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Mavridis T, Choratta T, Papadopoulou A, Sawafta A, Archontakis-Barakakis P, Laou E, Sakellakis M, Chalkias A. Protease-Activated Receptors (PARs): Biology and Therapeutic Potential in Perioperative Stroke. Transl Stroke Res 2025; 16:933-951. [PMID: 38326662 DOI: 10.1007/s12975-024-01233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/12/2024] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
Perioperative stroke is a devastating complication that occurs during surgery or within 30 days following the surgical procedure. Its prevalence ranges from 0.08 to 10% although it is most likely an underestimation, as sedatives and narcotics can substantially mask symptomatology and clinical presentation. Understanding the underlying pathophysiology and identifying potential therapeutic targets are of paramount importance. Protease-activated receptors (PARs), a unique family of G-protein-coupled receptors, are widely expressed throughout the human body and play essential roles in various physiological and pathological processes. This review elucidates the biology and significance of PARs, outlining their diverse functions in health and disease, and their intricate involvement in cerebrovascular (patho)physiology and neuroprotection. PARs exhibit a dual role in cerebral ischemia, which underscores their potential as therapeutic targets to mitigate the devastating effects of stroke in surgical patients.
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Affiliation(s)
- Theodoros Mavridis
- Department of Neurology, Tallaght University Hospital (TUH)/The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, D24 NR0A, Ireland
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528, Athens, Greece
| | - Theodora Choratta
- Department of General Surgery, Metaxa Hospital, 18537, Piraeus, Greece
| | - Androniki Papadopoulou
- Department of Anesthesiology, G. Gennimatas General Hospital, 54635, Thessaloniki, Greece
| | - Assaf Sawafta
- Department of Cardiology, University Hospital of Larisa, 41110, Larisa, Greece
| | | | - Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, 15773, Athens, Greece
| | - Minas Sakellakis
- Department of Medicine, Jacobi Medical Center-North Central Bronx Hospital, Bronx, NY, 10467, USA
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-5158, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
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Lele AV, Moreton EO, Sundararajan J, Blacker SN. Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis. Curr Opin Anaesthesiol 2024; 37:460-469. [PMID: 39011660 DOI: 10.1097/aco.0000000000001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting. RECENT FINDINGS Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued. SUMMARY In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
| | | | | | - Samuel Neal Blacker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA
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He W, Tang P. Management of perioperative anticoagulation in patients with mechanical heart valve replacement undergoing laparoscopic cholecystectomy: a case report of postoperative cerebral embolism. Front Surg 2024; 11:1404436. [PMID: 39233766 PMCID: PMC11371760 DOI: 10.3389/fsurg.2024.1404436] [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: 03/21/2024] [Accepted: 08/08/2024] [Indexed: 09/06/2024] Open
Abstract
Patients with mechanical heart valve replacement require lifelong anticoagulation therapy, and additional surgeries can pose a risk of bleeding and thromboembolic events due to the need for perioperative anticoagulation management. Here, we present a case report of a patient who underwent laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) after mechanical heart valve replacement and experienced postoperative cerebral embolism. The management of perioperative anticoagulation in these patients is discussed, including strategies for minimizing the risks of bleeding and thromboembolic events during and after surgery.
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Affiliation(s)
- Wei He
- Department of Ophthalmology, Sichuan Taikang Hospital, Chengdu, China
| | - Panli Tang
- Department of Cardiothoracic Surgery, Sichuan Taikang Hospital, Chengdu, China
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Watanabe SN, Imai K, Mitsui M, Ono T, Toda H, Takashima S, Kurihara N, Demura R, Fujibayashi T, Minamiya Y. Proximal ligation technique prevents thrombus formation in the pulmonary vein stump after lobectomy. Surg Today 2024; 54:839-846. [PMID: 38700586 DOI: 10.1007/s00595-024-02846-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/07/2023] [Indexed: 07/24/2024]
Abstract
PURPOSE To assess the risk factors for thrombosis in the pulmonary vein stump (PVT) and the efficacy of proximal ligation in preventing PVT after lobectomy. METHODS In total, 649 surgical patients with lung cancer were retrospectively reviewed. To compare the clinical effectiveness of PV proximal ligation, the simple stapler group (290 patients) and the proximal ligation group (359 patients who underwent thread ligation at the pericardial reflection with/without a stapler) were analyzed. RESULTS In the simple stapler group, 12 of 290 patients (4.1%) developed PVT. Among these, 9 of 58 underwent left upper lobectomy (LUL). In contrast, 5 of the 359 patients (1.4%) in the proximal ligation group developed PVT. All five patients received LUL. The incidence of PVT in the proximal ligation group was significantly lower than that in the simple stapler group (p = 0.0295) as well as in the analysis by LUL alone (p = 0.0263). A logistic regression analysis indicated that higher BMI and LUL were associated with the development of PVT (p = 0.0031, p < 0.0001), and PV proximal ligation reduced PVT (p = 0.0055). CONCLUSION Proximal ligation of the PV has the potential to prevent PVT, especially after LUL.
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Affiliation(s)
- Shin-Nosuke Watanabe
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Kazuhiro Imai
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan.
| | - Masafumi Mitsui
- Department of Thoracic Surgery, Hachinohe City Hospital, 3-1-1 Tamukai, Hachinohe, Aomori, 031-0011, Japan
| | - Takashi Ono
- Department of Thoracic Surgery, Odate Municipal General Hospital, 3-1 Yutakacho, Odate, Akita, 017-0885, Japan
| | - Hiroshi Toda
- Department of Thoracic Surgery, Hachinohe City Hospital, 3-1-1 Tamukai, Hachinohe, Aomori, 031-0011, Japan
| | - Shinogu Takashima
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Nobuyasu Kurihara
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Ryo Demura
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Tatsuki Fujibayashi
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Yoshihiro Minamiya
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
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Valencia Morales DJ, Garbajs NZ, Tawfic SS, Jose T, Laporta ML, Schroeder DR, Weingarten TN, Sprung J. Intraoperative Blood Pressure Variability and Early Postoperative Stroke: A Case-Control Study. Am Surg 2023; 89:5191-5200. [PMID: 36426383 DOI: 10.1177/00031348221136578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND This study aims to assess the association of postoperative stroke with intraoperative hemodynamic variability and transfusion management. METHODS In this case-control study, adult patients (≥ 18 years) who had a stroke within 72 hours of a surgical procedure were matched to 2 control patients according to age, sex, and procedure type. Primary risk factors assessed were intraoperative fluid administration, blood product transfusion, vasopressor use, and measures of variability in systolic and diastolic blood pressure and heart rate: maximum, minimum, range, SD, and average real variability. The variables were analyzed with conditional logistic regression, which accounted for the 1:2 matched case-control study design. RESULTS Among 687 581 procedures, we identified 64 postoperative strokes (incidence, 9.3 [95% CI, 7.2-11.9] strokes per 100 000 procedures). These cases were matched with 128 controls. Stroke cases had higher Charlson cmorbidity index scores than did controls (P = .046). Blood pressure and heart rate variability measures were not associated with stroke. The risk of stroke was increased with red blood cell (RBC) transfusion (odds ratio [OR], 14.82; 95% CI, 3.40-64.66; P < .001), vasopressor use (OR, 3.91; 95% CI, 1.59-9.60; P = .003), and longer procedure duration (OR, 1.23/h; 95% CI, 1.01-1.51; P = .04). Multivariable analysis of procedure duration, RBC transfusion, and vasopressor use showed that only RBC transfusion was independently associated with an increased risk of stroke (OR, 10.10; 95% CI, 2.14-47.72; P = .004). CONCLUSIONS Blood pressure variability was not associated with an increased risk of postoperative stroke; however, RBC transfusion was an independent risk factor.
