Perioperative
Stroke
Brian Katz MD
Neurovascular Fellow
University of Cincinnati Medical Center
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
Disclosures
• No financial Disclosure
• Pictures/Caricatures: Google
• Off label medications:
o IV IA therapy
Outline of Presentation
Prevention and Treatment of
Stroke Complicating Surgery
?
Evidence
Answer/Recommendations
KATZ UNIVERSITY
• READ OTHER JOURNALS!!!!
Outline of Presentation
What is the Definition of
Perioperative Stroke?
An updated definition of stroke
st
for the 21 century
World Health Organization 1970:
“neurologic deficit of cerebrovascular cause that persists
beyond 24 hours…”
AHA/ASA 2013:
Sacco RL, et al. Stroke. 2013;44:2064–2089.
“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.”
Society of Neuroscience in
Anesthesiology and CC 2014
“Brain infarction of ischemic or hemorrhagic etiology that
occurs during surgery or within 30 days after surgery”
Mashour GA et al. J Neurosurg Anesthesiol 2014;00:000–000.
Perioperative Stroke
Definition
“Owning”
Perioperative Stroke
When do most perioperative
strokes occur in relation to the
operation?
Timing of stroke in noncarotid
major vascular surgery
Sharifpour, Anesth Analg 2013;116(2):424-34
Recognition of postoperative
stroke is frequently delayed
Weightman ASA 2012 Abstract A476
40
35
# of Strokes
30
Medical Recognition to
Imaging Time
25
20
Last Known Normal to
Imaging Time
15
10
5
0
0-3
3-8
≤24
≤48
Hours post-surgery
>48
Are stroke subtypes different in
perioperative stroke than the
general population?
Mechanisms of
Perioperative Stroke
Ischemic
Hemorrhagic
“General” Strokes
80%
Perioperative Strokes
Ischemic
Ischemic
Hemorrhagic
Hemorrhagic
SAH
99%
SAH
Classification of Subtypes of
Acute Ischemic Stroke
Stroke subtypes in General Population
Stroke subtypes in postoperative stroke
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•
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•
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White, Circulation 2005;111:1327-1331
Cardiac Surgery
Embolic: 60%
Hypoperfuson:12%
Thrombotic: 3%
Multiple Etiology: 10%
Cryptogenic: 15%
General Surgery (9)
Thrombosis: 0-51%
Emboli: 20-57%
Hypoperfusion: 0-44%
Cryptogenic: 6-25%
Julie L et al Anesthesiology 2011; 115:879 –90
What is the incidence of
perioperative stroke in the
general population?
Incidence of Perioperative Stroke in
Surgical Patients
General Surgery:
Carotid Surgery:
Brooks DC, et al. Perioperative Stroke: Risk Assessment, Prevention and Treatment.
Curr Treat Options Cardio Med (2014) 16:282
Incidence of Perioperative Stroke in
Surgical Patients
Cardiac Surgery:
Brooks DC, et al. Perioperative Stroke: Risk Assessment, Prevention and Treatment.
Curr Treat Options Cardio Med (2014) 16:282
What are the risk factors for
perioperative stroke?
Mechanisms of Stroke
Comorbidities:
Perioperative Events:
1. Age
1. Antiplatelet cessation
2. TIA/stroke
2. Statin cessation
3. Afib
3. Afib
4. Renal disease
4. Hypotension
5. Female sex
5. Dehydration
6. Cardiac disease
6. Hypercoagulable state
High Risk Procedures:
7. Hypertension
7. Inflammatory response
8. Tobacco 1. CEA
2. Cardiopulmonary bypass
3. Open heart
4. Aortic Arch
Moore, Neurologic Outcomes of Surgery and Anesthesia, Cambridge Press 2013
Cumulative Risk of Stroke
Stroke incidence 1.9%, OR 21
Mashour Anesthesiology 2011;114(6): 1289-96
1-2-3 Rule
Type of patient Type of
Surgery
% of Strokes
Regular
General
< 1%
“Vasculopath”
General
< 2%
Prior Stroke
General
< 3%
Is Perioperative Stroke
important to study ?
# of surgical procedures daily at UCMC
100-150 surgeries requiring an OR
at UCMC on work day.
