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Vasivej T, Sathirapanya P, Kongkamol C. Incidence and Risk Factors of Perioperative Stroke in Noncardiac, and Nonaortic and Its Major Branches Surgery. J Stroke Cerebrovasc Dis 2016; 25:1172-1176. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/21/2016] [Accepted: 01/31/2016] [Indexed: 12/18/2022] Open
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McAlister FA, Jacka M, Graham M, Youngson E, Cembrowski G, Bagshaw SM, Pannu N, Townsend DR, Srinathan S, Alonso-Coello P, Devereaux PJ. The prediction of postoperative stroke or death in patients with preoperative atrial fibrillation undergoing non-cardiac surgery: a VISION sub-study. J Thromb Haemost 2015; 13:1768-75. [PMID: 26270168 DOI: 10.1111/jth.13110] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/07/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal means of pre-operative risk stratification in patients with atrial fibrillation (AF) is uncertain. OBJECTIVE To examine the accuracy of AF thromboembolic risk models (the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores) for predicting 30-day stroke and/or all-cause mortality after non-cardiac surgery in patients with preoperative AF, and to compare these risk scores with the Revised Cardiac Risk Index (RCRI). PATIENTS/METHODS A multicentre (8 countries, 2007-2011) prospective cohort study of patients ≥ 45 years of age undergoing inpatient non-cardiac surgery, who were followed until 30 days after surgery. We calculated c-statistics for each risk prediction model and net reclassification improvements (NRIs) compared with the RCRI. RESULTS The 961 patients with preoperative AF were at higher risk of any cardiovascular event in the 30 days postoperatively compared with the 13 001 patients without AF: 26.6% vs. 9.0%; adjusted odds ratio, 1.58; 95% confidence interval [CI], 1.33-1.88. All thromboembolic risk scores predicted postoperative death just as well as the RCRI (with c-indices between 0.67 and 0.72). Compared with the RCRI (which had a c-index of 0.64 for 30-day stroke/death), the CHADS2 (c-index, 0.67; NRI, 0.31; 95% CI, 0.02-0.61) significantly improved postoperative stroke/mortality risk prediction, largely due to improved discrimination of patients who did not subsequently have an event. CONCLUSIONS In AF patients, the three thromboembolic risk scores performed similarly to the RCRI in predicting death within 30 days and the CHADS2 score was the best predictor of postoperative stroke/death regardless of type of surgery.
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Affiliation(s)
- F A McAlister
- Patient Health Outcomes Research and Clinical Effectiveness Unit, Edmonton, AB, Canada
- Division of General Internal Medicine, Department of Medicine, Edmonton, AB, Canada
| | - M Jacka
- Division of Critical Care Medicine, Department of Medicine, Edmonton, AB, Canada
| | - M Graham
- Division of Cardiology, Department of Medicine, Edmonton, AB, Canada
| | - E Youngson
- Patient Health Outcomes Research and Clinical Effectiveness Unit, Edmonton, AB, Canada
| | - G Cembrowski
- Division of Medical Biochemistry, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - S M Bagshaw
- Division of Critical Care Medicine, Department of Medicine, Edmonton, AB, Canada
| | - N Pannu
- Division of Critical Care Medicine, Department of Medicine, Edmonton, AB, Canada
| | - D R Townsend
- Division of Critical Care Medicine, Department of Medicine, Edmonton, AB, Canada
| | - S Srinathan
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - P Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB-Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - P J Devereaux
- Departments of Clinical Epidemiology and Biostatistics and Medicine, The Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
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Rozec B, Cinotti R, Le Teurnier Y, Marret E, Lejus C, Asehnoune K, Blanloeil Y. [Epidemiology of cerebral perioperative vascular accidents]. ACTA ACUST UNITED AC 2014; 33:677-89. [PMID: 25447778 DOI: 10.1016/j.annfar.2014.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature. ARTICLE TYPE Systematic review. DATA SOURCES Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters. RESULTS In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients. CONCLUSION Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.