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Affiliation(s)
| | - Nika Zorko Garbajs
- Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia
| | - Sarah S Tawfic
- Department of Internal Medicine, Mayo Clinic Rochester, Minnesota
| | - Thulasee Jose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Original Research: Practice Variations in Documenting Neurologic Examinations in Non-Neuroscience ICUs. Am J Nurs 2023; 123:24-30. [PMID: 36546384 DOI: 10.1097/01.naj.0000905564.83124.2d] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In critical care units, the neurologic examination (neuro exam) is used to detect changes in neurologic function. Serial neuro exams are a hallmark of monitoring in neuroscience ICUs. But less is known about neuro exams that are performed in non-neuroscience ICUs. This knowledge gap likely contributes to the insufficient guidance on what constitutes an adequate neuro exam for patients admitted to a non-neuroscience ICU. PURPOSE The study purpose was to explore existing practices for documenting neuro exams in ICUs that don't routinely admit patients with a primary neurologic injury. METHODS A single-center, prospective, observational study examined documented neuro exams performed in medical, surgical, and cardiovascular ICUs. A comprehensive neuro exam assesses seven domains that can be divided into 20 components. In this study, each component was scored as present (documentation was found) or absent (documentation was not found); a domain was scored as present if one or more of its components had been documented. RESULTS There were 1,482 assessments documented on 120 patients over a one-week period. A majority of patients were male (56%), White (71%), non-Hispanic (77%), and over 60 years of age (50%). Overall, assessments of the domains of consciousness, injury severity, and cranial nerve function were documented 80% of the time or more. Assessments of the domains of pain, motor function, and sensory function were documented less than 60% of the time, and that of speech less than 5% of the time. Statistically significant differences in documentation were found between the medical, surgical, and cardiovascular ICUs for the domains of speech, cranial nerve function, and pain. There were no significant differences in documentation frequency between day and night shift nurses. Documentation practices were significantly different for RNs versus providers. CONCLUSIONS Our findings show that the frequency and specific components of neuro exam documentation vary significantly across nurses, providers, and ICUs. These findings are relevant for nurses and providers and may help to improve guidance for neurologic assessment of patients in non-neurologic ICUs. Further studies exploring variance in documentation practices and their implications for courses of treatment and patient outcomes are warranted.
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An J, Zhao L, Duan R, Sun K, Lu W, Yang J, Liang Y, Liu J, Zhang Z, Li L, Shi J. Potential nanotherapeutic strategies for perioperative stroke. CNS Neurosci Ther 2022; 28:510-520. [PMID: 35243774 PMCID: PMC8928924 DOI: 10.1111/cns.13819] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/24/2022] [Accepted: 02/04/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS Based on the complex pathological environment of perioperative stroke, the development of targeted therapeutic strategies is important to control the development of perioperative stroke. DISCUSSIONS Recently, great progress has been made in nanotechnology, and nanodrug delivery systems have been developed for the treatment of ischemic stroke. CONCLUSION In this review, the pathological processes and mechanisms of ischemic stroke during perioperative stroke onset were systematically sorted. As a potential treatment strategy for perioperative stroke, the review also summarizes the multifunctional nanodelivery systems based on ischemic stroke, thus providing insight into the nanotherapeutic strategies for perioperative stroke.
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Affiliation(s)
- Jingyi An
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
| | - Ling Zhao
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Ranran Duan
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Sun
- Department of Urinary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenxin Lu
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jiali Yang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yan Liang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Junjie Liu
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
| | - Zhenzhong Zhang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
| | - Li Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jinjin Shi
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
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Umehara T, Takumi K, Ueda K, Tokunaga T, Harada-Takeda A, Sato M. Hemodynamic features underlying pulmonary vein stump thrombus formation after left upper lobectomy: four-dimensional flow magnetic resonance imaging study. Quant Imaging Med Surg 2022; 12:992-1003. [PMID: 35111600 DOI: 10.21037/qims-21-472] [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: 05/02/2021] [Accepted: 09/13/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND We previously reported that to-and-fro blood movement near the pulmonary vein stump was particularly prominent after left upper lobectomy compared with other lobectomy, which may be the cause of the high susceptibility of pulmonary vein thrombus after left upper lobectomy. The aim of the present study was to compare the hemodynamics in patients who developed pulmonary vein thrombus after left upper lobectomy with those in patients who did not develop pulmonary vein thrombus using four-dimensional flow magnetic resonance imaging (4D MRI). METHODS This was a retrospective evaluation of a prospectively collected clinical and radiological database of 37 patients who underwent 4D MRI 7 days after left upper lobectomy for lung cancer (n=37). We obtained two parameters by 4D MRI: the grade of to-and-fro blood movement and the flow energy loss around the pulmonary vein stump. The length of the pulmonary vein stump, a known risk factor for pulmonary vein thrombus, was also measured. RESULTS According to a scatterplot of the grade of to-and-fro blood movement versus the flow energy loss, patients with pulmonary vein thrombus (n=15) were concentrated in an area which appears to be a 'dangerous' hemodynamic condition. There were few patients without pulmonary vein thrombus in this 'dangerous' area, except for one who unfortunately developed delayed pulmonary vein thrombus and cerebral infarction. We proposed a formula using the 4D MRI-derived parameters based on a stepwise multiple regression analysis that was more closely associated with the development of pulmonary vein thrombus than the length of the pulmonary vein stump (area under the receiver operating characteristics curve: 0.918 vs. 0.705, P=0.0500). CONCLUSIONS We proposed the existence of a 'dangerous' hemodynamic condition responsible for pulmonary vein thrombus formation. 4D MRI before the development of pulmonary vein thrombus may help identify patients requiring preventive therapy against pulmonary vein thrombus and subsequent thromboembolic complications.
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Affiliation(s)
- Tadashi Umehara
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Koji Takumi
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kazuhiro Ueda
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takuya Tokunaga
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Aya Harada-Takeda
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masami Sato
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Wongtangman K, Wachtendorf LJ, Blank M, Grabitz SD, Linhardt FC, Azimaraghi O, Raub D, Pham S, Kendale SM, Low YH, Houle TT, Eikermann M, Pollard RJ. Effect of Intraoperative Arterial Hypotension on the Risk of Perioperative Stroke After Noncardiac Surgery: A Retrospective Multicenter Cohort Study. Anesth Analg 2021; 133:1000-1008. [PMID: 34252055 DOI: 10.1213/ane.0000000000005604] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative cerebral blood flow is mainly determined by cerebral perfusion pressure and cerebral autoregulation of vasomotor tone. About 1% of patients undergoing noncardiac surgery develop ischemic stroke. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with an increased risk of perioperative ischemic stroke within 7 days after surgery. METHODS Adult noncardiac surgical patients undergoing general anesthesia at Beth Israel Deaconess Medical Center and Massachusetts General Hospital between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as a decrease in mean arterial pressure (MAP) below 55 mm Hg, categorized into no intraoperative hypotension, short (<15 minutes, median [interquartile range {IQR}], 2 minutes [1-5 minutes]) and prolonged (≥15 minutes, median [IQR], 21 minutes [17-31 minutes]) durations. The primary outcome was a new diagnosis of early perioperative ischemic stroke within 7 days after surgery. In secondary analyses, we assessed the effect of a MAP decrease by >30% from baseline on perioperative stroke. Analyses were adjusted for the preoperative STRoke After Surgery (STRAS) prediction score, work relative value units, and duration of surgery. RESULTS Among 358,391 included patients, a total of 1553 (0.4%) experienced an early perioperative ischemic stroke. About 42% and 3% of patients had a MAP of below 55 mm Hg for a short and a prolonged duration, and 49% and 29% had a MAP decrease by >30% from baseline for a short and a prolonged duration, respectively. In an adjusted analysis, neither a MAP <55 mm Hg (short duration: adjusted odds ratio [ORadj], 0.95; 95% confidence interval [CI], 0.85-1.07; P = .417 and prolonged duration: ORadj, 1.18; 95% CI, 0.91-1.55; P = .220) nor a MAP decrease >30% (short duration: ORadj, 0.97; 95% CI, 0.67-1.42; P = .883 and prolonged duration: ORadj, 1.30; 95% CI, 0.89-1.90; P = .176) was associated with early perioperative stroke. A high a priori stroke risk quantified based on preoperatively available risk factors (STRAS prediction score) was associated with longer intraoperative hypotension (adjusted incidence rate ratio, 1.04; 95% CI, 1.04-1.05; P < .001 per 5 points of the STRAS prediction score). CONCLUSIONS This study found no evidence to conclude that intraoperative hypotension within the range studied was associated with early perioperative stroke within 7 days after surgery. These findings emphasize the importance of perioperative cerebral blood flow autoregulation to prevent ischemic stroke.