Not including: endoscopy, catheter
lab, dentistry, etc.
Stroke Mortality Facts
Yearly Mortality Rate
Typical Stroke
Perioperative Stroke
Prior stroke w/ periop stroke
8-12.6%
26%
10-87%
Katz University
• Bimodal distribution: 48 hours
o <48 hours -- Only few are time eligible for tPA
• Mainly Ischemic => Embolic
• Increase Mortality
• RF: Surgical type, Prior Stroke, Age, and
Atrial Fibrillation
How long should
general surgery requiring
general anesthesia be
delayed after a stroke?
Perioperative stroke
Surgical delay
Mashour GA, et al. J Neurosug Anesthesiol 2014: 00:000-000
How long should general surgery under anesthesia be
delayed after a stroke?
Neurology exam/ evaluation Identify stroke mechanism
prior to elective surgery
How long should general surgery under anesthesia be
delayed after a stroke?
Delay Surgery Theory
Elective surgery 1-3 weeksmonths
Autoregulation impairment
Theoretical Risk
Hypotension: Anesthesia or
surgical (hemorrhage, anemia,
hypotension)
Use this time:
“Cool off the brain”
Discover the mechanism
Opinion-based evidence, Category A
Blacker DJ Mayo Clin Proc. 2004;79: 223–229.
BrownRD Mayo Clin Proc 19494;69:1027-1039
Retrospective Evidence
173 surgical pts w/ a recent &
remote stroke found no
relationship between
timing of stroke history
& incidence of
perioperative stroke.
Orthopedic pt s/p stroke or
ACS: stroke w/in 6
months prior to surgery
was not a predictor of
postop mortality.
Category B, Level 2
Landercasper J Surg. 1990;125:986–989.
Sanders RD, Ann Surg. 2012;255:901–907.
How long should general surgery under anesthesia be
delayed after a stroke?
Delay Surgery Theory
Retrospective Evidence
Elective surgery 1-3 weeks173 surgical pts w/ a recent &
months
remote stroke found no
Autoregulation impairment
relationship between
Theoretical Risk
timing of stroke history
Hypotension: Anesthesia or
& incidence of
surgical (hemorrhage, anemia,
perioperative stroke.
hypotension)
Orthopedic pt s/p stroke or
Use this time:
ACS: stroke w/in 6
“Cool off the brain”
months prior to surgery
Discover the mechanism
was not a predictor of
Opinion-based evidence, Category A
postop mortality.
Category B, Level 2
Blacker DJ Mayo Clin Proc. 2004;79: 223–229.
Brown RD Mayo Clin Proc 19494;69:1027-1039
Landercasper J Surg. 1990;125:986–989.
Sanders RD, Ann Surg. 2012;255:901–907.
How long should general surgery under anesthesia be
delayed after a stroke?
• 173 surgical pts w/ a recent and remote stroke
• No relationship between timing of stroke history and
incidence of perioperative stroke
o Unclear what prior stroke mechanism
• 2.9% risk of stroke when patients underwent subsequent
general surgeries.
• Published in 1990… Medicine has come a long way
o MOST IMPORTLY => CEA, statin, various antiplatelets
Landercasper J, ArchSurg. 1990;125:986-989.
What is the surgical delay for CABG
following ischemic stroke?
Timing of Cardiac
Surgery after Stroke
• Delay Surgery Theory
• Retrospective Evidence
• Cardiac surgical patients; the time interval between
stroke and coronary artery bypass graft surgery was not
found to be a predictor of postoperative stroke or
mortality.
Bottle A, Anesthesiology.2013;118:885–893.
Is Stroke a Contraindication for
Urgent Valve Replacement in
Acute Infective Endocarditis?
Katz University
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Timing of Surgery
Neurologist => Stroke Mechanism
? Autoregulation post stroke ?
General Surgery and CABG
Carotid: < 2 weeks (prefer <1 week)
IE: No Hemorrhage < 1 week
Hemorrhage > 4 weeks
What should we do about
anti-platelets prior to surgery?
