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Perioperative Stroke

Perioperative Stroke. Laurel Moore Associate Professor Director, Division of Neuroanesthesiology University of Michigan. Learning Objectives. Mechanisms and timing of stroke Procedures and comorbidities associated with perioperative stroke

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Perioperative Stroke

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  1. Perioperative Stroke Laurel Moore Associate Professor Director, Division of Neuroanesthesiology University of Michigan

  2. 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

  3. Outline of Presentation • Brief Review of Perioperative Stroke • Preoperative risk reduction • Intraoperative risk reduction • Postoperative recognition and possible treatment options

  4. Why care about perioperative stroke?

  5. Incidence of stroke by procedure

  6. An updated definition of stroke for the 21stcentury 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.”

  7. Mechanisms of Perioperative Stroke Ischemic Hemorrhagic

  8. Classification of Subtypes of Acute Ischemic Stroke (TOAST Stroke 1993;24:35-41) White, Circulation 2005;111:1327-1331

  9. Watershed Infarction Bijker, Can J Anaesth 2013;60(2):159-67

  10. Mechanisms of Stroke Comorbidities: Age TIA/stroke Renal disease Female sex Cardiac disease Hypertension Afib Tobacco Perioperative Events: Antiplatelet cessation Statin cessation Afib Hypotension Dehydration Hypercoagulable state Inflammatory response High Risk Procedures: CEA Cardiopulmonary bypass Open heart Aortic Arch Moore, Neurologic Outcomes of Surgery and Anesthesia, Cambridge Press 2013

  11. Cumulative Risk of Stroke High Risk ≥ 5 risk factors Stroke incidence 1.9%, OR 21 Mashour Anesthesiology 2011;114(6): 1289-96

  12. Timing of Stroke in THR Lalmohamed Stroke 2012;43:3225-3229

  13. Timing of stroke in noncarotid major vascular surgery Sharifpour, AnesthAnalg 2013;116(2):424-34

  14. Outline of Presentation • Brief Review of Stroke and Perioperative Stroke • Preoperative risk reduction • Intraoperative risk reduction • Postoperative recognition and possible treatment options Antiplatelet therapy Statin therapy

  15. Aspirin following cardiac surgeryMangano NEJM 2002;347:1309

  16. Should ASA be discontinued preoperatively? Cerebrovascular Complications Bleeding Complications

  17. 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

  18. “We should cease offering TURP in favour of alternative surgery options for anticoagulated patients” British Journal of Urology International 2011

  19. For patients on warfarin who should receive bridging therapy? Patients in atrial fibrillation with h/o of stroke or TIA within 6 months

  20. Primary and Secondary Stroke Prevention with Statins Primary stroke prevention Secondary stroke prevention Nassief Stroke 2008;39:1042-1048

  21. AF Stalenhoef, J Vasc Surg 2009;49(4):1091 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.”

  22. Outline of Presentation • Brief Review of Perioperative Stroke • Preoperative risk reduction • Intraoperative risk reduction • Postoperative recognition and possible treatment options • Anesthetic technique • Use of β-blockers • Blood pressure management

  23. Anesthetics as Neuroprotectants

  24. Stroke reduced with Neuroaxial Anesthesia in THR and TKR Memtsoudis, Anesthesiology 2013;118(5):1046-1058

  25. POISE Trial 2008 Lancet 2008;371(9627):1839-47

  26. Association of perioperative metoprolol and perioperative stroke Mashour Anesthesiology 2013

  27. Stroke incidence with anemia Metoprolol Atenolol Bisoprolol Ashes, Anesthesiology 2013;119(4):777-787

  28. The role of intraoperative hypotension in postoperative stroke Bijker Anesthesiology 2012;116(3):658-64

  29. A word about the dangers of the beach chair position…

  30. “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 Gelb Can J Anaesth 2013;60(2):159-67

  31. Outline of Presentation • Brief Review of Perioperative Stroke • Preoperative risk reduction • Intraoperative risk reduction • Postoperative recognition and possible treatment options

  32. Recognition of postoperative stroke is frequently delayed Weightman ASA 2012 Abstract A476 # of Strokes Hours post-surgery

  33. “Time is Brain” Kidwell Stroke 2004;35:2662-2665

  34. Mechanical Thrombolysis

  35. Suggestions for clinical management • Stroke is more common than you think • When possible continue anti-platelet rx • Statins and β-blockers should continue

  36. 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

  37. 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

  38. 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

  39. 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 Stroke George A. Mashour MD PhD, Laurel E. Moore MD, Abhijit V. Lele MD, Steven A Robicsek MD PhD, Adrian W. Gelb MBChB http://www.snacc.org/

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