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Affiliation(s)
- B Rozec
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France.
| | - R Cinotti
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
| | - Y Le Teurnier
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
| | - E Marret
- Département d'anesthésie-réanimation, institut hospitalier franco-britannique, 4, rue Kléber, 92300 Levallois-Perret, France
| | - C Lejus
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - K Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Y Blanloeil
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
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Urbanek C, Palm F, Buggle F, Wolf J, Safer A, Becher H, Grau AJ. Recent surgery or invasive procedures and the risk of stroke. Cerebrovasc Dis 2014; 38:370-6. [PMID: 25427844 DOI: 10.1159/000368596] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/23/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE A recent surgery may be one of the trigger factors precipitating stroke and transient ischemic attack (TIA). While stroke in cardiac and carotid surgery has been well studied, less is known on stroke risk after surgery outside the heart and brain supplying arteries. We tested the hypothesis that preceding non-neurosurgical, non-cardiothoracic, and non-carotid surgery and other interventions temporarily increase the risk of stroke and transient ischemic attack (TIA) and investigated the risk related to different time periods between interventions and stroke/TIA. METHODS In the Ludwigshafen Stroke Study, a population-based stroke registry, we assessed surgery and other interventions within the year preceding stroke and TIA. The risk factor profiles of patients with and without prior intervention were compared and rate ratios (RR) were calculated for different time periods with 91-365 days before stroke and TIA serving as reference period. RESULTS In 2006 and 2007, 803 patients without and 116 patients with non-neurosurgical, non-cardiothoracic, and non-carotid intervention within the preceding year were identified. Elective (n = 21) and posttraumatic orthopedic (n = 14), eye (n = 14), and visceral surgery (n = 11) dominated. Interventions within 0-30 days (n = 34; RR 4.72; 95% confidence interval (CI) 2.70-8.26) but not within 31-60 or 61-90 days before stroke/TIA were observed more often than in the reference period. Interventions were more common within day 8-30 before stroke/TIA (RR 3.26; 95% CI 1.66-6.39), particularly common within the preceding week (RR 9.52; 95% CI 3.77-24.1) and most common in the preceding 2 days (RR 27.1; 95% CI 5.97-123) as compared to the reference period. Atrial fibrillation (AF) but not other risk factors was more common in patients with interventions within 30 days (n = 15; 44.1%) as compared to patients with more antecedent interventions (n = 19; 23.2%, p = 0.022) and those without surgery (n = 222; 27.6%, p = 0.031). Interventions within 30 days before stroke/TIA, were associated with total ischemic stroke (RR 6.11; 95% CI 3.32-11.2), first-ever in a lifetime ischemic stroke (RR 5.62; 95% CI 2.83-11.1) and recurrent ischemic stroke (RR 7.50; 95% CI 2.88-19.6). CONCLUSION Recent non-cardiothoracic, non-carotid, and non-neurosurgical interventions are associated with an increased risk of stroke lasting for about 1 month and being particularly high within the first days. AF may be among the mechanisms linking interventions and stroke besides induction of a procoagulant state and interruption of medication.
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Affiliation(s)
- Christian Urbanek
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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20
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Which risk score best predicts perioperative outcomes in nonvalvular atrial fibrillation patients undergoing noncardiac surgery? Am Heart J 2014; 168:60-7.e5. [PMID: 24952861 DOI: 10.1016/j.ahj.2014.03.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/19/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with nonvalvular atrial fibrillation (NVAF) are at increased risk for adverse events after noncardiac surgery. The Revised Cardiac Index (RCI) is commonly used to predict perioperative events; however, the prognostic utility of NVAF risk scores (CHADS2, CHA2DS2-VASc, and R2CHADS2) has not been evaluated in patients undergoing noncardiac surgery. METHODS Using a population-based data set of NVAF patients (n = 32,160) who underwent major or minor noncardiac surgery between April 1, 1999, and November 30, 2009, in Alberta, Canada, we examined the incremental prognostic value of the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores over the RCI using continuous net reclassification improvement (NRI). The primary composite outcome was 30-day mortality, stroke, transient ischemic attack, or systemic embolism. RESULTS The median age was 73 years, 55.1% were male, 6.6% had a previous thromboembolism, 17% of patients underwent major surgery, and the median risk scores were as follows: RCI = 1, CHADS2 = 1, CHA2DS2-VASc = 3, and R2CHADS2 = 2. The incidence of our 30-day composite was 4.2% (mortality 3.3%; stroke, transient ischemic attack, or systemic embolism 1.2%); and c indices were 0.65 for the RCI, 0.67 for the CHADS2 (NRI 14.3%, P < .001), 0.67 for CHA2DS2-VASc (NRI 10.7%, P < .001), and 0.68 for R2CHADS2 (NRI 11.4%, P < .001). The CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were also all significantly better than the RCI for mortality risk prediction (NRI 12.3%, 8.4%, and 13.3%, respectively; all Ps < .01). CONCLUSIONS In NVAF patients undergoing noncardiac surgery, the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores all improved the prediction of major perioperative events including mortality compared to the RCI.