Aspirin following cardiac surgery
Mangano NEJM 2002;347:1309
Management of Anti-platelet Rx in
General Surgery
Rebound
Hypercoagulability
Bleeding
Complications
Limited data to guide management of this
situation that pertain specifically to perioperative stroke.
Management of Anti-platelet Rx in
General Surgery
Bleeding
Complications
Limited data to guide management of this
situation that pertain specifically to perioperative stroke.
Management of Anti-Anti-platet Rx in
General Surgery
Darvish-Kazem S, Semin Thromb
Hemost. 2012;38:652–660.
Management of Anti-platelet Rx in
General Surgery
April, 2014
Management of Anti-platelet Rx in
General Surgery
“Vascular”
Patients
Baseline
5% Stroke
DB RCT
Cont. ASA
On ASA
4998
Study Drug Timing:
3 days prior to
surgery to 30 days
post-surgery
Placebo
10,010
Initiated ASA
No ASA
1:1 Randomization
5012
Placebo
Devereaux J. POISE 2. NEJM 2014
Management of Anti-platelet Rx in
General Surgery
81.7%
82.9%
Devereaux J. POISE 2. NEJM 2014
Management of Anti-platelet Rx in
General Surgery
Vascular
Patients
Baseline
5% Stroke
DB RCT
Cont. ASA
On ASA
4998
Placebo
10,010
Initiated ASA
Outcomes:
Neutral: Mortality and
non-fatal MI
All Incidence Stroke:
ASA: 16 (0.3)
None: 19 (0.4)
p= 0.62
No ASA
5012
Placebo
Devereaux J. POISE 2. NEJM 2014
Management of Anti-platelet Rx in
General Surgery
Vascular
Patients
Baseline
5% Stroke
DB RCT
Outcomes:
Cont. ASA
On ASA
4998
Placebo
10,010
Initiated ASA
No ASA
5012
Site and Major
Bleeding
(life threatening bleeding
was neutral)
Placebo
Devereaux J. POISE 2. NEJM 2014
Management of Anti-platelet Rx in
General Surgery
Devereaux J. POISE 2. NEJM 2014
Management of Anti-platelet Rx in
General Surgery
Vascular
Patients
Baseline
5% Stroke
DB RCT
Cont. ASA
On ASA
Secondary Endpoints:
New AKI ->
Dialysis
4998
Placebo
10,010
Initiated ASA
Decrease stroke
No ASA
5012
Placebo
Devereaux J. POISE 2. NEJM 2014
Before you raise your hand
• Just published=> no spin-off publications yet!
• No specifics about:
o Risks/bleed % for individual surgery types
o Prior stroke and TIA patients and their outcomes.
Before you raise your hand
• Just published=> no spin-off publications yet!
• No specifics about:
o Risks/bleed % for individual surgery types
o Prior stroke and TIA patients and their outcomes.
• SNACC 2014 Guidelines:
o No Evidence to suggest that continuation of ASA
in patients at risk for vascular complication
reduces the risk of stroke after noncardiac
surgeries (Category A, Level A)
o Is this applicable to our stroke pts????
Management of Anti-platelet Rx in
General Surgery
Rebound
Hypercoagulability
Limited data to guide management of this
situation that pertain specifically to perioperative stroke.
Effects of antiplatelet
therapy withdrawal
• Population-based ~5% of ischemic
strokes are ~ w/ withdrawal of AT w/in
60 days of onset.
o Antiplatelet vs Warfarin withdrawal
o ?Stroke risk in Withdrawal of only Antiplatelet ?
o EASIER SAID THAN DONE
Broderick JP Stroke 2012
For patients on warfarin who
should receive bridging therapy?
Patients in atrial fibrillation with h/o
of stroke or TIA within 6 months
Pt w/ A fib on anticoagulation
undergoing general surgery
Warfarin
Opinion-based evidence
Category A
• BRIDGE Study
o Enrollment stopped
• PERIOP 2 Study
o Almost done enrolling
Darvish-Kazem S, Semin Thromb Hemost. 2012;38:652–660.
Douketis JD, Chest. 2012;141:e326S–e350S.
