Marc Holland
Strokes are a medical emergency and the faster you receive treatment, the better. A stroke occurs when there is an abrupt interruption to the constant blood flow to the brain, resulting in a loss of neurological function. Depending on the severity of the stroke, you may need to spend time in intensive care or acute care.
The rehabilitation process after a stroke is slow and uncertain, and varies from person to person. The rehabilitation team includes physiatrists, neurologists, physical and occupational therapists, speech-language pathologists and nurses, who work together to help the patient recover as much function as possible in day-to-day activities.
The recovery timeline after a stroke typically includes:
- Initial treatment in the emergency department
- Intensive inpatient stroke rehab
- Inpatient rehabilitation unit or independent rehabilitation facility
- Subacute rehabilitation facility
- Outpatient rehabilitation clinic
The most rapid recovery from a stroke takes place within the first three to four months, with improvements continuing for up to 18 months post-stroke. However, it is important to note that having a stroke puts you at high risk of having another one.
| Characteristics | Values |
|---|---|
| Risk factors | Age, sex, history of stroke or transient ischemic attack, cardiac surgery, neurosurgery, concomitant carotid and cardiac surgery, aortic surgery, mitral valve surgery, coronary artery bypass graft surgery, external carotid-internal carotid bypass surgery, carotid endarterectomy, aneurysm clipping, thoracic surgery, vascular surgery, transplantation surgery, high blood pressure, high cholesterol, Type 2 diabetes, smoking, heart failure, renal disease, atrial fibrillation, prior stroke or heart attack, heredity and race |
| Prevention | Pre-screening, intraoperative imaging of the aorta, tight blood pressure control, blood flow monitoring, blood loss and transfusion monitoring |
| Early diagnosis | Complete neurological exam, fast-track anesthesia protocol, stroke team, head CT and CT angiography of head and neck |
| Treatment | Intensive care, brain oxygenation and perfusion optimization, clot-busting or clot removal therapy, speech and swallow function evaluation, rehabilitation, depression screening, deep vein thrombosis preventive therapy |
What You'll Learn
What is a perioperative stroke?
A perioperative stroke is a brain infarction of ischemic or hemorrhagic origin that occurs during surgery or within 30 days after surgery, including the period after recovering from anesthesia. It is considered the most unwanted complication for patients, surgeons, and anesthesiologists. The risk of perioperative stroke varies with the type of surgery, ranging from approximately 0.1% to 1.9% in non-cardiac, non-neurologic, and non-major surgery, and up to 10% in high-risk cardiac or brain surgery.
The risk factors for perioperative stroke can be categorized into modifiable and non-modifiable factors. Non-modifiable risk factors include age, sex, and a history of stroke or transient ischemic attack. Being female and elderly are associated with a higher risk of perioperative stroke. The risk increases significantly among octogenarians compared to younger populations. A history of stroke is a strong predictor of perioperative stroke, and patients with a previous stroke remain at a higher risk of future cerebrovascular complications.
Modifiable risk factors include severe carotid stenosis, atrial fibrillation, recent myocardial infarction, diabetes, peripheral vascular disease, and previous cardiac surgery. Severe carotid stenosis may limit cerebral perfusion and increase the risk of cerebral embolism during surgery. Atrial fibrillation can cause dangerous blood clots that can dislodge and travel to the brain, leading to a stroke. Recent myocardial infarction, diabetes, and peripheral vascular disease are associated with increased blood thrombogenicity and impaired autoregulation of cerebral blood flow.
The prevention, early diagnosis, and proper management of perioperative stroke are crucial. Pre-screening, surgical technique changes, early diagnosis during surgery, and quick team response can improve patient survival and reduce the risk of major disability.
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What are the risk factors for perioperative stroke?
The risk factors for perioperative stroke can be divided into modifiable and non-modifiable categories.
Non-modifiable risk factors
- Age: The risk of perioperative stroke increases by six-fold among octogenarians compared to younger populations.
- Sex: Being female is a risk factor for perioperative stroke in both cardiovascular and non-cardiovascular surgeries.
- History of stroke or transient ischemic attack: Patients with a history of stroke or transient ischemic attack have an elevated risk of perioperative stroke.
Modifiable risk factors
- Perioperative beta-blockade: Beta-blockers are associated with an increased risk of perioperative stroke, especially in non-cardiac surgery patients.
- Anticoagulant and antiplatelet therapy: The risk of perioperative stroke associated with anticoagulant and antiplatelet therapy is unclear and requires further investigation.
- Intraoperative hypotension: Most anesthetic agents induce hypotension, which is a risk factor for perioperative stroke, especially when patients have significant large vessel stenosis.
- Intraoperative hypoxia: Poor systemic oxygenation during surgery might be a risk factor for perioperative stroke.
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How can you reduce the risk of perioperative stroke?
Prevention During Surgery
- Monitor blood flow to the brain
- Perform intraoperative imaging of the aorta
- Maintain tight blood pressure control
- Monitor blood loss and the need for transfusion closely
Early Stroke Diagnosis
- Perform a complete neurological exam as soon as possible after surgery
- If the patient is at high risk of perioperative stroke, consider a fast-track anesthesia protocol to help quickly identify signs of a stroke after surgery
- Have a stroke team on hand to provide emergency treatment if a stroke is suspected
- Conduct a head CT and CT angiography of the head and neck as soon as a stroke is suspected
Rapid Treatment of Perioperative Stroke
- Transfer the patient to intensive care
- Optimize brain oxygenation and perfusion
- Consider clot-busting or clot removal therapy
- Evaluate the patient's speech and swallow function, evaluate for rehabilitation, screen for depression, and begin preventive therapy for deep vein thrombosis
Other Considerations
- Delay elective non-neurological non-cardiac surgery by at least one month after a stroke, to allow for the restoration of cerebral autoregulation and a decrease in the risk of developing perioperative stroke
- Monitor and control intraoperative hypotension and hypoxia, especially in patients with significant large vessel stenosis
- In the case of patients with atrial fibrillation, consider the risks and benefits of anticoagulation therapy
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What are the treatment options for ischemic stroke?