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Morales-Vidal S, Schneck M, Golombieski E. Commonly asked questions in the management of perioperative stroke. Expert Rev Neurother 2014; 13:167-75. [DOI: 10.1586/ern.13.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kallas PG. Assessing and Managing Neurovascular, Neurodegenerative, and Neuromuscular Disorders. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Wu JC, Chen YC, Liu L, Huang WC, Thien PF, Chen TJ, Cheng H, Lo SS. Lumbar spine fusion surgery and stroke: a national cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21:2680-7. [PMID: 22722922 DOI: 10.1007/s00586-012-2405-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 05/02/2012] [Accepted: 06/09/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To investigate the incidence and risk of stroke after lumbar spinal fusion surgery. METHOD Study subjects were identified from a nationwide cohort of 1 million people from 2000 to 2005 and were divided into the lumbar spinal fusion group (n = 2,015), who received posterior lumbar spinal fusion surgery, and the comparison group (n = 16,120) composed of age-, sex-, and propensity score-matched control subjects. The matching process was intended to adjust for demographics, comorbidities, and other immeasurable covariates to minimize selection bias. All subjects were followed up for 3 years for stroke, including hemorrhagic and ischemic strokes. Kaplan-Meier and Cox regression analyses were performed. RESULTS The overall incidence rate of stroke in the cohort was 9.99 per 1,000 person-year. The lumbar spinal fusion group was less likely to have any stroke (adjusted hazard ratio (HR) = 0.83, p = 0.293), hemorrhagic stroke (adjusted HR = 0.74, p = 0.739) and ischemic stroke (adjusted HR = 0.81, p = 0.250) than the comparison group, but without significance. CONCLUSIONS Three years post-operatively, patients who received lumbar spinal fusion had stroke incidence rates similar to those without surgery. Posterior lumbar spinal fusion surgery is not associated with increased risks for any kind of stroke.
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Affiliation(s)
- Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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Abstract
A growing elderly population with an increasing number of comorbidities is presenting for orthopaedic procedures and interventions, lending themselves to greater risk for complications, including stroke. Prior stroke or transient ischemic attack, hypertension, diabetes mellitus, atrial fibrillation, carotid stenosis, and advanced age are the most common risk factors for perioperative stroke. A comprehensive neurologic assessment should include a thorough history including identification of risk factors, pertinent medications, and a physical examination. This assessment is important to establish a baseline for subsequent neurologic evaluations in the postoperative period. Neurologic physical assessment can be an intimidating task, especially for the orthopaedic nurse who lacks experience in caring for the neurologic patient. Patients who are found with a focal neurologic deficit that is suspicious for stroke require urgent assessment, exclusion of stroke mimics, and activation of the institution's stroke team to allow for brain saving interventions. Time is brain.
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Macellari F, Paciaroni M, Agnelli G, Caso V. Perioperative Stroke Risk in Nonvascular Surgery. Cerebrovasc Dis 2012; 34:175-81. [DOI: 10.1159/000339982] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 06/04/2012] [Indexed: 02/02/2023] Open
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Biccard BM, Kassanjee R, Welte A. Is it possible to decrease the incidence of peri-operative stroke associated with acute peri-operative beta-blocker administration? Anaesthesia 2011; 66:80-3. [PMID: 21254981 DOI: 10.1111/j.1365-2044.2010.06614.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Jacobs LK, Sapers BL. Postoperative Stroke and Seizures. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Guluma KZ, Liu L, Hemmen TM, Acharya AB, Rapp KS, Raman R, Lyden PD. Therapeutic hypothermia is associated with a decrease in urine output in acute stroke patients. Resuscitation 2010; 81:1642-7. [PMID: 20817376 PMCID: PMC2991385 DOI: 10.1016/j.resuscitation.2010.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 07/07/2010] [Accepted: 08/02/2010] [Indexed: 11/30/2022]
Abstract
AIMS It is unclear what effect therapeutic hypothermia may have on renal function, because its effect has so far been primarily evaluated in settings in which there may be possible confounding perturbations in cardiovascular and renal physiology, such deep intraoperative hypothermia, general anesthesia, and post-cardiac arrest. We sought to determine if therapeutic hypothermia affects renal function in awake patients with normal renal function who were enrolled into a clinical trial of hypothermia plus intravenous thrombolysis for acute ischemic stroke. METHODS Eleven patients with normal renal function were cooled to 33°C for 24 h using an endovascular catheter, and then re-warmed over 12 h to 36.5°C, while hourly temperature, blood pressure, and fluid status data was recorded. Blood samples for blood urea nitrogen (BUN), creatinine, and hematocrit were drawn prior to treatment (baseline), immediately after hypothermia and re-warming (day 2), and again at day 7 or discharge, and values compared. RESULTS On initiation of cooling, temperatures dropped from a median pre-treatment value of 36.1°C (IQR: 35.8-36.4°C) to 33.1°C (IQR: 33.1-33.4°C). Urine output decreased 5.1 ml/h for every 1°C decrease in body temperature (p-value=0.001), with no associated serious adverse events. There were no statistically significant changes in BUN, creatinine, or hematocrit in the hypothermia patients. CONCLUSION Inducing hypothermia in patients with relatively unperturbed renal physiology results in a decrease in urine output that is linearly correlated with the decrease in core temperature. This has important implications for fluid management in patients undergoing therapeutic hypothermia.
