.. .. Webdocs Slideshow PV 2014 Moore Perioperative Stroke

8/10/2019 .. .. Webdocs Slideshow PV 2014 Moore Perioperative Stroke

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Perioperative

StrokeLaurel MooreAssociate ProfessorDirector, Division of Neuroanesthesiology

University of Michigan


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Learning Objectives Mechanisms and timing of stroke

Procedures and comorbidities associated withperioperative stroke

Clinical management options that mayreduce theincidence of perioperative stroke

Significance of early recognition and treatment ofstroke in the postoperative patient


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Outline of Presentation

Brief Review of Perioperative Stroke Preoperative risk reduction

Intraoperative risk reduction

Postoperative recognition and possibletreatment options


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Why care about perioperative stroke?

Perioperative Complication Incidence (range)%

Myocardial infarction 0.0005-5.1

Stroke0.1-3.0

Postoperative visual loss 0.1-0.2


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Incidence of stroke by

procedure

Surgical Procedure Incidence (%)

Noncardiac nonneurologic1

0.1Total hip arthroplasty2 0.2

Vascular noncarotid3, 20 0.4-0.8

Vascular carotid27 0.9

Coronary artery bypass

19, 60

2.0-3.1Double and triple valve replacement61 9.7

Aortic arch procedures with DHA4 19.2


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An updated definition of

stroke for the 21stcenturyWorld Health Organization 1970:

neurologic deficit of cerebrovascular cause that

persists beyond 24 hours

AHA/ASA 2013:

CNS infarction is defined as brain, spinal cord orretinal cell death attributable to ischemia, based on

neuropathological, neuroimaging, and/or

clinical evidence of permanent injury.


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Mechanisms of

Perioperative Stroke

Ischemic

Hemorrhagic


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Classification of Subtypes of

Acute Ischemic Stroke

(TOAST Stroke 1993;24:35-41)

White, Circulation 2005;111:1327-1331


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Watershed Infarction

Bijker, Can J Anaesth 2013;60(2):159-67


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Mechanisms of Stroke

Moore, Neurologic Outcomes of Surgery and Anesthesia, Cambridge Press 2013

Comorbidities:

1. Age

2. TIA/stroke

3. Renal disease4. Female sex

5. Cardiac disease

6. Hypertension

7. Afib

8. Tobacco

High Risk Procedures:

1. CEA2. Cardiopulmonary bypass

3. Open heart

4. Aortic Arch

Perioperative Events:

1. Antiplatelet cessation

2. Statin cessation

3. Afib4. Hypotension

5. Dehydration

6. Hypercoagulable state

7. Inflammatory response


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Cumulative Risk of Stroke

Mashour Anesthesiology 2011;114(6): 1289-96

High Risk 5 risk factors

Stroke incidence 1.9%, OR 21


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Timing of Stroke in THR

Lalmohamed Stroke 2012;43:3225-3229


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Timing of stroke in noncarotid

major vascular surgery

Sharifpour, Anesth Analg 2013;116(2):424-34


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Brief Review of Stroke and Perioperative Stroke

Preoperative risk reduction Intraoperative risk reduction

Postoperative recognition and possible treatment

options

1.Antiplatelet therapy

2.Statin therapy


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Aspirin following cardiac surgeryMangano NEJM 2002;347:1309


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Should ASA be discontinued

preoperatively?

BleedingComplications

CerebrovascularComplications


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Effects of antiplatelettherapy 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


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We should cease offering

TURP in favour ofalternative surgery options

for anticoagulated patientsBritish Journal of Urology International 2011


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For patients on warfarin who

should receive bridging

therapy?

Patients in atrial fibrillation with h/oof stroke or TIA within 6 months


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Primary and Secondary Stroke

Prevention with Statins

Nassief Stroke 2008;39:1042-1048

Primary stroke prevention

Secondary stroke prevention


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As regards perioperative statins:

Prospective randomized trialscannot

be performed anymorebecause all

vascular patients should receive statin

treatment as secondary prevention of

cardiovascular disease.AF Stalenhoef, J Vasc Surg 2009;49(4):1091


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Brief Review of Perioperative Stroke

Preoperative risk reduction

Intraoperative risk reduction Postoperative recognition and possible treatment

options1.Anesthetic technique

2.Use of -blockers

3.Blood pressure management


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Anesthetics as

Neuroprotectants


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Stroke reduced with Neuroaxial

Anesthesia in THR and TKR

Memtsoudis, Anesthesiology 2013;118(5):1046-1058


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Lancet 2008;371(9627):1839-47

POISE Trial 2008


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Association of perioperative

metoprolol and perioperative stroke

Mashour Anesthesiology 2013


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Stroke incidence with anemia

Metoprolol

Atenolol

Bisoprolol

Ashes, Anesthesiology 2013;119(4):777-787


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The role of intraoperative hypotension

in postoperative stroke

Bijker Anesthesiology 2012;116(3):658-64


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A word about the dangers of

the beach chair position


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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 wellinvestigated. 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


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Brief Review of Perioperative Stroke

Preoperative risk reduction

Intraoperative risk reduction

Postoperative recognition andpossible treatment options


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Recognition of postoperative

stroke is frequently delayed

0

5

10

15

20

25

30

35

40

0-3 3-8 24 48 >48

Medical Recognition toImaging Time

Last Known Normal to

Imaging Time

#

of

Strokes

Hours post-surgery

Weightman ASA 2012 Abstract A476


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Time is Brain

Kidwell Stroke 2004;35:2662-2665


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Mechanical Thrombolysis


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Suggestions for clinical

management

Stroke is more common than you think

When possible continue anti-platelet rx

Statins and -blockers should continue


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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 chairposition definitely bad

Nitrous oxide okay


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Intraop management cont.

Patients on -blockers may be

more sensitive to anemia

Short-acting or 1-selective -blockers when possible

Glucose levels 80-150 mg/dL


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Conclusions Perioperative stroke is rare but potentially

devastating

Associated co-morbidities are well-defined

Intraoperative associations are not well-defined

Improved recognition of postoperativestroke is necessary before acute interventioncan be considered


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Perioperative Care of Patients at High Riskfor 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. MooreMD, Abhijit V. Lele MD, Steven A Robicsek MD

PhD, Adrian W. Gelb MBChB

http://www.snacc.org/

.. .. Webdocs Slideshow PV 2014 Moore Perioperative Stroke

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