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Affiliation(s)
- Karuna Wongtangman
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Luca J Wachtendorf
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michael Blank
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Stephanie D Grabitz
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Felix C Linhardt
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Omid Azimaraghi
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Dana Raub
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Pham
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samir M Kendale
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ying H Low
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Richard J Pollard
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Reinert NJ, Patel BM, Al-Robaidi K, Gao X, Fabio A, Jadhav A, Muluk VS, Esper SA, Zuckerbraun BS, Thirumala PD. Perioperative stroke-related mortality after non-cardiovascular, non-neurological procedures: A retrospective risk factor evaluation of common surgical comorbidities. J Perioper Pract 2021; 31:80-88. [PMID: 32301383 DOI: 10.1177/1750458920911830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population is an uncommon, yet devastating outcome. A combination of emboli and hypoperfusion may cause large vessel occlusions leading to perioperative strokes and mortality. Identifying independent risk factors for perioperative stroke-related mortality may enhance risk-stratification algorithms and preventative therapies. OBJECTIVES This study utilised cause-of-death data to determine independent risk scores for common surgical comorbidities that may lead to perioperative stroke-related mortality, including atrial fibrillation and asymptomatic carotid stenosis. METHODS This retrospective, IRB-exempt, case-control study evaluated non-cardiovascular, non-neurological surgical patients in a claims-based database. ICD-10-CM and ICD-9-CM codes identified cause of death and comorbidity incidences, respectively. A multivariate regression analysis then established adjusted independent risk scores of each comorbidity in relation to perioperative stroke-related mortality. RESULTS Patients with atrial fibrillation were more likely (1.7 aOR, 95% CI (1.1, 2.8) p = 0.02) to die from perioperative stroke-related mortality than from other causes. No association was found with asymptomatic carotid stenosis. Further, in-hospital strokes (25.9 aOR, 95% CI (16.0, 41.8) p < 0.001) or diabetes (1.8 aOR, 95% CI (1.1, 2.9) p = 0.02) may increase perioperative stroke-related mortality risk. CONCLUSIONS Atrial fibrillation, diabetes and in-hospital strokes may be independent risk factors for perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population.
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Affiliation(s)
- Nathan J Reinert
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bansri M Patel
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Khaled Al-Robaidi
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Xiaotian Gao
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony Fabio
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Visala S Muluk
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
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Umehara T, Takumi K, Ueda K, Tokunaga T, Harada-Takeda A, Suzuki S, Sato M. Four-dimensional flow magnetic resonance imaging study to explain high prevalence of pulmonary vein stump thrombus after left upper lobectomy. J Thorac Dis 2020; 12:5542-5551. [PMID: 33209387 PMCID: PMC7656367 DOI: 10.21037/jtd-20-1606] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Pulmonary vein (PV) stump thrombus, a known source of cerebral infarction, develops almost exclusively after left upper lobectomy; however, the mechanism remains unclear. We therefore evaluated the hemodynamics in the left atrium with four-dimensional flow magnetic resonance imaging (4D-flow MRI), which enables the simultaneous depiction of blood flow at three locations and the evaluation of hemodynamics. Methods 4D-flow MRI was basically performed 7 days after lobectomy for cancer arising in the right upper lobe (n=11), right lower lobe (n=8), left upper lobe (n=13), or left lower lobe (n=8). We evaluated dynamic blood movement from the ipsilateral remaining PV, the resected PV stump, and the contralateral PVs into the left atrium using 4D-flow MRI. Results There were some characteristic blood flow patterns that seemed to either promote or prevent PV stump thrombus. Promotive flow patterns were significantly more frequent and preventive flow patterns were significantly less frequent in patients who had undergone left upper lobectomy than in those who had undergone other lobectomy. Accordingly, the degree of blood turbulence near the vein stump, as measured by the extent of change in the blood movement, was significantly higher in patients who had undergone left upper lobectomy than in patients who had undergone other lobectomy. Conclusions Our study revealed that left upper lobectomy likely causes blood turbulence near the vein stump through complicated blood streams in the left atrium, which can play a part in the development of vein stump thrombus. Further study to identify patients at high risk of vein stump thrombus is warranted.
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Affiliation(s)
- Tadashi Umehara
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Koji Takumi
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Kazuhiro Ueda
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Takuya Tokunaga
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Aya Harada-Takeda
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Soichi Suzuki
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Masami Sato
- Department of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, Japan
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Abstract
PURPOSE OF REVIEW This review overviews perioperative stroke as it pertains to specific surgical procedures. RECENT FINDINGS As awareness of perioperative stroke increases, so does the opportunity to potentially improve outcomes for these patients by early stroke recognition and intervention. Perioperative stroke is defined to be any stroke that occurs within 30 days of the initial surgical procedure. The incidence of perioperative stroke varies and is dependent on the specific type of surgery performed. This chapter overviews the risks, mechanisms, and acute evaluation and management of perioperative stroke in four surgical populations: cardiac surgery, carotid endarterectomy, neurosurgery, and non-cardiac/non-carotid/non-neurological surgeries.