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Affiliation(s)
- Kama Z Guluma
- Department of Emergency Medicine, University of California San Diego Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8676, United States
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Ghaly RF, Candido KD, Knezevic NN. Perioperative fatal embolic cerebrovascular accident after radical prostatectomy. Surg Neurol Int 2010; 1. [PMID: 20847908 PMCID: PMC2940086 DOI: 10.4103/2152-7806.65055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 05/25/2010] [Indexed: 11/06/2022] Open
Abstract
Background: There is little written about the management of perioperative cerebrovascular accident (CVA). To the best of our knowledge, the present case report represents the first case in the literature of a well-documented intraoperative embolic CVA and perioperative mortality in a relatively healthy, young patient with no contributing comorbidity and no noteworthy intraoperative event. Case Description: A 53-year-old man presented for radical prostatectomy under general anesthesia. The anesthetic course and procedure were uneventful. In the postanesthesia care unit (PACU), the patient was moving all extremities but was still sedated. One hour later, he developed left hemiplegia, facial dropping, slurred speech and his head was turned to the right. The next day his mental status deteriorated, and on an emergency basis he was intubated. A CT scan of the head showed a malignant hemispheric right cerebrovascular accident with leftward midline shift. Even aggressive treatment, including a right decompressive hemicraniectomy, could not lower the high intracranial pressure, and the patient expired on the third postoperative day. Conclusion: Guidelines for identifying and treating perioperative hemispheric CVA are urgently needed, with modification of the antiquated and useless criterion of “patient seen neurologically normal at induction time” to more useful objective criteria including “intraoperative neurophysiological recording change, gross extremity movements, facial dropping, follows simple commands” while excluding a drug-induced, sedative-influenced globally-impaired cognitive state that may last for hours.
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Affiliation(s)
- Ramsis F Ghaly
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA
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Kikura M, Bateman BT, Tanaka KA. Perioperative ischemic stroke in non-cardiovascular surgery patients. J Anesth 2010; 24:733-8. [DOI: 10.1007/s00540-010-0969-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 05/03/2010] [Indexed: 11/30/2022]
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31
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Papangelou A, Mirski M. Risk Assessment and Prevention of Perioperative Stroke. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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van Lier F, Schouten O, van Domburg RT, van der Geest PJ, Boersma E, Fleisher LA, Poldermans D. Effect of chronic beta-blocker use on stroke after noncardiac surgery. Am J Cardiol 2009; 104:429-33. [PMID: 19616679 DOI: 10.1016/j.amjcard.2009.03.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 03/24/2009] [Accepted: 03/24/2009] [Indexed: 11/18/2022]
Abstract
The incidence of postoperative stroke ranges from 0.08% to 0.7% in noncardiac surgery. Recently, the PeriOperative ISchemic Evaluation (POISE) study reported an incidence of postoperative stroke of 1% in patients scheduled for noncardiac surgery when beta blockers were initiated immediately before surgery. To assess the association between chronic beta-blocker use and postoperative stroke in noncardiac surgery, we undertook a case-control study among 186,779 patients who underwent noncardiac surgery from 2000 to 2008 at the Erasmus Medical Centre. Patients who were undergoing intracerebral surgery or carotid surgery or who had head and/or carotid trauma were excluded. The case subjects were 34 patients (0.02%) who had experienced a stroke within 30 days after surgery. Of the remaining patients, 2 controls were selected for each case and were stratified according to calendar year, type of surgery, and age. For cases and controls, information was obtained regarding beta-blocker use before surgery, the presence of cardiac risk factors, and the use of other cardiovascular medication. The use of beta blockers was as common in the cases as in the controls (29% vs 29%; p = 1.0). The adjusted odds ratio for postoperative stroke among beta-blocker users compared with nonusers was 0.4 (95% confidence interval 0.1 to 1.5). Similar results were obtained in the subgroups of patients stratified according to the use of cardiovascular therapy and the presence of cardiac risk factors. In conclusion, the present case-control study has shown no increased risk of postoperative stroke in patients taking chronic beta-blocker therapy.
