Anesthesia for Patients with Prior Stroke

Abstract

An increasing number of patients with a prior history of stroke present for various types of surgeries. They have varying degree of neurological disability and associated co-morbidities, which pose challenges for their perioperative management. There is paucity in literature about their management guidelines for noncardiac, noncarotid surgeries. The available literature suggests higher risk of perioperative stroke, postoperative neurological deficits, and other morbidities. Measures to reduce perioperative risks are discussed in this review. Prior optimization by improving modifiable risk factors, choosing appropriate timing of elective surgery, and careful titration of anesthesia and close monitoring are needed.

Keywords

stroke - anesthesia - perioperative risk - cerebral ischemia

• References

• 1 Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res 2017; 120 (03) 439-448
• 2 Krishnamurthi RV, Moran AE, Feigin VL. et al; GBD 2013 Stroke Panel Experts Group. Stroke prevalence, mortality and disability-adjusted life years in adults aged 20–64 Years in 1990–2013: data from the global burden of disease 2013 study. Neuroepidemiology 2015; 45 (03) 190-202
• 3 Logvinova AV, Litt L, Young WL, Lee CZ. Anesthetic concerns in patients with known cerebrovascular insufficiency. Anesthesiol Clin 2010; 28 (01) 1-12
• 4 Kim J, Gelb AW. Predicting perioperative stroke. J Neurosurg Anesthesiol 1995; 7 (03) 211-215
• 5 Mehdi Z, Birns J, Partridge J, Bhalla A, Dhesi J. Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery. Clin Med (Lond) 2016; 16 (06) 535-540 (Northfield Il)
• 6 McCrary MR, Song W, Ling W. Ischemic stroke mechanisms, prevention, and treatment: the anesthesiologist's perspective. J Anesth Perioper Med 2017; 4: 76-86
• 7 Meschia JF, Bushnell C, Boden-Albala B. et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45 (12) 3754-3832
• 8 Kernan WN, Ovbiagele B, Black HR. et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45 (07) 2160-2236
• 9 Aries MJ, Elting JW, De Keyser J, Kremer BP, Vroomen PC. Cerebral autoregulation in stroke: a review of transcranial Doppler studies. Stroke 2010; 41 (11) 2697-2704
• 10 Dawson SL, Blake MJ, Panerai RB, Potter JF. Dynamic but not static cerebral autoregulation is impaired in acute ischaemic stroke. Cerebrovasc Dis 2000; 10 (02) 126-132
• 11 Reinhard M, Roth M, Guschlbauer B. et al. Dynamic cerebral autoregulation in acute ischemic stroke assessed from spontaneous blood pressure fluctuations. Stroke 2005; 36 (08) 1684-1689
• 12 Zhao P, Alsop DC, Abduljalil A. et al. Vasoreactivity and peri-infarct hyperintensities in stroke. Neurology 2009; 72 (07) 643-649
• 13 Gommer ED, Staals J, van Oostenbrugge RJ, Lodder J, Mess WH, Reulen JP. Dynamic cerebral autoregulation and cerebrovascular reactivity: a comparative study in lacunar infarct patients. Physiol Meas 2008; 29 (11) 1293-1303
• 14 Nudo RJ. Postinfarct cortical plasticity and behavioral recovery. Stroke 2007; 38 (02) Suppl 840-845
• 15 Takeuchi N, Izumi S. Maladaptive plasticity for motor recovery after stroke: mechanisms and approaches. Neural Plast 2012; 2012: 359728
• 16 Ng JL, Chan MT, Gelb AW. Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology 2011; 115 (04) 879-890
• 17 Selim M. Perioperative stroke. N Engl J Med 2007; 356 (07) 706-713
• 18 Mashour GA, Moore LE, Lele AV, Robicsek SA, Gelb AW. Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2014; 26 (04) 273-285
• 19 Landercasper J, Merz BJ, Cogbill TH. et al. Perioperative stroke risk in 173 consecutive patients with a past history of stroke. Arch Surg 1990; 125 (08) 986-989
• 20 Mashour GA, Sharifpour M, Freundlich RE. et al. Perioperative metoprolol and risk of stroke after noncardiac surgery. Anesthesiology 2013; 119 (06) 1340-1346
• 21 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 (05) [phone]
• 22 Jørgensen ME, Torp-Pedersen C, Gislason GH. et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA 2014; 312 (03) 269-277
• 23 Biteker M, Kayatas K, Türkmen FM, Mısırlı CH. Impact of perioperative acute ischemic stroke on the outcomes of non-cardiac and nonvascular surgery: a single centre prospective study. Can J Surg 2014; 57 (03) E55-E61