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Affiliation(s)
- Megan C Leary
- Department of Neurology, Lehigh Valley Hospital and Health Network, 1250 S Cedar Crest Blvd, Suite 405, Allentown, PA, 18103-6224, USA. .,Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Preet Varade
- Department of Neurology, Lehigh Valley Hospital and Health Network, 1250 S Cedar Crest Blvd, Suite 405, Allentown, PA, 18103-6224, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Lee GJ, Lee MA, Yoo B, Park Y, Jang MJ, Choi KK. Immediate Post-laparotomy Hypotension in Patients with Severe Traumatic Hemoperitoneum. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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14
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Intraoperative Ischemic Stroke in Elective Spine Surgery: A Retrospective Study of Incidence and Risk. Spine (Phila Pa 1976) 2020; 45:109-115. [PMID: 31389864 DOI: 10.1097/brs.0000000000003184] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN . Retrospective study. OBJECTIVE . To determine incidence, risk factors, complications, and early postoperative outcome in patients with intraoperative ischemic stroke during elective spine surgery. SUMMARY OF BACKGROUND DATA . Overall, stroke is the fifth leading cause of death in the United States and the second leading cause of death worldwide. It can be a catastrophic event and the main cause of neurological disability in adults. METHODS . A retrospective review of the electronic medical records of patients who underwent elective spine surgery between January 2016 and November 2018 at a larger tertiary referral center was conducted. Patients with infection and neoplastic disease were excluded. Patient demographics, pre- and postoperative neurological status, surgical treatment, surgical time, blood loss, intraoperative abnormalities, risk factors, history of stroke, medical treatment, diagnostics, hospital stay, complications, and mortality were collected. RESULTS . Out of 5029 surgically treated patients receiving elective spine surgery, a total of seven patients (0.15%) were identified who developed an ischemic stroke during the surgical procedure. Patients were predominantly females (n = 6). Ischemic pontine stroke occurred in two patients. Further distributions of ischemic stroke were: left caudate nucleus, left posterior inferior cerebellar artery, left external capsule, left middle cerebral artery, and acute ischemic supratentorial spots. The main risk factors identified for intraoperative ischemic stroke include hypertension, diabetes, smoking, dyslipidemia, and possibly major intraoperative CSF leak. Three patients (43%) had neurological deficits which did not improve during hospital stay. Two patients recovered fully and two patients died. Therefore, in-hospital mortality rate of this subset of patients was 29%. CONCLUSION . With the increase of spinal procedures, it is important to identify patients at risk for having an ischemic stroke and to optimize their comorbidities preoperatively. Patients with intraoperative ischemic stroke carry a higher risk for morbidity and mortality during the index hospitalization. LEVEL OF EVIDENCE 4.
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15
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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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Jayaraman DK, Mehla S, Joshi S, Rajasekaran D, Goddeau RP. Update in the Evaluation and Management of Perioperative Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:76. [DOI: 10.1007/s11936-019-0779-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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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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Li J, Zhao Y, Zhao M, Cao P, Liu X, Ren H, Zhang D, Zhang Y, Wang R, Zhao J. High variance of intraoperative blood pressure predicts early cerebral infarction after revascularization surgery in patients with Moyamoya disease. Neurosurg Rev 2019; 43:759-769. [PMID: 31203482 DOI: 10.1007/s10143-019-01118-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/05/2019] [Accepted: 05/17/2019] [Indexed: 01/28/2023]
Abstract
Few studies focused on the intraoperative blood pressure in Moyamoya disease (MMD) patients. We aimed to clarify whether or not it relates to early cerebral infarction after revascularization. We reviewed a retrospective cohort of Moyamoya disease from 2011 to 2018 in Beijing Tiantan Hospital, and patients with radiologically confirmed early postoperative infarction were included in the analysis. Controls were matched based on age, sex, and revascularization modality at a ratio of 1:5. Perioperative clinical factors and intraoperative blood pressure data were collected and analyzed. A total of 52 patients out of 1497 revascularization surgeries (3.5%) who experienced CT or MRI confirmed early postoperatively cerebral infarction, aged 38.46 ± 11.70; 26 were male (50.0%). Average real variability (ARV)-systolic blood pressure (SBP) (OR 3.29, p = 0.003), ARV-diastolic blood pressure (DBP) (OR 4.10, p = 0.005), ARV-mean arterial pressure (MAP) (OR 4.08, p = 0.004), and the maximum drops of DBP (OR 1.08, p = 0.003) and MAP (OR 1.06, p = 0.004) were associated with early postoperative infarction. In patients who experienced massive cerebral infarction, the maximum drops of DBP (OR 1.11, p = 0.004) and MAP (OR 1.11, p = 0.003) are independent risk factors, whereas ARVs of SBP (OR 3.90, p < 0.001), DBP (OR 4.69, p = 0.008), and MAP (OR 4.72, p = 0.003) are significantly associated with regional infarction. High variance of intraoperative blood pressure and drastic blood pressure decline are independent risk factors for postoperative infarction in MMD patients who underwent revascularization surgery. Maintaining stable intraoperative blood pressure is suggested to prevent early postoperative cerebral infarction in MMD patients.
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Affiliation(s)
- Jiaxi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Meng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Penghui Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Xingju Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Hao Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases (NCRC-ND), No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China. .,Center of Stroke, Beijing Institute for Brain Disorders, No.119, S. 4th Ring Road West, Fengtai District, Beijing, 100070, China.
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Sherlock S, Way M, Tabah A. Audit of practice in Australasian hyperbaric units on the incidence of central nervous system oxygen toxicity. Diving Hyperb Med 2019; 48:73-78. [PMID: 29888378 DOI: 10.28920/dhm48.2.73-78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 04/12/2018] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Central nervous system oxygen toxicity (CNS-OT) is an uncommon complication of hyperbaric oxygen treatment (HBOT). Different facilities have developed local protocols in an attempt to reduce the risk of CNS-OT. This audit was performed to elucidate which protocols might be of benefit in mitigating CNS-OT and to open discussion on adopting a common protocol for Treatment Table 14 (TT14) to enable future multicentre clinical trials. METHODS Audit of CNS-OT events between units using different compression profiles for TT14, performed at 243 kPa with variable durations of oxygen breathing and 'air breaks', to assess whether there is a statistical diference between protocols. Data were collected retrospectively from public and private hyperbaric facilities in Australia and New Zealand between 01 January 2010 and 31 December 2014. RESULTS Eight of 15 units approached participated. During the five-year period 5,193 patients received 96,670 treatments. There were a total of 38 seizures in 33 patients when all treatment pressures were examined. In the group of patients treated at 243 kPa there were a total of 26 seizures in 23 patients. The incidence of seizure per treatment was 0.024% (2.4 per 10,000 treatments) at 243 kPa and the risk per patient was 0.45% (4.5 in 1,000 patients). There were no statistically significant differences between the incidences of CNS-OT using different TT14 protocols in this analysis. CONCLUSION HBOT is safe and CNS-OT is uncommon. The risk of CNS-OT per patient at 243 kPa was 1 in 222 (0.45%; range 0-1%) and the overall risk irrespective of treatment table was 0.6% (range 0.31-1.8%). These figures are higher than previously reported as they represent individual patient risk as opposed to risk per treatment. The wide disparity of facility protocols for a 243 kPa table without discernible influence on the incidence of CNS-OT rates should facilitate a national approach to consensus.
