
A perioperative stroke is a stroke that occurs during or within 30 days of surgery. Although rare, it is one of the most feared complications of surgery, especially heart surgery. The risk of a perioperative stroke is higher in certain types of people, such as those who are elderly, female, or who suffer from migraines. The risk also varies depending on the type of surgery, with high-risk cardiac and brain surgeries increasing the chance of a perioperative stroke to as high as 10%.
Characteristics | Values |
---|---|
Chance of stroke during surgery | Low for most surgeries, but can be as high as 10% for high-risk cardiac and brain surgeries |
Risk factors | Age, gender, migraines, obesity, high blood pressure, high cholesterol, diabetes, previous stroke, atrial fibrillation, recent myocardial infarction |
Perioperative stroke | Stroke during surgery or within 30 days after surgery |
Impact | Potential brain damage or death, long-term disabilities such as paralysis, speech problems, vision loss, and loss of cognitive function |
Prevention | Maintaining a healthy diet and weight, not smoking, exercising, and eating a diet rich in fruits and vegetables |
What You'll Learn
Risk factors for perioperative stroke
Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. The risk factors for perioperative stroke can be categorised into modifiable and non-modifiable factors.
Non-modifiable risk factors
- Age: The risk of perioperative stroke increases with age. For people in their 80s or older, the risk can be six times greater.
- Gender: Female patients, especially elderly women, can have a higher risk of perioperative stroke due to increased atherosclerosis after menopause.
- Medical history: A history of stroke, atrial fibrillation, and recent myocardial infarction are also factors that increase the risk of perioperative stroke.
- Migraines: People who suffer from migraines, especially migraines with auras, showed an increased risk of perioperative stroke.
Modifiable risk factors
- Beta-blockers: Perioperative beta-blockade has emerged as a risk factor for stroke across the general surgical population.
- Anticoagulant and antiplatelet therapy: The risk of excessive perioperative bleeding is weighed against the risk of thromboembolism.
- Intraoperative hypotension: Most anesthetic agents may induce hypotension, which is a risk factor for perioperative stroke, especially when patients have significant large vessel stenosis.
- Intraoperative hypoxia: Poor systemic oxygenation might be a risk factor for perioperative stroke in patients with cardiopulmonary bypass.
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Lifestyle changes to reduce the risk of stroke
While there are some factors that cannot be controlled, such as age and genetics, there are many lifestyle changes that can be made to reduce the risk of a stroke.
Diet
A healthy, balanced diet is key to reducing the risk of a stroke. This includes eating plenty of fruit and vegetables (at least 4-5 cups a day), whole grains, lean proteins, and fish. A Mediterranean diet has been shown to be particularly beneficial. It is also important to limit salt and high-cholesterol food intake, as these can increase blood pressure and cholesterol levels, which are risk factors for a stroke.
Exercise
Regular exercise is another important factor in reducing the risk of a stroke. Aim for at least 150 minutes of moderate-intensity aerobic activity every week. This can include activities such as cycling or fast walking. Exercise helps to keep your blood flowing and your heart strong, as well as lowering cholesterol and maintaining healthy blood pressure.
Smoking
Smoking significantly increases the risk of a stroke, as it narrows the arteries and makes the blood more likely to clot. Quitting smoking will immediately lower your risk of a stroke and improve your overall health.
Alcohol Consumption
Excessive alcohol consumption can lead to high blood pressure and irregular heartbeat, both of which increase the risk of a stroke. Binge drinking also thins the blood, increasing the risk of bleeding. It is recommended that alcohol consumption is limited to one drink per day for women and two drinks for men.
Managing Underlying Conditions
If you have any underlying conditions that increase the risk of a stroke, such as high blood pressure, high cholesterol, atrial fibrillation, or diabetes, it is important to work with your doctor to manage and control these conditions. This may include taking regular medication and making the necessary lifestyle changes.
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Pre-screening and prevention during surgery
Pre-screening:
- Assessment of age: Older age is a significant risk factor for perioperative stroke, with the risk increasing up to six times for individuals in their 80s or older.
- Gender consideration: Female patients, especially elderly women, are at higher risk due to increased atherosclerosis after menopause.
- Medical history evaluation: Previous stroke, atrial fibrillation, recent myocardial infarction, and migraines (especially with auras) are associated with an increased risk of perioperative stroke.
- Vascular risk factors: High blood pressure, high cholesterol, Type 2 diabetes, smoking, heart failure, and renal disease are common vascular risk factors that can contribute to stroke.
- Carotid artery screening: A carotid ultrasound can detect the buildup of cholesterol-filled plaque in the carotid arteries, which supply blood to the brain. However, this test is generally not recommended for healthy individuals at average risk.
- Electrocardiogram (EKG): This non-invasive test helps assess the heart's function and rhythm, as an irregular heartbeat can be a stroke risk factor.
- Ankle-brachial index study: This non-invasive method helps determine if blood is efficiently flowing from the heart to the legs and arms, as inefficient blood flow is a risk factor.
- Metabolic and lipid panel: Lab tests that analyse blood can reveal high cholesterol, which is a risk factor for stroke.
- Glucose test: Checking for abnormal blood sugar levels is important as diabetes is a risk factor.
- C-reactive protein (CRP) test: This quick, finger-prick blood test checks for high C-reactive proteins, which can be an early warning sign of stroke.
- Body mass index (BMI) assessment: A BMI that is too high or too low can increase the risk of stroke.
Prevention during surgery:
- Monitor blood flow to the brain: Continuous monitoring ensures early detection of any changes in cerebral perfusion, which is crucial for prompt intervention.
