This document provides guidelines for the prevention and management of perioperative stroke. It begins with definitions of perioperative stroke and outlines contents to be covered. These include preoperative, intraoperative, and postoperative sections. In the preoperative section, it discusses evaluation and risk factors, timing of surgery after stroke, anticoagulant management, and use of beta-blockers and statins. The intraoperative section addresses anesthetic techniques, blood pressure control, ventilation, hemorrhage management, glycemic control, and beta-blockade. The postoperative section focuses on the need for a coordinated team approach and protocols for rapid assessment and intervention. It provides mortality rates for perioperative stroke and reviews studies on various prevention strategies discussed in the

1. Prevention and management for
Perioperative Stroke
Boohwi Hong
koho0127@gmail.com
2020. 8.

2. • Brain infarction of ischemic or hemorrhagic etiology that
occurs during surgery or within 30 days after surgery
Definition of Perioperative stroke

3. Contents
J Neurosurg Anesthesiol 2014;26:273–285
J Neurosurg Anesthesiol 2020;32:210–226

4. •PREOPERATIVE
•Preoperative Evaluation & Informed Consent
•Timing of Elective Surgery After Stroke
•Anticoagulant and Antiplatelet Drugs
•Preoperative Beta-blockers and Statins
Contents
•INTRAOPERATIVE
•Anesthetic technique
•Blood pressure management
•Ventilation strategy
•Hemorrhage/blood transfusion
•Glycemic management
•Intraoperative beta-blockade
•POSTOPERATIVE
•Team
•Assessing Stroke
•Interventions
•Supportive Care

5. • 0.1% incidence
• 8 fold increased mortality
• American College of Surgeons National Surgical Quality
Improvement Program (ACS NSQIP)
Anesthesiology 2011; 114:1289–96
Mortality of Periop Stroke
Mashour Model

6. JAMA Cardiol. 2017;2(2):181-187.
Rates of periop events
0.52%
0.77%

7. Covert stroke = Silent stroke
• NeuroVISION study
• 2014 ~2017,. 1114 participants
• 7 % had a perioperative covert stroke
• Cognitive decline 1 year after surgery
• OR 1.98, RD increase 13%
• Perioperative delirium
• HR 2.24, RD increase 6%
• Overt stroke or transient ischaemic attack
• HR 4·13, RD increase 3%
Lancet. 2019;394:1022–1029.

8. Anesthesiology 2011; 115:879 –90

9. JAMA Neurol. 2015;72:749–755
Longer waiting & intervention time
Lower use of thrombolysis
Longer length of stay
More dead or disabled at discharge
Less discharged home
Standardized approach ensuring access to
rapid acute stroke care
Periop vs Non-op stroke

10. PREOPERATIVE
GUIDELINES

11. • Large vessel (anterior&middle),
• cardioembolic etiology
• 25-30% unknown etiology
• Limited cerebrovascular reserve
• Hypoxic-ischemic injury
Stroke Pathophysiology and Etiology

12. Vasodilatory reserve
Stroke. 2018;49:2011–2018.

13. • Cerebrovascular vulnerability
• No standard system
• Cerebrovascular reserve test ?
• Transcranial Doppler ?
• EEG pattern ?
• Identifying patients at high risk
• Clinical risk factors, Comorbidity-based risk factors
• Advanced age, Prior cerebrovascular disease, Renal failure
Preoperative Risk Evaluation

14. 2018
2016
2014
2013
2011
2009

15. Risk models predicting stroke
Stroke. 2019;50:2002-2006

17. MICA (Myocardial Infarction or Cardiac Arrest)
• 5 predictors
• Gupta Perioperative Risk for
MICA

18. • Incidence >1% should be discussed
• Perioperative stroke education and counseling
Informed Consent

19. • Impaired cerebrovascular autoregulation and chemoregulation for months
• Increased oxygen extraction
• Compromised cerebral blood flow
• Inadequate cerebral perfusion
• Physiological vulnerabilities may lead to increased perioperative stroke risk
• 2014 guide 1 to 3 months
Timing of Elective Surgery After Stroke
2014
2020