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Affiliation(s)
- Susannah Sherlock
- Corresponding author: Hyperbaric Medicine Unit and Anaesthesia, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Queensland 4029, Australia. .,Hyperbaric Medicine Unit and Anaesthesia, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland
| | - Mandy Way
- QIMR Berghofer, Biostatistics, Herston, Queensland
| | - Alexis Tabah
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland.,Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland
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Petersen PB, Kehlet H, Jørgensen CC, Hansen TB, Husted H, Laursen MB, Hansen LT, Kjærsgaard-Andersen P, Solgaard S, Krarup NH. Incidence and Risk Factors for Stroke in Fast-Track Hip and Knee Arthroplasty-A Clinical Registry Study of 24,862 Procedures. J Arthroplasty 2019; 34:743-749.e2. [PMID: 30665835 DOI: 10.1016/j.arth.2018.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/03/2018] [Accepted: 12/16/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative stroke is a severe complication with a reported 30-day incidence of 0.4%-0.6% after total hip (THA) and knee arthroplasty (TKA). However, most data are based on diagnostic codes and with limited details on perioperative care, including the use of fast-track protocols. We investigated the incidence of and preoperative and postoperative factors for stroke after fast-track THA/TKA. METHODS We used an observational study design of elective fast-track THA/TKA patients with prospective collection of comorbidity and complete 90-day follow-up. Medical records were evaluated for events potentially disposing to stroke. Identification of relevant preoperative risk factors was done by multivariable logistic regression. Incidence of stroke was compared with a Danish background population. RESULTS Of 24,862 procedures with a median length of stay of 2 (interquartile range, 2-3) days, we found 27 (0.11%; 95% confidence interval [CI], 0.08%-0.16%) and 43 strokes (0.17%, 95% CI, 0.13%-0.23%) ≤30 and ≤90 days after surgery, respectively. Preoperative risk factors for stroke ≤30 days were age ≥ 85 years (odds ratio [OR], 4.3; 95% CI, 1.1-16.3) and anticoagulant treatment (OR, 3.1; 95% CI, 1.2-7.9). Preoperative anemia was near significant (OR, 2.1; 95% CI, 0.98-4.6, P = .055). Eight strokes ≤30 days were preceded by a cardiovascular event within the second postoperative day. Incidence of stroke after postoperative day 30 was similar to a Danish background population. CONCLUSION Risk of postoperative stroke in fast-track THA and TKA was low but may be further reduced with increased focus on avoiding perioperative cardiovascular events and in patients with preoperative anticoagulants or anemia.
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Affiliation(s)
- Pelle B Petersen
- Section for Surgical Pathophysiology, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, University of Copenhagen, Copenhagen, Denmark; Lundbeck Foundation Center for Fast-Track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Christoffer C Jørgensen
- Section for Surgical Pathophysiology, University of Copenhagen, Copenhagen, Denmark; Lundbeck Foundation Center for Fast-Track Hip and Knee Arthroplasty, Copenhagen, Denmark
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Frequency of cerebral infarction after pulmonary resection: a multicenter, retrospective study in Japan. Surg Today 2018; 48:571-572. [PMID: 29327086 DOI: 10.1007/s00595-017-1620-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 11/27/2017] [Indexed: 02/07/2023]
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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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Hsieh JK, Dalton JE, Yang D, Farag ES, Sessler DI, Kurz AM. The Association Between Mild Intraoperative Hypotension and Stroke in General Surgery Patients. Anesth Analg 2017; 123:933-9. [PMID: 27636576 DOI: 10.1213/ane.0000000000001526] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Intraoperative hypotension may contribute to perioperative strokes. We therefore tested the hypothesis that intraoperative hypotension is associated with perioperative stroke. METHODS After institutional review board approval for this case-control study, we identified patients who had nonneurological, noncardiac, and noncarotid surgery under general anesthesia at the Cleveland Clinic between 2005 and 2011 and experienced a postoperative stroke. Control patients not experiencing postoperative stroke were matched in a 4-to-1 ratio using propensity scores and restriction to the same procedure type as stroke patients. The association between intraoperative hypotension, measured as time-integrated area under a mean arterial pressure (MAP) of 70 mm Hg, and postoperative stroke was assessed using zero-inflated negative binomial regression. RESULTS Among 106 337 patients meeting inclusion criteria, we identified 120 who had confirmed postoperative stroke events based on manual chart review. Four-to-one propensity matching yielded a final matched sample of 104 stroke cases and 398 controls. There was no association between stroke and intraoperative hypotension. Stroke patients were not more likely than controls to have been hypotensive (odds ratio, 0.49 [0.18-1.38]), and among patients with intraoperative hypotension, stroke patients did not experience a greater degree of hypotension than controls (ratio of geometric means, 1.07 [0.76-1.53]). CONCLUSIONS In our propensity score-matched case-control study, we did not find an association between intraoperative hypotension, defined as MAP < 70 mm Hg, and postoperative stroke.
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Affiliation(s)
- Jason K Hsieh
- From the *Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; Departments of †Quantitative Health Sciences, ‡Outcomes Research, and §General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
Perioperative care of the patients with neurological diseases can be challenging. Most important consideration is the management and understanding of pathophysiology of these disorders and evaluation of new neurological changes that occur perioperatively. Perioperative generally refers to 3 phases of surgery: preoperative, intraoperative, and postoperative. We have tried to address few commonly encountered neurological conditions in clinical practice, such as delirium, stroke, epilepsy, myasthenia gravis, and Parkinson disease. In this article, we emphasize on early diagnosis and management strategies of neurological disorders in the perioperative period to minimize morbidity and mortality of patients.
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Affiliation(s)
- Manjeet Singh Dhallu
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed Baiomi
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhavi Biyyam
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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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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Li D, Bohringer C, Liu H. What is "normal" intraoperative blood pressure and do deviations from it really affect postoperative outcome? J Biomed Res 2017; 31:79-81. [PMID: 28808189 PMCID: PMC5445210 DOI: 10.7555/jbr.31.20160167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- David Li
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA 95817USA
| | - Christian Bohringer
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA 95817USA
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA 95817USA
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Grau AJ, Eicke M, Burmeister C, Hardt R, Schmitt E, Dienlin S. Risk of Ischemic Stroke and Transient Ischemic Attack Is Increased up to 90 Days after Non-Carotid and Non-Cardiac Surgery. Cerebrovasc Dis 2017; 43:242-249. [DOI: 10.1159/000460827] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 02/08/2017] [Indexed: 12/21/2022] Open
Abstract
Background: The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Methods: Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Results: Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay; and it was inversely associated with microangiopathic etiology and discharge at home. In 34.5% of patients with recent/planned surgery, prior antithrombotic or anticoagulant medication had been interrupted. Conclusions: Recent or planned surgery imposes a considerable short-term stroke risk particularly by cardioembolism with cessation of medication as an important contributor. Stroke after surgery is associated with poor outcome and high mortality. Better strategies to reduce the burden of perioperative stroke are urgently required.
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Perioperative stroke after carotid endarterectomy: etiology and implications. Acta Neurochir (Wien) 2016; 158:2377-2383. [PMID: 27696001 DOI: 10.1007/s00701-016-2966-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is the procedure of choice for reducing the risk of stroke in both symptomatic and asymptomatic carotid artery stenoses. Stroke is associated with significant morbidity and mortality peri-operatively (2-3 %). Our primary aim is to evaluate the etiology of these strokes after CEA and their impact on morbidity by comparing the length of stay in the hospital. METHODS A total of 584 patients with documented neurological status evaluations who underwent CEAs were included in the study. Neurophysiological monitoring data was obtained during CEA for carotid stenosis included eight-channel electroencephalography (EEG) and upper extremity somatosensory evoked potentials (SSEPs). RESULTS Twenty-one (3.595 %) patients had strokes in the perioperative period and they were more likely to have left-sided surgery (p = 0.008), intraoperative monitoring (IOM) changes (p < 0.001), an intraoperative shunt placed (p = 0.0002) or a hospital stay longer than 5 days (p = 0.0042). Unilateral anterior circulation ischemic stroke were the most common in our series. In a logistic regression model, left-sided surgery was shown to be 4.78 times more likely to be associated with perioperative stroke (1.50-15.27; p = 0.008) while intraoperative shunts were 11.85 times more likely to have strokes (3.97-35.34; p < 0.0001). Patients with stenosis greater than 70 % were 6.67 times less likely to have a stroke (0.04-0.59; p = 0.007). CONCLUSIONS Ischemic anterior circulation strokes are the most common type of post-operative neurological changes in patients undergoing CEA. Intraoperative shunt placement was a strong predictor of perioperative strokes. Since shunts are only placed following intraoperative monitoring changes, SSEPs and EEG can therefore function as a biomarker of cerebral hypo-perfusion.
