Upload
evangeline-young
View
215
Download
0
Embed Size (px)
Citation preview
Perioperative Stroke
Laurel MooreAssociate Professor
Director, Division of NeuroanesthesiologyUniversity of Michigan
Learning Objectives• Mechanisms and timing of stroke• Procedures and comorbidities associated
with perioperative stroke• Clinical management options that may
reduce the incidence of perioperative stroke • Significance of early recognition and
treatment of stroke in the postoperative patient
Outline of Presentation
• Brief Review of Perioperative Stroke
• Preoperative risk reduction• Intraoperative risk reduction• Postoperative recognition and
possible treatment options
Why care about perioperative
stroke?
Perioperative Complication
Incidence (range)%
Myocardial infarction 0.0005-5.1
Stroke 0.1-3.0
Postoperative visual loss 0.1-0.2
Incidence of stroke by procedure
Surgical Procedure Incidence (%)
Noncardiac nonneurologic1 0.1
Total hip arthroplasty2 0.2
Vascular noncarotid3, 20 0.4-0.8
Vascular carotid27 0.9
Coronary artery bypass19, 60 2.0-3.1
Double and triple valve replacement61 9.7Aortic arch procedures with DHA4 19.2
An updated definition of stroke for the 21st century
World Health Organization 1970:“neurologic deficit of cerebrovascular cause
that persists beyond 24 hours…”
AHA/ASA 2013:“CNS infarction is defined as brain, spinal cord or retinal cell death attributable to ischemia,
based on neuropathological, neuroimaging, and/or clinical evidence of
permanent injury.”
Mechanisms of Perioperative Stroke
Ischemic
Hemorrhagic
Classification of Subtypes of Acute Ischemic Stroke
(TOAST Stroke 1993;24:35-41)
White, Circulation 2005;111:1327-1331
Watershed Infarction
Bijker, Can J Anaesth 2013;60(2):159-67
Mechanisms of Stroke
Moore, Neurologic Outcomes of Surgery and Anesthesia, Cambridge Press 2013
Comorbidities:1. Age2. TIA/stroke3. Renal disease4. Female sex5. Cardiac disease6. Hypertension7. Afib8. Tobacco
High Risk Procedures:1. CEA2. Cardiopulmonary bypass3. Open heart4. Aortic Arch
Perioperative Events:1. Antiplatelet cessation2. Statin cessation3. Afib4. Hypotension5. Dehydration6. Hypercoagulable state7. Inflammatory response
Cumulative Risk of Stroke
Mashour Anesthesiology 2011;114(6): 1289-96
High Risk ≥ 5 risk factors
Stroke incidence 1.9%, OR 21
Timing of Stroke in THR
Lalmohamed Stroke 2012;43:3225-3229
Timing of stroke in noncarotid major vascular surgery
Sharifpour, Anesth Analg 2013;116(2):424-34
Outline of Presentation• Brief Review of Stroke and Perioperative
Stroke
• Preoperative risk reduction• Intraoperative risk reduction• Postoperative recognition and possible
treatment options
1.Antiplatelet therapy2.Statin therapy
Aspirin following cardiac surgery
Mangano NEJM 2002;347:1309
Should ASA be discontinued preoperatively?
Bleeding Complications
Cerebrovascular Complications
Effects of antiplatelet therapy withdrawal
• Rebound in platelet activity with abrupt cessation
• 5% of nonoperative ischemic stroke associated with withdrawal of antiplatelet therapy
• Strokes generally occur within 2 weeks of antiplatelet cessation
“We should cease offering TURP in favour of alternative surgery
options for anticoagulated
patients”British Journal of Urology International
2011
For patients on warfarin who should receive bridging therapy?
Patients in atrial fibrillation with h/o of stroke or TIA within
6 months
Primary and Secondary Stroke
Prevention with Statins
Nassief Stroke 2008;39:1042-1048
Primary stroke prevention
Secondary stroke prevention
As regards perioperative statins:
“Prospective randomized trials…cannot
be performed anymore…because all
vascular patients should receive statin
treatment as secondary prevention of
cardiovascular disease.”AF Stalenhoef, J Vasc Surg 2009;49(4):1091
Outline of Presentation• Brief Review of Perioperative Stroke• Preoperative risk reduction
• Intraoperative risk reduction• Postoperative recognition and possible
treatment options1.Anesthetic technique2.Use of β-blockers3.Blood pressure management
Anesthetics as Neuroprotectants
Stroke reduced with Neuroaxial
Anesthesia in THR and TKR
Memtsoudis, Anesthesiology 2013;118(5):1046-1058
Lancet 2008;371(9627):1839-47
POISE Trial 2008
Association of perioperative metoprolol and perioperative stroke
Mashour Anesthesiology 2013
Stroke incidence with anemia
Metoprolol
Atenolol
Bisoprolol
Ashes, Anesthesiology 2013;119(4):777-787
The role of intraoperative hypotension in postoperative stroke
Bijker Anesthesiology 2012;116(3):658-64
A word about the dangers of the beach
chair position…
“Unusually low blood pressure will eventually result in neurological damage;
however, the threshold and duration at which an association might be found between a perioperative stroke and
hypotension have not been well investigated. Thus, the exact role of
hypotension in the etiology of perioperative stroke is still largely unknown.”
Bijker and GelbCan J Anaesth 2013;60(2):159-67
Outline of Presentation
• Brief Review of Perioperative Stroke• Preoperative risk reduction• Intraoperative risk reduction
• Postoperative recognition and possible treatment options
Recognition of postoperative stroke is frequently delayed
0-3 3-8 ≤24 ≤48 >48 0
5
10
15
20
25
30
35
40
Medical Recognition to Imaging Time
Last Known Normal to Imaging Time
# of
Str
okes
Hours post-surgery
Weightman ASA 2012 Abstract A476
“Time is Brain”
Kidwell Stroke 2004;35:2662-2665
Mechanical Thrombolysis
Suggestions for clinical management
• Stroke is more common than you think
• When possible continue anti-platelet rx
• Statins and β-blockers should continue
Suggestions for Intraoperative management
• Blood pressure goals should be assessed as % variance from baseline
• Prolonged hypotension probably bad• Normocapnia probably good• Induced hypotension for beach chair
position definitely bad• Nitrous oxide okay
Intraop management cont.
• Patients on β-blockers may be more sensitive to anemia
• Short-acting or β1-selective β-blockers when possible
• Glucose levels 80-150 mg/dL
Conclusions
• Perioperative stroke is rare but potentially devastating
• Associated co-morbidities are well-defined
• Intraoperative associations are not well-defined
• Improved recognition of postoperative stroke is necessary before acute intervention can be considered
Perioperative Care of Patients at High Risk for Stroke after Non-
Cardiac, Non-Neurologic Surgery: Guidelines from the Society for
Neuroscience in Anesthesiology and Critical Care
SNACC Task Force on Perioperative StrokeGeorge A. Mashour MD PhD, Laurel E. Moore MD, Abhijit V. Lele MD, Steven A Robicsek MD
PhD, Adrian W. Gelb MBChBhttp://www.snacc.org/