- Intraoperative imaging of the aorta: Visualising the aorta during surgery can help identify atherosclerotic plaques or other abnormalities that may increase the risk of stroke.
- Tight blood pressure control: Maintaining stable blood pressure is essential to prevent sudden surges or drops that can lead to cerebral hyperperfusion or hypoperfusion, respectively.
- Close monitoring of blood loss and transfusion: Careful monitoring of blood loss and transfusion requirements helps maintain adequate blood volume and prevent complications that may increase stroke risk.
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Early diagnosis and treatment of perioperative stroke
- Timing of surgery following a stroke: It is recommended to delay elective non-neurological and non-cardiac surgery by at least three months after a stroke to allow for the restoration of cerebral autoregulation and reduce the risk of perioperative stroke.
- Preoperative carotid artery revascularisation: Patients with a history of stroke or transient ischaemic attack (TIA) who are scheduled for elective non-cardiac surgery should undergo carotid imaging. If symptomatic carotid stenosis of more than 50% is detected, revascularisation within 12 weeks of the event is recommended.
- Perioperative management of antiplatelet agents: The perioperative withdrawal of antiplatelet therapy increases the risk of perioperative stroke due to rebound hypercoagulability. However, continuing antiplatelet therapy may increase the risk of surgical site bleeding. A comprehensive individual assessment of thrombotic risk versus bleeding risk is crucial in guiding perioperative management.
- Perioperative management of oral anticoagulants: Temporary discontinuation of oral anticoagulants during the perioperative period requires careful management. The risk of thromboembolism during anticoagulation interruption must be balanced against the risk of bleeding associated with surgery. Bridging therapy with low molecular weight heparin may be considered to minimise thrombotic risk.
- Intraoperative and postoperative considerations: Maintaining adequate cerebral perfusion is crucial, especially in patients with carotid artery stenosis. Avoiding extreme blood glucose levels and optimising blood pressure management may also help reduce stroke risk.
- Perioperative beta-blockade: Beta-blockers, particularly non-selective beta-blockers, have been associated with an increased risk of perioperative stroke, especially in patients with anaemia. A risk-benefit analysis is recommended to guide perioperative beta-blockade management.
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Recovery and rehabilitation after perioperative stroke
Recovery and rehabilitation after a perioperative stroke can be a slow and uncertain process, and it varies from person to person. Here are some key aspects of recovery and rehabilitation:
Initial Treatment and Hospital Stay
After a stroke, the patient is typically admitted to an emergency department for initial treatment and stabilization. If the stroke is caused by a blood clot (ischemic stroke), clot-busting medication can be administered to reduce long-term effects. The patient may need to spend time in intensive or acute care. Rehabilitation should begin as soon as possible, ideally within 24 hours after the stroke. The rehabilitation team includes various specialists such as physiatrists, neurologists, physical and occupational therapists, speech-language pathologists, and nurses. The typical length of a hospital stay after a stroke is five to seven days. During this time, the stroke care team will evaluate the effects of the stroke and develop a rehabilitation plan.
Therapy and Rehabilitation
The long-term effects of a stroke vary depending on its severity and the area of the brain affected. Common effects include cognitive symptoms (e.g., memory problems, speech difficulties), physical symptoms (e.g., weakness, paralysis, swallowing difficulties), and emotional symptoms (e.g., depression, impulsivity). Physical and occupational therapy are crucial for helping patients regain function and adapt to any lasting impairments. Speech-language therapy is important for those with swallowing difficulties. Therapy sessions are typically conducted multiple times per day during the hospital stay and continue on an outpatient basis as needed. Rehabilitation psychologists and neuropsychologists can also provide support for cognitive and emotional challenges, helping patients and caregivers develop resilience in the face of potential lifestyle changes.
Discharge and Ongoing Recovery
The discharge plan will depend on the patient's level of functional impairment. Some patients may continue their rehabilitation in an inpatient or independent rehabilitation facility, while others may transition to a subacute rehabilitation facility or return home with outpatient rehabilitation services. The first three months after a stroke are considered the most critical for recovery, with most patients making significant progress during this time. Spontaneous recovery, where lost skills or abilities suddenly return, may occur during this period. However, setbacks, such as pneumonia, heart attacks, or additional strokes, can also happen and may require adjustments to the rehabilitation plan. Even after six months, improvements are still possible, but they will be slower. Most stroke patients reach a relatively steady state by this time, with some achieving a full recovery while others experience ongoing impairments.
Prevention of Perioperative Stroke
To prevent perioperative strokes, it is essential to identify and manage risk factors. These include patient-related factors such as age, sex, health conditions (e.g., obesity, high blood pressure, diabetes), and medical history (e.g., previous stroke, atrial fibrillation). The type of surgery also plays a role, with high-risk cardiac and brain surgeries carrying a higher risk of perioperative stroke. Proper management of anesthesia and vital signs during surgery is crucial, as intraoperative hypotension and hypoxia are risk factors for perioperative stroke.
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Frequently asked questions
A perioperative stroke is a stroke that occurs during surgery or within 30 days after surgery.
The risk of a perioperative stroke is generally low, but it depends on the type of surgery and the patient's health. For non-cardiac, non-neurological, and non-major surgery, the incidence is approximately 0.1% to 1.9%. However, for high-risk cardiac or brain surgery, the risk can be as high as 10%.
Factors that increase the risk of a perioperative stroke include age, sex, obesity, high blood pressure, high cholesterol, diabetes, history of stroke, atrial fibrillation, and recent myocardial infarction.