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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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Linton M, Tong L, Simon A, Buffa E, McGregor R, Labruyére J, Foster D. Hepatic fibrosarcoma incarcerated in a peritoneopericardial diaphragmatic hernia in a cat. JFMS Open Rep 2016; 2:2055116916638681. [PMID: 28491416 PMCID: PMC5362868 DOI: 10.1177/2055116916638681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2016] [Indexed: 11/17/2022] Open
Abstract
Case summary A 14-year-old, female neutered domestic shorthair presented for dyspnoea. Thoracic ultrasonography and radiography showed that a heterogeneous mass was present within the pericardial sac, and the mass continued caudally with the mesenteric fat. On CT, the outline of the diaphragm was not continuous and there was an obvious defect with diaphragmatic thickening present at the mid-level of the liver. A pleural effusion and a small-volume pericardial effusion were also present. A ventral midline coeliotomy and median sternotomy revealed a 5 × 6 × 7 cm firm, irregular, tan-coloured soft tissue mass within the pericardial sac attached to both the diaphragmatic defect and liver. The mass was carefully dissected away from the heart and the diaphragmatic defect was repaired with primary closure. Postoperatively, the cat had a persistent pneumothorax that required continuous pleural suction for 41 h. The cat died 44 h postoperatively. Histopathology and immunohistochemistry confirmed the mass to be a hepatic fibrosarcoma incarcerated in a peritoneopericardial diaphragmatic hernia (PPDH). Relevance and novel information This is the first reported case of metaplastic transformation of liver into a sarcoma in a cat with PPDH. In addition, hepatic fibrosarcoma is a rarely reported location for fibrosarcoma in this species.
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Affiliation(s)
- Michael Linton
- Eastside Veterinary Emergency and Specialists, Rose Bay, NSW, Australia
| | - Lydia Tong
- Faculty of Veterinary Science, The University of Sydney, Sydney, Australia
| | - Adrian Simon
- Eastside Veterinary Emergency and Specialists, Rose Bay, NSW, Australia
| | - Eugene Buffa
- Eastside Veterinary Emergency and Specialists, Rose Bay, NSW, Australia
| | - Ross McGregor
- Eastside Veterinary Emergency and Specialists, Rose Bay, NSW, Australia
| | - Julien Labruyére
- VetCT Consultants in Telemedicine, St John's Innovation Centre, Cowley Road Cambridge, England CB4 OW
| | - Darren Foster
- Eastside Veterinary Emergency and Specialists, Rose Bay, NSW, Australia
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Minhas SV, Goyal P, Patel AA. What are the Risk Factors for Cerebrovascular Accidents After Elective Orthopaedic Surgery? Clin Orthop Relat Res 2016; 474:611-8. [PMID: 26290342 PMCID: PMC4746182 DOI: 10.1007/s11999-015-4496-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/31/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative cerebrovascular accidents (CVAs) are one of the leading causes of patient morbidity, mortality, and medical costs. However, little is known regarding the rates of these events and risk factors for CVA after elective orthopaedic surgery. QUESTIONS/PURPOSES Our goals were to (1) establish the national, baseline proportion of patients experiencing a 30-day CVA and the timing of CVA; and (2) determine independent risk factors for 30-day CVA rates after common elective orthopaedic procedures. METHODS Patients undergoing elective TKA, THA, posterior or posterolateral lumbar fusion, anterior cervical discectomy and fusion, and total shoulder arthroplasty, from 2006 to 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program(®) database. A total of 42,150 patients met inclusion criteria. Thirty-day CVA rates were recorded for each procedure, and patients were assessed for characteristics associated with CVA through univariate analysis. Multivariate regression models were created to identify independent risk factors for CVA. RESULTS A total of 55 (0.13%) patients experienced a CVA within 30 days of the procedure, occurring a median of 2 days after surgery (range, 1-30 days) with 0.08% of patients experiencing a CVA after TKA, 0.15% after THA, 0.00% after single-level anterior cervical discectomy and fusion, 0.38% after multilevel anterior cervical discectomy and fusions, 0.20% after single-level posterior or posterolateral lumbar fusion, 0.70% after multilevel posterior or posterolateral lumbar fusion, and 0.22% after total shoulder arthroplasty. Independent risk factors for CVA included age of 75 years or older (odds ratio [OR], 2.50; 95% CI, 1.44-4.35; p = 0.001), insulin-dependent diabetes mellitus (OR, 3.08; CI, 1.47-6.45; p = 0.003), hypertension (OR, 2.71; CI, 1.19-6.13; p = 0.017), history of transient ischemic attack (OR, 2.83; CI, 1.24-6.45; p = 0.013), dyspnea (OR, 2.51; CI, 1.30-4.86; p = 0.006), chronic obstructive pulmonary disease (OR, 2.33; CI, 1.06-5.13; p = 0.036), and operative time of 180 minutes or greater (OR, 3.25; CI 1.60-6.60; p = 0.001). CONCLUSIONS Numerous nonmodifiable patient comorbidities and increased operative time were associated with CVA after elective orthopaedic procedures. However, the American College of Surgeons National Surgical Quality Improvement Program(®) database does not code for cardiac arrhythmia or atrial fibrillation, which other studies have suggested may be important predictor variables; those may be important risk factors, although we were unable to evaluate them in our study. Surgeons should counsel patients with these risk factors and limit their operative time to reduce the risk of these adverse events, and future studies should examine other patient characteristics such as arrhythmia and noncoronary heart disease and assess the role of pharmacologic prophylaxis in patients with these risk factors. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Shobhit V Minhas
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA
| | - Preeya Goyal
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, NMH/Arkes Family Pavilion, Suite 1350, Chicago, IL, 60611, USA.
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STA-MCA Bypass as a "Bridge" to Pituitary Surgery in a Patient with an Adenoma Occluding the Internal Carotid Artery: Case Report and Review of the Literature. Case Rep Neurol Med 2015; 2015:359586. [PMID: 26425379 PMCID: PMC4575713 DOI: 10.1155/2015/359586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 08/23/2015] [Indexed: 11/18/2022] Open
Abstract
Occlusion of the intracranial internal carotid artery (ICA) by a pituitary adenoma with resulting cerebral ischemia is a very rare but devastating occurrence. The authors present a case in which a condition of symptomatic ICA occlusion due to a giant pituitary adenoma was successfully treated using a preliminary extraintracranial bypass as a “bridge” to the tumor removal. A 52-year-old patient presented with a minor stroke followed by pressure-dependent transient ischemic attacks consistent with a condition of hypoperfusion. MR imaging and a digital subtraction angiography revealed a pituitary adenoma occluding the ICA on the right side. He underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with the aim of revascularizing the ischemic hemisphere and reducing the risk of perioperative stroke or stroke evolution. The patient was subsequently operated on to remove the adenoma through a transsphenoidal approach. The postoperative course was uneventful and the patient has suffered no further ischemic events. When there are no emergency indications to decompress the optical pathways but the patient is at risk of impending stroke because of ICA occlusion, a two-step strategy consisting of a bypass and subsequent removal of the pituitary adenoma may be a valuable option.