Treatment Options for Ischemic Stroke
Ischemic stroke is the most common type of stroke, accounting for about 87% of all strokes. It occurs when a vessel supplying blood to the brain is blocked, usually by a blood clot. This blockage cuts off the blood supply to the brain, causing damage. The urgent treatment for ischemic stroke is clot removal, which can be achieved through medication or mechanical treatments.
Medication
Tissue plasminogen activator, r-tPA (alteplase), is a drug approved by the FDA to treat ischemic stroke. It is administered through an IV in the arm, dissolving the clot and restoring blood flow to the affected area of the brain. This treatment is time-sensitive, and many people do not arrive at the hospital in time to receive it. Therefore, it is crucial to identify stroke symptoms and seek immediate medical attention.
Mechanical Treatments
Mechanical thrombectomy is a procedure used to remove clots in eligible patients with a large vessel occlusion (LVO). In this procedure, doctors use a wire-cage device called a stent retriever, which is guided through an artery in the groin up to the blocked artery in the brain. The stent opens and captures the clot, and special suction tubes may also be used for removal. This procedure is typically performed within six hours of the onset of acute stroke symptoms but can be done up to 24 hours after symptoms begin if imaging tests show undamaged brain tissue.
Additional Treatments and Prevention
In addition to clot removal, the focus of hospital care for stroke patients includes monitoring to detect and prevent complications, finding the cause of the stroke, initiating treatment to prevent future strokes, and starting the recovery process, which may include rehabilitation. Lifestyle changes, such as improving diet and quitting smoking, can also help lower the risk of having another stroke.
In some cases, surgery may be recommended to open blocked arteries and improve blood flow to the brain. This includes procedures such as carotid endarterectomy, where a vascular surgeon makes a small incision in the neck at the site of the blockage to clean out the plaque. Carotid angioplasty is another option, where a small tube (catheter) is inserted into an artery in the leg or arm and guided to the blocked carotid artery. A tiny balloon at the end is inflated to widen the artery, and a stent is usually left behind to keep it open and prevent future blockages.
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What are the treatment options for hemorrhagic stroke?
Hemorrhagic stroke is a life-threatening medical emergency that occurs when a blood vessel inside or on the surface of the brain ruptures. It is less common than ischemic strokes, which are caused by blood clots or atherosclerosis in the arteries. Hemorrhagic strokes account for 10-15% of all strokes and are more common among men and older people (65+).
- Hemostatic therapy: Doctors work to reduce the size of the hematoma, which is a mass of blood that forms when a blood vessel ruptures. This helps to prevent further brain injury and increase the chances of survival. Some hematomas are surgically removed, but many do not require surgery.
- Surgery to repair an aneurysm: Surgeons may place a stent, coil, or clip at the site of the ruptured blood vessel to stop the bleeding and reinforce the weakened blood vessel wall.
- Surgery to remove an arteriovenous malformation (AVM): This procedure is recommended if the AVM is easily accessible and not located deep within the brain tissue. AVMs are rare tangles of blood vessels that disrupt normal blood flow and oxygen circulation.
- Stereotactic radiosurgery: When an AVM is inaccessible by surgery, this procedure may be used to prevent it from bleeding again. It involves aiming high-energy beams at the weakened spot to create scar tissue and prevent future bleeding.
- Reducing pressure on the brain: The patient's head may be elevated at a 30-degree angle to help relieve pressure. Other medical treatments may also be used to control brain swelling.
- Medication: Medication may be prescribed to alleviate intense headaches, reduce blood pressure, control pain, and prevent anxiety, headaches, and seizures. Beta-blockers, calcium channel blockers, and ACE inhibitors are commonly used to lower blood pressure. Anti-seizure medications are also used, as about one-third of hemorrhagic stroke survivors experience seizures during the first few weeks.
- Lifestyle changes: To reduce the risk of recurrent hemorrhagic stroke, doctors may recommend controlling blood pressure, consuming less alcohol, avoiding cocaine and amphetamine use, and stopping blood-thinning medications.
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Frequently asked questions
A stroke is an abrupt interruption of constant blood flow to the brain that causes a loss of neurological function.
The interruption of blood flow can be caused by a blockage, leading to the more common ischemic stroke, or by bleeding in the brain, leading to the more deadly hemorrhagic stroke. Ischemic strokes constitute an estimated 87% of all stroke cases.
Controllable or treatable risk factors for stroke include smoking, high blood pressure, carotid or other artery disease, diabetes, high blood cholesterol, physical inactivity and obesity.
Uncontrollable risk factors include age, gender, heredity and race, and a prior stroke or heart attack.
Warning signs may include dizziness, nausea or vomiting, an unusually severe headache, confusion, disorientation or memory loss, numbness, weakness in an arm, leg or the face, abnormal or slurred speech, difficulty with comprehension, loss of vision or difficulty seeing, and loss of balance, coordination or the ability to walk.