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Affiliation(s)
- Felix van Lier
- Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
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Pang W, Collins J, Wu RSC. Severe transient hemiplegia after general anaesthesia for prostatectomy. Br J Anaesth 2009; 102:720-1. [DOI: 10.1093/bja/aep074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Popa AS, Rabinstein AA, Huddleston PM, Larson DR, Gullerud RE, Huddleston JM. Predictors of ischemic stroke after hip operation: a population-based study. J Hosp Med 2009; 4:298-303. [PMID: 19484726 PMCID: PMC2933135 DOI: 10.1002/jhm.531] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hip operation (total hip arthroplasty [THA] or fracture repair) is the most common noncardiac surgical procedure performed in patients age 65 years and older. OBJECTIVE To determine the predictors of ischemic stroke in patients who have undergone hip operation. DESIGN Population-based historical cohort study, in which postoperative ischemic strokes were identified from medical record review for stroke diagnostic codes and brain imaging results and were confirmed by physician review. SETTING Tertiary care center in Olmsted County, Minnesota. PATIENTS Residents of Olmsted County who underwent hip surgical procedure. MEASUREMENTS Incidence of ischemic stroke within 1 year of hip operation. RESULTS In total, 1606 patients underwent 1886 hip procedures from 1988 through 2002 and were observed for ischemic stroke for 1 year after their procedure. Sixty-seven ischemic strokes were identified. The rate of stroke at 1 year after hip operation was 3.9%. In univariate analysis, history of atrial fibrillation (hazard ratio [HR], 2.16; P = 0.005), hip fracture repair vs. total hip arthroplasty (HR, 3.80; P < 0.001), age 75 years or older (HR, 2.20; P = 0.02), aspirin use (HR, 1.8; P = 0.01), and history of previous stroke (HR, 4.18; P < 0.001) were significantly associated with increased risk of stroke. In multivariable analysis, history of stroke (HR, 3.27; P < 0.001) and hip fracture repair (HR, 2.74; P = 0.004) were strong predictors of postoperative stroke. CONCLUSIONS This population-based historical cohort of patients with hip operation had a 3.9% cumulative probability of ischemic stroke over the first postoperative year. Hip fracture repair and history of stroke were the strongest predictors of this complication.