• 24 Sanders RD, Jørgensen ME, Mashour GA. Perioperative stroke: a question of timing?. Br J Anaesth 2015; 115 (01) 11-13
• 25 Bucerius J, Gummert JF, Borger MA. et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003; 75 (02) 472-478
• 26 Maatz W, Köhler J, Botsios S, John V, Walterbusch G. Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion. Ann Vasc Surg 2008; 22 (01) 45-51
• 27 Chiao SS, Zuo ZY. Approach to risk management of perioperative stroke. J Anesth Perioper Med 2015; 2: 268-276
• 28 Wong GY, Warner DO, Schroeder DR. et al. Risk of surgery and anesthesia for ischemic stroke. Anesthesiology 2000; 92 (02) 425-432
• 29 Bateman BT, Schumacher HC, Wang S, Shaefi S, Berman MF. Perioperative acute ischemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes. Anesthesiology 2009; 110 (02) 231-238
• 30 Mortazavi SM, Kakli H, Bican O, Moussouttas M, Parvizi J, Rothman RH. Perioperative stroke after total joint arthroplasty: prevalence, predictors, and outcome. J Bone Joint Surg Am 2010; 92 (11) 2095-2101
• 31 Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology 2011; 114 (06) 1289-1296
• 32 Pasternak JJ, Lanier WL. Diseases affecting the brain. In: Hines RL, Marschall KE. eds. Stoelting's Anesthesia and Co-Existing Disease. 7th ed.. Philadelphia: Elsevier Inc.; 2018: 218-254
• 33 Parikh S, Cohen JR. Perioperative stroke after general surgical procedures. N Y State J Med 1993; 93 (03) 162-165
• 34 Herderscheê D, Hijdra A, Algra A, Koudstaal PJ, Kappelle LJ, van Gijn J. The Dutch TIA Trial Study Group. Silent stroke in patients with transient ischemic attack or minor ischemic stroke. Stroke 1992; 23 (09) 1220-1224
• 35 Streifler JY, den Hartog AG, Pan S. et al; ACST-1 trial collaborators. Ten-year risk of stroke in patients with previous cerebral infarction and the impact of carotid surgery in the Asymptomatic Carotid Surgery Trial. Int J Stroke 2016; 11 (09) 1020-1027
• 36 Thal GD, Szabo MD, Lopez-Bresnahan M, Crosby G. Exacerbation or unmasking of focal neurologic deficits by sedatives. Anesthesiology 1996; 85 (01) 21-25 discussion 29A–30A
• 37 Lazar RM, Fitzsimmons BF, Marshall RS. et al Reemergence of stroke deficits with midazolam challenge. Stroke 2002; 33 (01) 283-285
• 38 Bernstock JD, Budinich CS, Cohen LG, Awosika OO. Recrudescence of focal stroke symptoms during pain management with hydromorphone. Front Neurol 2016; 7: 50
• 39 Topcuoglu MA, Saka E, Silverman SB, Schwamm LH, Singhal AB. Recrudescence of deficits after stroke: Clinical and imaging phenotype, triggers, and risk factors. JAMA Neurol 2017; 74 (09) 1048-1055
• 40 Cucchiara RF. Differential awakening. Anesth Analg 1992; 75 (03) 467
• 41 Matthew E, Andreason P, Pettigrew K. et al. Benzodiazepine receptors mediate regional blood flow changes in the living human brain. Proc Natl Acad Sci U S A 1995; 92 (07) 2775-2779
• 42 Lazar RM, Fitzsimmons BF, Marshall RS, Mohr JP, Berman MF. Midazolam challenge reinduces neurological deficits after transient ischemic attack. Stroke 2003; 34 (03) 794-796
• 43 Pang W, Lin RM, Lin M. et al. Midazolam-induced unexpected monoparesis : not contraindicated for ambulatory general anesthesia. Ambul Surg 2018; 24: 12-14
• 44 Aldrete JA, Reza-Medina M, Daud O. et al. Exacerbation of preexisting neurological deficits by neuraxial anesthesia: report of 7 cases. J Clin Anesth 2005; 17 (04) 304-313
• 45 Veenith TV, Din AH, Eaton DM, Burnstein RM. Perioperative care of a patient with stroke. Int Arch Med 2010; 3: 33
• 46 Keldahl ML, Eskandari MK. Timing of carotid surgery after acute stroke. Expert Rev Cardiovasc Ther 2010; 8 (10) 1399-1403
• 47 Rockman CB, Maldonado TS, Jacobowitz GR, Cayne NS, Gagne PJ, Riles TS. Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes. J Vasc Surg 2006; 44 (03) 480-487
• 48 Annambhotla S, Park MS, Keldahl ML. et al. Early versus delayed carotid endarterectomy in symptomatic patients. J Vasc Surg 2012; 56 (05) 1296-1302 discussion 1302
• 49 Liu H, Chu J, Zhang L, Liu C, Yan Z, Zhou S. Clinical comparison of outcomes of early versus delayed carotid artery stenting for symptomatic cerebral watershed infarction due to stenosis of the proximal internal carotid artery. BioMed Res Int 2016; 2016: 6241546