Baron TH, N Engl J Med. 2013;368:2113–2124
Katz University
• Surgery type => Talk to Surgeon
• Acutely stopping Rx => Rebound hypercoag
Aspirin
• Stroke patients => Stay on aspirin
• Respect aspirin’s bleeding risk
Warfarin
• I follow bridging guidelines; mostly.
• Watch for those 2 RCT
Does Asymptomatic
Carotid Artery Stenosis Predict
Perioperative Stroke After
Non-cardiac Surgery?
Carotid Revascularization prior to
General Surgery ???
# of surgical procedures daily at UCMC
100-150 surgeries requiring an OR
at UCMC on work day
Prevalence of Asymptomatic Carotid Stenosis
Moderate
Severe
Brooks DC, et al. Perioperative Stroke: Risk Assessment, Prevention and Treatment.
Curr Treat Options Cardio Med (2014) 16:282
Carotid Revascularization prior to
General Surgery???
2005 RCT
CCF 5 year experience
• “Major Vascular” Surgeries • “noncardiac surgery”
• 5-year period 2110 pts
• 40 per-op CEA vs. 39 control • Carotid U/S
o 13% >70% stenosis
• Results:
o 30 day follow up
o No perioperative strokes or death
o 37%: >50-69%
o 50%: <50%
• No association of carotid
artery stenosis and periop
Stroke
o No stenosis cut off
• Carotid artery stenosis
was not associated with
postoperative MI
Ballotta E, et al Ann Vasc Surg. 2005 Nov;19(6):876-81.
Sony, A et al. Anesthesiology. 2014 Nov;12
Does Symptomatic
Intracranial Stenosis Predict
Perioperative Stroke After
Non-Cardiac Surgery?
N= 38
50 operations w/ gen anesthesia
3 ischemic strokes
- Prolonged hypotension
- SBP <100 mmHg for > 10 min
6.0% stroke risk / surgery
Katz University
• Asymptomatic => No Touch
• Symptomatic => Treat underlying
mechanism
• Avoid Hypotension (easier said than done)
Intraoperative Recommendations
Does the type of anesthesia
change your stroke risk?
Stroke reduced with Neuroaxial
Anesthesia in THR & TKR
Memtsoudis, Anesthesiology 2013;118(5):1046-1058
Types of Anesthetics for
Carotid Surgery?
What about intraoperative
medications and stroke risk?
Intraoperative Beta-Blockers
(metoprolol) in General Surgery
Lancet 2008;371(9627):1839-47
Perioperative metoprolol and
perioperative stroke
Mashour Anesthesiology 2013
Perioperative Stroke with
various Beta Blockers
Metoprolol
Atenolol
Bisoprolol
Ashes, Anesthesiology 2013;119(4):777-787
Why Metoprolol?
?
What about intraoperative
hypotension and stroke risk?
The role of intraoperative hypotension
in postoperative stroke
Bijker Anesthesiology 2012;116(3):658-64
• “Unusually low blood pressure will eventually result
in neurological damage …”
• Threshold and duration at which an association
might be found between a perioperative stroke and
hypotension have not been well investigated…
• “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
Katz University
• Avoid introducing Beta Blockers in surgery
• Use Regional Anesthesia if possible
• Avoid Intraoperative Hypotension
o General Population vs. Complex Stroke Patient
What acute treatments can we
provide for
acute ischemic strokes in the
perioperative state?
Recognition of postoperative
stroke is frequently delayed
Weightman ASA 2012 Abstract A476
40
35
# of Strokes
30
Medical Recognition to
Imaging Time
25
20
Last Known Normal to
Imaging Time
15
10
5
0
0-3
3-8
≤24
≤48
Hours post-surgery
>48
Acute Revascularization Tools
Perioperative stroke
Bleeding
Mashour GA, et al. J Neurosug Anesthesiol 2014: 00:000-000
Acute Revascularization Tools
Katz University
• S/P “Major Surgery” IV tPA is contraindicated
• If Large Vessel Occlusion (NIHSS >10) strongly
consider IA treatments.
Generally Safe (except in post-craniotomy pts)
Conclusions
• Perioperative stroke is rare but potentially
devastating
• Associated co-morbidities are well-defined
• Intraoperative associations are not welldefined
• Improved recognition of postoperative
stroke is necessary before acute intervention
can be considered
Questions