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Affiliation(s)
- Alina S. Popa
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Dirk R. Larson
- Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
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35
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Rodriguez GJ, Cordina SM, Vazquez G, Suri MFK, Kirmani JF, Ezzeddine MA, Qureshi AI. The Hydration Influence on the Risk of Stroke (THIRST) Study. Neurocrit Care 2008; 10:187-94. [DOI: 10.1007/s12028-008-9169-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 11/04/2008] [Indexed: 11/28/2022]
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36
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Kikura M, Oikawa F, Yamamoto K, Iwamoto T, Tanaka KA, Sato S, Landesberg G. Myocardial infarction and cerebrovascular accident following non-cardiac surgery: differences in postoperative temporal distribution and risk factors. J Thromb Haemost 2008; 6:742-8. [PMID: 18331455 DOI: 10.1111/j.1538-7836.2008.02948.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Myocardial infarction and stroke after non-cardiac surgery are two ominous cardiovascular complications believed to share similar pathophysiological processes. However, the differences in the temporal distribution between them have not been adequately investigated in a large cohort of patients. METHODS AND RESULTS The preoperative clinical features and daily occurrence of myocardial infarction and stroke were routinely recorded in 36 634 consecutive patients following elective non-cardiac, non-carotid surgery. The preoperative characteristics and postoperative daily distribution of postoperative myocardial infarction and stroke were compared using exponential and linear regressions models. Myocardial infarction and stroke occurred in 122 (0.33%) and 126 (0.34%) patients, respectively, during the first 30 days after surgery. More patients with myocardial infarction had diabetes mellitus and cardiac disease (P = 0.041 and <0.0001, respectively) whereas more patients with stroke were older and female (P = 0.003 and 0.038, respectively). The peak incidence of myocardial infarction was on the day of surgery (43%) and declined exponentially thereafter (F = 725.4, P < 0.0001). However, postoperative stroke best fitted a linear regression with almost even daily distribution (F = 15.9, P = 0.0004). The median time to myocardial infarction was one day [95% confidence interval (95% CI) = 0-2 days] compared with nine days (95% CI = 7-11 days) for stroke. CONCLUSIONS The peak incidence of postoperative myocardial infarction is early after non-cardiac surgery and declines exponentially thereafter, as opposed to stroke, which occurs at a constant rate during the postoperative period. Myocardial infarction and cerebrovascular accident following non-cardiac surgery differ in their preoperative risk factors, and in the postoperative time-line of their occurrence.
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Affiliation(s)
- M Kikura
- Department of Anesthesiology and Intensive Care, Hamamatsu Medical Center, Japan.
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Maharaj R. A review of recent developments in the management of carotid artery stenosis. J Cardiothorac Vasc Anesth 2008; 22:277-89. [PMID: 18375336 DOI: 10.1053/j.jvca.2007.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Ritesh Maharaj
- Department of Anaesthesia, University of Natal, Congella, South Africa
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38
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Cardona P, Rubio F, Martinez-Yélamos S, Krupinski J. Endarterectomy, best medical treatment or both for stroke prevention in patients with asymptomatic carotid artery stenosis. Cerebrovasc Dis 2007; 24 Suppl 1:126-33. [PMID: 17971648 DOI: 10.1159/000107388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Carotid endarterectomy (CEA) is currently frequently performed in subjects with asymptomatic carotid artery stenosis over 70%, as clinical trials like the Asymptomatic Carotid Atherosclerosis Study and Asymptomatic Carotid Surgery Trial demonstrated a significant benefit for stroke prevention. A low risk reduction in the long-term prevention of stroke or death and the required lower than 3% of surgical risk are associated with surgery. That means that an important number of patients needs to be operated to prevent 1 stroke over 5 years (number needed to treat: 21) with an absolute risk reduction of 5.4%. It is reasonable to consider CEA for patients aged 40-75 years and with asymptomatic stenosis of 60-99%, for patients with a life expectancy of at least 5 years, and in centres with a surgical morbidity-mortality of less than 3%. Therefore, it is of interest to identify high-risk patients with asymptomatic carotid stenosis who will more likely benefit from surgery. Techniques such as ultrasound or magnetic resonance imaging may identify plaque morphology or detect clinically asymptomatic embolization. CEA combined with the best medical treatment and good management of modifiable risk factors might be superior to medical management alone or surgery in preventing stroke. There is no level I evidence to support carotid artery stenting in asymptomatic carotid stenosis even in a subgroup of patients with a high surgical risk.
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Affiliation(s)
- Pedro Cardona
- Stroke Unit, Department of Neurology, Bellvitge University Hospital, IDIBELL, Barcelona, Spain.
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39
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Choi YW, Chung MY, Kim CJ, Lee BH, Lee HJ, Chea JS. Cerebral Infarction following Total Hip Replacement Arthroplasty in Geriatric Patient - A case report -. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.1.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Yong Woo Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee Young Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang Jae Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung Ho Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo Jung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Seuk Chea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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40
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Abstract
Neurologists often assess the risk of stroke from general surgical procedures in patients who have cerebrovascular disease. Common questions for neurologists include: Should a symptomatic or an asymptomatic carotid stenosis be revascularized before general surgery? What is the risk of surgery in patients who have stenoses in the cervicocephalic vasculature? What is the risk of recurrent stroke in patients who have a history of stroke requiring surgery? Can antithrombotic therapy be interrupted for surgery? and How soon after a stroke may elective surgeries be performed? Although definite answers to these questions are lacking, available clinical evidence and knowledge of cerebrovascular pathophysiology can help inform recommendations.