20. JAMA. 2014;312(3):269-277
Danish nationwide data
2005-2011
481,183 surgeries

21. JAMA. 2014;312(3):269-277

22. JAMA. 2014;312:1930–1931

23. • Atrial fibrillation
• Bridging necessary ?
• High risk pt. excluded
• Direct oral anticoagulation agents
• Dabigatran (thrombin inhibitor)
• ~xaban (factor Xa inhibitor)
• Short, predictable half-life
• Shorter interruption period
N Engl J Med. 2015;373:823–833.
Anticoagulant and Antiplatelet Drugs

24. Direct oral anticoagulants: 1-3 d stop, no
bridging therapy
Warfarin: 5 d stop, bridging (moderate-to-high
risk pt. only)

25. • Bridging anticoagulation is reserved for patients with
moderate-to-high thromboembolic risk
J Am Coll Surg. 2018

27. Bleeding risk
• Invasiveness of surgery
• Comorbidity
• Previous surgery, trauma, family history,
and current antithrombotic medications
• HAS-BLED score
• ≥ 3 indicates “high bleeding risk”
• (5.8% yearly risk)
• Predictor of bleeding events during
bridging

28. Standardized clinical protocol
• Stroke vs major bleeding
• Minimal interruption window
• DOAC : No requirement for heparin bridging.
• The 30-day postoperative rates of major bleeding were less
than 2%, and the rates of stroke were less than 1%.
JAMA Intern Med. 2019;179(11):1469-1478.

29. International Journal of Cardiology 258 (2018) 59–67
Aspirin

30. International Journal of Cardiology 258 (2018) 59–67
Aspirin

31. Bridging data
Am Heart J 2018;195:108-14

32. • Aspirin reduced the risk of
• Mortality (5.5%)
• Nonfatal MI (5.9%)
Ann Intern Med. 2018;168:237-244
Aspirin
* POISE 2 trial
Aspirin did not prevent death and nonfatal MI
but did increase the risk for major bleeding

33. • 9 RCT
• Prevents nonfatal MI
• Increases risks of stroke, death, hypotension, and bradycardia.
• Increased risk of nonfatal stroke (RR = 1.86, 95% CI: 1.09-3.16).
• POISE Trial
• Beta-blocker–naive patients
• Extended-release metoprolol
• Relative high dose
Beta-blockers
Circulation. 2014;130:2246–2264

34. Chronic beta-blocker ?
JAMA Intern Med. 2015;175(12):1923-1931.
Cardiovascular death was
higher in β-blockers
(0.90% vs 0.45%; P < .001)
Nonfatal stroke
(0.23% vs 0.21%; P = .68)
Nonfatal acute MI
(0.18% vs 0.17%; P = .81).
Chronic beta-blocker?

35. European Heart Journal (2017) 38, 2421–2428
Subtype ?

36. • Previous coronary revascularization
• No adjusted increased risk of stroke in those on prior beta-
blocker therapy

37. • Taiwanese nationwide data
• DM ~ CHD  Cardioprotective beta-blocker ?
• Initiation time (>30 and ≤30 days preoperatively)
• >30 days
• Decreased risk of in-hospital mortality (OR 0.72, 95% CI 0.65–0.78)
• 30-day mortality (OR 0.72, 95% CI 0.66–0.78)
• Preoperative beta-blocker use and risk of stroke (OR 1.33, 95% CI 0.94–1.88)
J Am Heart Assoc. 2017;6:e004392

38. statin
• statin use was associated with
• decreased adjusted mortality across multiple cohorts
• studied.
• 오탁규 선생님 논문…
Statin
Ann Surg 2019

39. Statin
JAMA Intern Med. 2017;177:231–242.

40. Ann Med. 2018;50:402–409.
Statin Meta
12 RCT
4707 pt.

41. INTRAOPERATIVE
GUIDELINES

42. Anesthetic Technique: mixed results
• General
• vs
• Epidural or Spinal anesthesia
J Vasc Surg 2019;69:1874-9
General VS Regional

43. • Vaginal reconstructive surgery
• 37,426 women who underwent vaginal reconstructive surgery
• 30 day
GA VS RA
Int Urogynecol J. 2020;31:181–189