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Ohya J, Chikuda H, Oichi T, Horiguchi H, Takeshita K, Tanaka S, Yasunaga H. Perioperative stroke in patients undergoing elective spinal surgery: a retrospective analysis using the Japanese diagnosis procedure combination database. BMC Musculoskelet Disord 2015; 16:276. [PMID: 26431951 PMCID: PMC4592557 DOI: 10.1186/s12891-015-0743-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 09/29/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although a few studies on perioperative stroke following spinal surgery have been reported, differences in the incidence of perioperative stroke among various surgical procedures have not been determined. The purpose of this retrospective analysis was to investigate the incidence of perioperative stroke during hospitalization in patients undergoing elective spinal surgery, and to examine whether the incidence varied according to the surgical procedure. METHODS A retrospective analysis of data from the Diagnosis Procedure Combination database, a nationwide administrative impatient database in Japan, identified 167,106 patients who underwent elective spinal surgery during 2007-2012. Patient information extracted included age, sex, preoperative comorbidity, administration of blood transfusion, length of hospitalization, and type of hospital. Clinical outcomes included perioperative stroke during hospitalization, and in-hospital death. RESULTS The overall incidence of perioperative stroke was 0.22 % (371/167,106) during hospitalization. A logistic regression model fitted with a generalized estimating equation showed perioperative stroke was associated with advanced age, a history of cardiac disease, an academic institution, and resection of a spinal tumor. Patients who underwent resection of a spinal cord tumor (reference) had a higher risk of stroke compared with those undergoing discectomy (odds ratio (OR), 0.29; 95 % confidence interval (CI), 0.14-0.58; p = 0.001), decompression surgery (OR, 0.44; 95 % CI, 0.26-0.73; p = 0.001), or arthrodesis surgery (OR, 0.55; 95 % CI, 0.34-0.90); p = 0.02). Advanced age (≥80 years; OR, 5.66; 95 % CI, 3.10-10.34; p ≤ 0.001), history of cardiac disease (OR, 1.58; 95 % CI, 1.10-2.26; p = 0.01), diabetes (OR, 1.73; 95 % CI, 1.36-2.20; p ≤ 0.001), hypertension (OR, 1.53; 95 % CI, 1.18-1.98; p = 0.001), cervical spine surgery (OR, 1.44; 95 % CI, 1.09-1.90; p = 0.01), a teaching hospital (OR, 1.36; 95 % CI, 1.01-1.82; p = 0.04), and length of stay (OR, 1.008; 95 % CI, 1.005-1.010; p ≤ 0.001) were also risk factors for perioperative stroke. CONCLUSIONS Perioperative stroke occurred in 0.22 % of patients undergoing spinal surgery. Resection of a spinal cord tumor was associated with increased risk of perioperative stroke as well as advanced age, comorbidities at admission, cervical spine surgery, surgery in a teaching hospital, and length of stay.
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Affiliation(s)
- Junichi Ohya
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
| | - Takeshi Oichi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
| | - Hiromasa Horiguchi
- Department of Health Economics and Epidemiology Research, School of Public Health, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
| | - Hideo Yasunaga
- Department of Health Economics and Epidemiology Research, School of Public Health, The University of Tokyo, Hongo 7-3-1, Bunkyo, Tokyo, Japan.
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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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Vlisides P, Mashour GA. Perioperative stroke. Can J Anaesth 2015; 63:193-204. [PMID: 26391795 DOI: 10.1007/s12630-015-0494-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/02/2015] [Accepted: 09/11/2015] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. In this review, we examine the significance, pathophysiology, risk factors, and evidence-based recommendations for the prevention and management of perioperative stroke. SOURCE This is a narrative review based on literature from the PubMed database regarding perioperative stroke across a broad surgical population. The Society for Neuroscience in Anesthesiology and Critical Care recently published evidence-based recommendations for perioperative management of patients at high risk for stroke; these recommendations were analyzed and incorporated into this review. PRINCIPAL FINDINGS The incidence of overt perioperative stroke is highest in patients presenting for cardiac and major vascular surgery, although preliminary data suggest that the incidence of covert stroke may be as high as 10% in non-cardiac surgery patients. The pathophysiology of perioperative stroke involves different pathways. Thrombotic stroke can result from increased inflammation and hypercoagulability; cardioembolic stroke can result from disease states such as atrial fibrillation, and tissue hypoxia from anemia can result from the combination of anemia and beta-blockade. Across large-scale database studies, common risk factors for perioperative stroke include advanced age, history of cerebrovascular disease, ischemic heart disease, congestive heart failure, atrial fibrillation, and renal disease. Recommendations for prevention and management of perioperative stroke are evolving, though further work is needed to clarify the role of proposed modifiable risk factors such as perioperative anticoagulation, antiplatelet therapy, appropriate transfusion thresholds, and perioperative beta-blockade. CONCLUSIONS Perioperative stroke carries a significant clinical burden. The incidence of perioperative stroke may be higher than previously recognized, and there are diverse pathophysiologic mechanisms. There are many opportunities for further investigation of the pathophysiology, prevention, and management of perioperative stroke.
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Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Health System, University Hospital 1H247, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan Health System, University Hospital 1H247, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109, USA.
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Wesselink EM, Kappen TH, van Klei WA, Dieleman JM, van Dijk D, Slooter AJC. Intraoperative hypotension and delirium after on-pump cardiac surgery. Br J Anaesth 2015. [PMID: 26209856 DOI: 10.1093/bja/aev256] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Delirium is a common complication after cardiac surgery and may be as a result of inadequate cerebral perfusion. We studied delirium after cardiac surgery in relation to intraoperative hypotension (IOH). METHODS This observational single-centre, cohort study was nested in a randomized trial, on a single intraoperative dose of dexamethasone vs placebo during cardiac surgery. During the first four postoperative days, patients were screened for delirium based on the Confusion Assessment Method (CAM) for Intensive Care Unit on the intensive care unit, CAM on the ward, and by inspection of medical records. To combine depth and duration of IOH, we computed the area under the curve for four blood pressure thresholds. Logistic regression analyses were performed to investigate the association between IOH and the occurrence of postoperative delirium, adjusting for confounding and using a 99% confidence interval to correct for multiple testing. RESULTS Of the 734 included patients, 99 patients (13%) developed postoperative delirium. The adjusted Odds Ratio for the Mean Arterial Pressure <60 mm Hg threshold was 1.04 (99% confidence interval: 0.99-1.10) for each 1000 mm Hg(2) min(2) AUC(2) increase. IOH, as defined according to the other three definitions, was not associated with postoperative delirium either. Deep and prolonged IOH seemed to increase the risk of delirium, but this was not statistically significant. CONCLUSIONS Independent of the applied definition, IOH was not associated with the occurrence of delirium after cardiac surgery.
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Affiliation(s)
- E M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - T H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - W A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - J M Dieleman
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - D van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
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Garg A, Singh D, Bansal AR, Sharma P, Kasliwal RR, Trehan N. Prevalence of carotid stenosis and its correlation with incidence of perioperative stroke in patients of coronary artery bypass graft surgery. Indian J Thorac Cardiovasc Surg 2014. [DOI: 10.1007/s12055-014-0336-3] [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] Open
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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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Perioperative Care of Patients at High Risk for Stroke during or after Non-Cardiac, Non-Neurologic Surgery. J Neurosurg Anesthesiol 2014; 26:273-85. [DOI: 10.1097/ana.0000000000000087] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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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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Probasco J, Sahin B, Tran T, Chung TH, Rosenthal LS, Mari Z, Levy M. The preoperative neurological evaluation. Neurohospitalist 2014; 3:209-20. [PMID: 24198903 DOI: 10.1177/1941874413476042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient's neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.