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Affiliation(s)
- Richard A Bernstein
- Stroke Program, Davee Department of Neurology and Clinical Neurological Sciences, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, USA.
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41
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Tsai YF, Doufas AG, Huang CS, Liou FC, Lin CM. Postoperative coma in a patient with complete basilar syndrome after anterior cervical discectomy. Can J Anaesth 2006; 53:202-7. [PMID: 16434763 DOI: 10.1007/bf03021828] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Ischemic brainstem stroke resulting from occlusion of the basilar artery during cervical spine surgery in a previously asymptomatic patient is a rare event. We report the development of a large ischemic brainstem stroke, resulting from occlusion of the basilar artery during anterior cervical discectomy, in a patient without previous neurological deficit, or signs of vertebrobasilar insufficiency. CLINICAL FEATURES A 55-yr-old, diabetic and hypertensive male who developed a cervical spine infection, underwent surgery for anterior discectomy at C5-C6. During the 2.5-hr long procedure the patient was lying supine with his neck hyperextended. Except for a temporary reduction in systolic blood pressure, the intraoperative course was uneventful. At the end of surgery the patient remained unconscious with flaccid paralysis in all extremities, fixed pinpoint pupils, low respiratory rate, and no response to painful stimuli. Naloxone administration did not improve the clinical picture, while brain computed tomography showed a large brainstem and cerebellar stroke, implicating basilar artery occlusion. The patient died five days later from stroke complications. Intraoperative surgical manipulation with a severely inflamed vertebral system, as well as prolonged neck hyperextension occluding the blood flow of vertebrobasilar arteries might have contributed to fatal brainstem stroke in this patient. CONCLUSION Neck surgery carries a potential risk for posterior circulation stroke, and this report heightens awareness of this rare, but serious complication.
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Affiliation(s)
- Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Tao Yuan, Taiwan
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42
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Coetzee A, Levin A. Is a rethink of our approach to hypertension necessary? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2005. [DOI: 10.1080/22201173.2005.10872411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Paciaroni M, Caso V, Acciarresi M, Baumgartner RW, Agnelli G. Management of asymptomatic carotid stenosis in patients undergoing general and vascular surgical procedures. J Neurol Neurosurg Psychiatry 2005; 76:1332-6. [PMID: 16170071 PMCID: PMC1739358 DOI: 10.1136/jnnp.2005.066936] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Current available data do not seem to support the strategy for carotid endarterectomy prior to surgical intervention in patients with asymptomatic carotid stenosis. However, in patients with coronary artery disease, synchronous carotid endarterectomy and coronary artery bypass grafting should be considered where there is a proven surgical risk of <3% with unilateral asymptomatic stenosis >60% or bilateral carotid stenosis >75% on the same side as the most severe stenosis. Clarification of the optimal strategy requires an adequately powered, multicentre, randomised clinical trial.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, University of Perugia, Ospedale Silvestrini, Sant'Andrea delle Fratte, Perugia 06126, Italy.
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44
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Vink R, Rienstra M, van Dongen CJJ, Levi M, Büller HR, Crijns HJ, van Gelder IC. Risk of thromboembolism and bleeding after general surgery in patients with atrial fibrillation. Am J Cardiol 2005; 96:822-4. [PMID: 16169369 DOI: 10.1016/j.amjcard.2005.05.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 05/11/2005] [Accepted: 05/11/2005] [Indexed: 11/19/2022]
Abstract
We provide insight into the risk of perioperative thromboembolism and bleeding in patients who have atrial fibrillation, use anticoagulants, and undergo a surgical procedure. Ninety-four patients underwent 121 noncardiac operations during a mean follow-up of 29 months. There was a 3.6-fold increased risk for all bleeding complications within 1 month after surgery compared with the control period (95% confidence interval 1.05 to 12.0). No thromboembolic event occurred in the first month after surgery compared with 11 events in the remaining period (0.4% per month).