44. Anesthesiology 2013; 118:1046-58

45. 2010 to 2012
ACS NSQIP
20,936 patients
J Bone Joint Surg Am. 2015;97:455-61

46. • spinal or
epidural
J Bone Joint Surg Am. 2015;97:186-93

47. • CABG
• Stroke high risk patients
N Engl J Med 2019; 380:1214-1225
VA VS TIVA

48. • Mortality
• AKI
• MI
• ? CNS
Anesthesiology 2015; 123:307-19
Hypotension & other outcomes

49. Anesthesiology 2018; 129:440-7
Intraoperative hypotension & Stroke
in cardiac surgery

50. Anesth Analg 2016;123:933–9
Noncardiac surgical population

51. • 48241, 2002-2009
• Time spent with MAP > 30% below baseline
• Postoperative stroke (OR = 1.013/min hypotension, 99.9% CI:
1.000-1.025)
• Effect size is of unclear clinical significance
• Routine intraoperative blood pressures (ie, MAPs ≥60 to
70mmHg) are unlikely to be a major driver of overt
perioperative stroke. Anesthesiology 2012; 116:658–64

52. • Rare
• 24,701 patients
• Only 1 case of a postoperative neurocognitive deficit
• (overall incidence, 0.004%).
• Case report: 6 patients with a catastrophic neurocognitive
complication after shoulder surgery in the BCP.
• Intraoperative cerebral desaturation (0%-100%; mean, 41.1%)
Am J Orthop (Belle Mead NJ). 2016;45:E63–E68
Neurocognitive deficits and cerebral
desaturation after shoulder surgery

53. • Position Lateral vs Beach chair
• MAP and rSco2 High correlation = Diminished cerebral
autoregulation (cerebral oximetry index (COx) )
• No differences in composite cognitive outcomes or serum
ischemic biomarkers
Anesth Analg 2015;120:176–85
Diminished cerebral autoregulation
in the beach chair

54. • Limited data between
intraoperative PaCO2 or EtCO2
and cerebrovascular reserve
• Vasodilatory reserve
• Hypocapnia 30mmHg
• Hypercapnia
• Steal phenomenon
• Hypoxic-ischemic injury
• Hypotension + vasodilatory
reserve X
Maintain Normocapnia

55. • Hemorrhage and anemia  cerebral hypoxic-ischemic injury
• Transfusion itself may increase stroke risk
• Red blood cell aggregation
• Thrombogenic potential
• Impaired microcirculation
Relative risk for 30-day mortality and stroke J Vasc Surg. 2013
Retrospective, Scarce derailed data, Baseline imbalance
Hemorrhage and Blood Transfusion

56. • Reduce blood loss and transfusion
• CRASH-3
• Within 3 h of Traumatic brain injury
• Head injury-related death
• Only mild-to-moderate injury
Lancet. 2019;394:1713–1723
Tranexamic acid

57. • 9.0 g/dL
• Reduced CO +
• beta2-mediated
cerebrovascular vasodilatation
Blue Metoprolol (β1/β2 =2.3)
Green atenolol (β1/β2 = 4.7)
Red bisoprolol (β1/β2 = 13.5)
Anesthesiology 2013; 119:777-87
Transfusion threshold & beta-blocker

58. • Poor glycemic control is a strong predictor of postoperative
morbidity and mortality
• Perioperative stroke is more likely to be associated with an
elevated fasting blood sugar than nonoperative Stroke
J Vasc Surg 2019;69:1219-26
Glycemic control

59. • 1151 acute ischemic stroke patients who were hyperglycemic
at admission
• 90-day modified Rankin Scale score (disability score)
• 80-179mg/dL vs 80-130mg/dL

60. • 2014. 60-180 mg/dL (opinion based)
• 2020

61. • Metoprolol, as a relatively nonselective beta1-antagonist
• β1/β2 =2.3
• Perioperative stroke (OR = 3.3, 95% CI: 1.4-7.8, P =0.003)
• No collinearity with hypotension
Anesthesiology 2013; 119:1340-6
Intraoperative Beta-blockade

62. • HR 10%
• Reduced CO +
• Beta2-mediated cerebrovascular
vasodilatation
• Reduce brain tissue oxygenation
J Appl Physiol 111: 1125–1133, 2011.