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Affiliation(s)
- John Probasco
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Biteker M, Kayatas K, Türkmen FM, Misirli CH. Impact of perioperative acute ischemic stroke on the outcomes of noncardiac and nonvascular surgery: a single centre prospective study. Can J Surg 2014; 57:E55-61. [PMID: 24869617 PMCID: PMC4035406 DOI: 10.1503/cjs.003913] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although ischemic stroke is a well-known complication of cardiovascular surgery it has not been extensively studied in patients undergoing noncardiac surgery. The aim of this study was to assess the predictors and outcomes of perioperative acute ischemic stroke (PAIS) in patients undergoing noncardiothoracic, nonvascular surgery (NCS). METHODS We prospectively evaluated patients undergoing NCS and enrolled patients older than 18 years who underwent an elective, non-daytime, open surgical procedure. Electrocardiography and cardiac biomarkers were obtained 1 day before surgery, and on postoperative days 1, 3 and 7. RESULTS Of the 1340 patients undergoing NCS, 31 (2.3%) experienced PAIS. Only age (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.01-3.2, p < 0.001) and preoperative history of stroke (OR 3.6, 95% CI 1.2-4.8, p < 0.001) were independent predictors of PAIS according to multivariate analysis. Patients with PAIS had more cardiovascular (51.6% v. 10.6%, p < 0.001) and noncardiovascular complications (67.7% v. 28.3%, p < 0.001). In-hospital mortality was 19.3% for the PAIS group and 1% for those without PAIS (p < 0.001). CONCLUSION Age and preoperative history of stroke were strong risk factors for PAIS in patients undergoing NCS. Patients with PAIS carry an elevated risk of perioperative morbidity and mortality.
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Affiliation(s)
- Murat Biteker
- Istanbul Medipol University, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Kadir Kayatas
- Haydarpasa Numune Education and Research Hospital, Department of Internal Medicine, Istanbul, Turkey
| | - Funda Muserref Türkmen
- Haydarpasa Numune Education and Research Hospital, Department of Internal Medicine, Istanbul, Turkey
| | - Cemile Handan Misirli
- Haydarpasa Numune Education and Research Hospital, Department of Neurology, Istanbul, Turkey
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Singhal NS, Josephson SA. A practical approach to neurologic evaluation in the intensive care unit. J Crit Care 2014; 29:627-33. [PMID: 24636925 DOI: 10.1016/j.jcrc.2014.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
Delirium and neurologic impairment are extremely common in the intensive care setting, and their delayed identification is an important contributor to patient morbidity. Even in comatose patients, the clinical neurologic examination remains the most accurate and effective tool in assessing nervous system function. Rapid identification of neurologic deficits with a practical and easily reproducible neurologic examination is a core skill for effectively caring for critically ill patients. The purpose of this tutorial is to discuss techniques of neurologic examination and localization with an emphasis on comatose patients. Commonly encountered cases of encephalopathy and coma along with clinical pearls are presented.
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Affiliation(s)
- Neel S Singhal
- Department of Neurology, University of California, San Francisco, CA.
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Abstract
OPINION STATEMENT Numerous risk factors for perioperative stroke have been identified and many are modifiable. Surgical patients with a history of cerebrovascular disease should be evaluated by a neurologist. Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke. The identification and treatment of carotid disease in the context of upcoming surgery has been a source of controversy. Routine carotid revascularization performed with coronary artery bypass graft (CABG) surgery for incidentally discovered carotid stenosis is not recommended. Prior to aortic manipulation during CABG, epiaortic ultrasound should be performed to identify aortic atheromatous plaques. If possible, preoperative aspirin, beta blocker, statin, and angiotensin converting-enzyme (ACE) inhibitor therapy should be continued in the perioperative period. Patients who are prescribed anticoagulation at high risk of thromboembolism should receive bridging anticoagulation during the perioperative period. The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention. CABG patients should be initiated on beta blockade +/- amiodarone to prevent postoperative AF. Many practitioners have been traditionally nihilistic towards acute perioperative stroke treatment. Given the narrow therapeutic window of treatment options, candidacy is dependent on timely recognition. Intravenous and endovascular thrombolysis/therapies are viable options in selected patients under the guidance and expertise of a neurologist. This article will present the epidemiology of perioperative stroke, the pathophysiology, risk assessment and stratification for common surgeries. The article will additionally focus on treatment options including modifiable risk factor reduction and the perioperative management of medications.
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Abstract
It is increasingly recognized that one can identify a higher risk patient for perioperative stroke. The risk of stroke around the time of operative procedures is fairly substantial and it is recognized that patients initially at risk for vascular events are those most likely to have this risk heightened by invasive procedures. Higher risk patients include those of advanced age and there is a cumulative risk, over time, of coexistent hypertension, atherosclerosis, diabetes mellitus, cardiac disease and clotting disorders. There are a number of possible mechanisms associated with the procedure (e.g., preoperative hypercoagulability, holding of antithrombic therapy at the time of the procedure and cardiac arrhythmia) that can promote a thrombo-embolic event. Examples of these include: direct mechanical trauma to extracranial vessels related to operations on the head and neck; and vascular injury as a consequence of vascular and innovative endovascular procedures affecting the cerebral circulation (e.g., carotid endarterectomy, extracranial or intracranial angioplasty with stenting, and use of the MERCI clot retrieval device), as well as various endovascular methods that have been developed to obliterate cerebral aneurysms and arteriovenous malformations as an alternative to surgical clipping and surgical resection, respectively.
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Affiliation(s)
- Uma Menon
- Department of Neurology, LSU Health Sciences Center, Shreveport, LA 71103, USA.
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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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Preoperative hematocrit concentration and the risk of stroke in patients undergoing isolated coronary-artery bypass grafting. Anemia 2013; 2013:206829. [PMID: 23738059 PMCID: PMC3657438 DOI: 10.1155/2013/206829] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/10/2013] [Indexed: 12/20/2022] Open
Abstract
Background. Identification and management of risk factors for stroke following isolated coronary artery bypass grafting (CABG) could potentially lower the risk of such serious morbidity. Methods. We retrieved data for 30-day stroke incidence and perioperative variables for patients undergoing isolated CABG and used multivariate logistic regression to assess the adjusted effect of preoperative hematocrit concentration on stroke incidence. Results. In 2,313 patients (mean age 65.9 years, 73.6% men), 43 (1.9%, 95% CI: 1.4–2.5) developed stroke within 30 days following CABG (74.4% within 6 days). After adjustment for a priori defined potential confounders, each 1% drop in preoperative hematocrit concentration was associated with 1.07 (95% CI: 1.01–1.13) increased odds for stroke (men, OR: 1.08, 95% CI: 1.01–1.16; women, OR: 1.02, 95% CI: 0.91–1.16). The predicted probability of stroke for descending preoperative hematocrit concentration exceeded 2% for values <37% (<37% for men (adjusted OR: 2.39, 95% CI: 1.08–5.26) and <38% for women (adjusted OR: 2.52, 95% CI: 0.53–11.98), with a steeper probability increase noted in men). The association between lower preoperative hematocrit concentration and stroke was evident irrespective of intraoperative transfusion use. Conclusion. Screening and management of patients with low preoperative hematocrit concentration may alter postoperative stroke risk in patients undergoing isolated CABG.
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Sharifpour M, Moore LE, Shanks AM, Didier TJ, Kheterpal S, Mashour GA. Incidence, Predictors, and Outcomes of Perioperative Stroke in Noncarotid Major Vascular Surgery. Anesth Analg 2013; 116:424-34. [DOI: 10.1213/ane.0b013e31826a1a32] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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