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Affiliation(s)
- Roel Vink
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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45
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Reeves ST, Reves J. Anesthesia and Hypertension. Hypertension 2005. [DOI: 10.1016/b978-0-7216-0258-5.50167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Affiliation(s)
- David S Warner
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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47
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Verbrugge SJC, Klimek M, Klein J. Ein zerebraler Grenzzoneninfarkt nach Allgemeinan�sthesie bei einem Patienten mit erh�hten Antikardiolipinantik�rpern. Anaesthesist 2004; 53:341-6. [PMID: 15088096 DOI: 10.1007/s00101-003-0644-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
During the first generalised epileptic attack, a patient suffered a humerus fracture which necessitated an operation. This patient also had a history of spontaneous lung emboli and an elevated anti-cardiolipin plasma level for which coumarin was prescribed but was stopped preoperatively. After induction of general anaesthesia for a total shoulder arthroplasty, the patient became hypotensive and the bispectral index recorded perioperatively dropped to 0. Postoperatively, the patient developed signs of a unilateral borderzone cerebral infarct in the area of the medial cerebral artery. The possible pathomechanisms involved are discussed. In cases of known cerebral pathology intraoperative hypotension should be avoided by at all costs. Patients with increased anti-cardiolipin antibody levels and who suffer from epileptic attacks have an increased risk of thromboembolic events.
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Affiliation(s)
- S J C Verbrugge
- Afdeling Anesthesiologie, Erasmus MC, Rotterdam, Netherlands.
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48
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Abstract
UNLABELLED Rarely, cancer invades a pulmonary vein and subsequently embolizes to the cerebral circulation, causing a stroke. Tumor embolism typically involves large, centrally located lung tumors. We report a case of immediate postoperative stroke caused by an arterial tumor embolism during pulmonary resection of metastatic sarcoma. This case is unique because the resected lesions were smaller than those previously associated with tumor embolism and unusual in that the tumors were peripherally located. Tumor embolization should be considered in the differential diagnosis of stroke after lung cancer surgery even with small, peripherally located pulmonary malignancies. IMPLICATIONS We present a case of stroke diagnosed in the recovery room after lung cancer resection. The cause of the stroke was tumor that embolized from the lung to the middle cerebral artery. Tumor embolism should be considered in the differential diagnosis of immediate postoperative stroke after lung cancer surgery.
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Affiliation(s)
- Douglas V Brown
- Department of Anesthesiology, Rush Medical College, Rush University Medical Center, Chicago, Illinois 60612, USA.
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49
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Blacker DJ, Flemming KD, Link MJ, Brown RD. The preoperative cerebrovascular consultation: common cerebrovascular questions before general or cardiac surgery. Mayo Clin Proc 2004; 79:223-9. [PMID: 14959917 DOI: 10.4065/79.2.223] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
All types of health care providers may be called on to evaluate the risk of ischemic stroke related to an upcoming surgical procedure, particularly in patients with established cerebrovascular disease. We outline possible mechanisms contributing to perioperative stroke, summarize available data on the stroke risk associated with selected surgeries, and highlight recognized risk factors. We then provide recommended answers to some of the questions commonly encountered at the preoperative cerebrovascular consultation: What is the appropriate time interval between a stroke and elective surgery? What is the perioperative stroke risk for patients with established carotid or vertebrobasilar large artery stenosis, and what are the cardiac implications of detecting a cerebrovascular large artery stenosis? Should patients with a large artery stenosis undergo prophylactic revascularization procedures before undergoing general surgery? What treatment is appropriate for patients with both coronary artery and carotid or vertebrobasilar large artery stenosis? What is the appropriate perioperative management of antiplatelet and anticoagulant medications with respect to stroke risk?
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Affiliation(s)
- David J Blacker
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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50
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Abstract
Between 6.5% and 15.0% of all strokes occur in patients already in hospital, many of whom are there for surgical procedures or cardiac disorders. This important group of patients could potentially be assessed more rapidly than others and could be candidates for interventional therapies. However, delays in recognition and assessment are common, possibly related to comorbidities and the complexities of hospital practice. Risk factors for in-hospital stroke include specific operations and procedures (eg, cardiac surgery), previous medical disorders (especially a history of stroke), and certain physiological characteristics (including fever and dehydration). The stroke subtype is embolic in a large proportion, and there are various possible precipitating mechanisms. Outcome can be poor, with high mortality. Interventional therapies, particularly thrombolysis, are possible options. In the postoperative setting, intra-arterial thrombolysis is feasible and reasonably safe in carefully selected patients. Experimental agents and the manipulation of physiological variables are other treatment possibilities that could be applied early in this group of patients. Increasing the awareness by hospital physicians of such interventions may be an important factor that reduces delays in assessment of patients who have stokes while in hospital.
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Affiliation(s)
- David J Blacker
- Department of Neurology and Clinical Neurophysiology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia.
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