63. POSTOPERATIVE
GUIDELINES

64. • Rapid recognition
• Communication
• Timely management
• Organized protocol
• Higher efficiency
• Rapid therapeutic intervention
• Reliable communication
Team, Networks, and Triage

65. British Journal of Anaesthesia, 116 (3): 328–38 (2016)
Assessing Stroke
No perioperative stroke assessment scales
hat satisfy all such criteria.

66. mNIHSS (modified National Institutes of Health Stroke Scale)
2019 Guidelines for Management of AIS. Stroke. 2019;50:e344–e418

67. modified Rankin Scale
• Ordinal, 7-point global disability scale

68. JAMA. 2019;322(4):326-335
Intensive vs Standard Treatment of Hyperglycemia
Baseline
NIHSS
score

69. Proportion of participants with acute increases in mNIHSS scores
• First 3 postoperative days.
• 20% to 30% incidence
• Overt stroke (0.1 -1.9%)
• Covert stroke (7%)
• false positives
• low positive predictive
value
Front Neurol. 2019;10:560.
Routine clinical screening for stroke is
not recommended

70. • Glial fibrillary acid protein
• S-100β, neuron-specific enolase
• Matrix metalloproteinase-9
• Electroencephalographic slow-wave activity
• Oscillatory asymmetry
• Transcranial Doppler
• ?
Biochemical and neurophysiological methods

71. • Ischemic or hemorrhagic origin
• Correlate neurological deficit with radiologic findings
• Targeted assessments that focus on large-vessel pathology
• (1) distinct, robust pattern of neurological deficits
• (2) availability of effective neurointerventional therapies
(thrombectomy)
Immediate CT or MRI

72. • Recombinant tissue plasminogen activator (rtPA) or
mechanical thrombectomy
• Risk/benefit balance
• rtPA remains the standard therapy
• ? Perioperative state (bleeding ? )
Acute Interventions for Ischemic Stroke

73. Stroke. 2016;47:581-641.
Intracranial or
spinal surgery within 3 months

74. ACC 2019 February 34(1):86-91
rtPA
Immediate post op
VS
Delayed post op
Drainage ?
Transfusion ?

75. off-label use of tPA in periop stroke
• 134 patients
• recent surgery within 10 days 37 %,
• 64% had major surgery
• Nine patients (7%) developed surgical site hemorrhage after
IVT, of whom 4 (3%) were serious, but none was fatal
• Intracranial hemorrhage occurred in 9.7% and was
asymptomatic in all cases
Stroke. 2017;48:3034-3039

76. • Reduced disability at
90 days
• Reduce disability by
at least one level on
mRS for one patient
was 2.6 (NNT)
• Time window ?
HERMES (Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials)
collaboration.
Endovascular thrombectomy
Lancet 2016; 387: 1723–31

77. • Late endovascular therapy based on perfusion imaging, even
with intervention time windows up to 24 hours.
N Engl J Med 2018;378:11-21.
N Engl J Med 2018;378:708-18.
Intervention timing
N Engl J Med 2018;378:11-21.
DAWN
DEFUSE 3 trials

78. • Cardiac monitoring for at least the first 24 hours
• (Myocardial ischemia and cardiac arrhythmia)
• Hypertension (stress response to surgery, pain, and nausea, hypervolemia, full
bladder, response to hypoxia)
• Systolic blood pressure is usually treated only if it is >220mmHg, and diastolic
pressure is treated only if it is >120mmHg
• rtPA (intravenous or intra-arterial), systolic blood pressure >180mmHg and
diastolic pressure >105mmHg
Supportive Care for Acute Ischemic Stroke Patients

79. • SBP 130mmHg
Journal of Internal Medicine 2004; 255: 257–265
BP & mortality U-shaped pattern

80. Stroke. 2019;50:e344–e418.

81. 9 month
Wafarin 5 d, bridging
(mo~high risk)
NOAC 1-3 d (No bridging)
Normocapnia
Glucose 80-180
Routine screening X
Emergency imaging
Thrombectomy

82. 감사합니다
Boohwi Hong
koho0127@gmail.com