• 50 Koraen-Smith L, Troëng T, Björck M, Kragsterman B, Wahlgren CM. Swedish Vascular Registry and the Riks-Stroke Collaboration. Urgent carotid surgery and stenting may be safe after systemic thrombolysis for stroke. Stroke 2014; 45 (03) 776-780
• 51 Christiansen MN, Andersson C, Gislason GH. et al. Risks of cardiovascular adverse events and death in patients with previous stroke undergoing emergency noncardiac, non-intracranial surgery: the importance of operative timing. Anesthesiology 2017; 127 (01) 9-19
• 52 Blacker DJ, Flemming KD, Link MJ, Brown Jr. RD. The preoperative cerebrovascular consultation: common cerebrovascular questions before general or cardiac surgery. Mayo Clin Proc 2004; 79 (02) 223-229
• 53 Pini R, Faggioli G, Longhi M. et al. The detrimental impact of silent cerebral infarcts on asymptomatic carotid endarterectomy outcome. J Vasc Surg 2016; 64 (01) 15-24
• 54 Ramnemark A, Nyberg L, Borssén B, Olsson T, Gustafson Y. Fractures after stroke. Osteoporos Int 1998; 8 (01) 92-95
• 55 Kristensen SD, Knuuti J, Saraste A. et al; Authors/Task Force Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35 (35) 2383-2431
• 56 Mills EJ, Wu P, Chong G. et al. Efficacy and safety of statin treatment for cardiovascular disease: a network meta-analysis of 170,255 patients from 76 randomized trials. QJM 2011; 104 (02) 109-124
• 57 Fallouh N, Chopra V. Statin withdrawal after major noncardiac surgery: risks, consequences, and preventative strategies. J Hosp Med 2012; 7 (07) 573-579
• 58 Wallace AW, Au S, Cason BA. Association of the pattern of use of perioperative β-blockade and postoperative mortality. Anesthesiology 2010; 113 (04) 794-805
• 59 Devereaux PJ, Mrkobrada M, Sessler DI. et al; POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370 (16) 1494-1503
• 60 Gerstein NS, Schulman PM, Gerstein WH, Petersen TR, Tawil I. Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg 2012; 255 (05) 811-819
• 61 Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005; 257 (05) 399-414
• 62 Oscarsson A, Gupta A, Fredrikson M. et al. To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth 2010; 104 (03) 305-312
• 63 Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J. Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol 2005; 62 (08) 1217-1220
• 64 Mehta SR, Yusuf S. Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Study Investigators. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial programme; rationale, design and baseline characteristics including a meta-analysis of the effects of thienopyridines in vascular disease. Eur Heart J 2000; 21 (24) 2033-2041
• 65 Douketis JD, Spyropoulos AC, Spencer FA. et al. Perioperative management of antithrombotic therapy. Antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141 (02) suppl e326S-e350S
• 66 Armstrong MJ, Gronseth G, Anderson DC. et al. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013; 80 (22) 2065-2069
• 67 Müller R, Knüttgen D, Vorweg M, Doehn M. Neuromuscular monitoring in a patient with hemiparesis. Resistance of the paralysed musculature to non-depolarising muscle relaxants [German]. Anaesthesist 2002; 51 (08) 644-649
• 68 Engelhard K. Anaesthetic techniques to prevent perioperative stroke. Curr Opin Anaesthesiol 2013; 26 (03) 368-374
• 69 Fuhrer H, Reinhard M, Niesen WD. Paradigm change? Cardiac output better associates with cerebral perfusion than blood pressure in ischemic stroke. Front Neurol 2017; 8: 706
• 70 Gillespie R, Shishani Y, Streit J. et al. The safety of controlled hypotension for shoulder arthroscopy in the beach-chair position. J Bone Joint Surg Am 2012; 94 (14) 1284-1290
• 71 Vohra HA, Modi A, Ohri SK. Does use of intraoperative cerebral regional oxygen saturation monitoring during cardiac surgery lead to improved clinical outcomes?. Interact Cardiovasc Thorac Surg 2009; 9 (02) 318-322
• 72 Lewis SC, Warlow CP, Bodenham AR. et al; GALA Trial Collaborative Group. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008; 372 9656 2132-2142
• 73 Memtsoudis SG, Sun X, Chiu YL. et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013; 118 (05) 1046-1058
• 74 Sanders RD, Graham C, Lewis SC, Bodenham A, Gough MJ, Warlow C. GALA Trial Investigators. Nitrous oxide exposure does not seem to be associated with increased mortality, stroke, and myocardial infarction: a non-randomized subgroup analysis of the General Anaesthesia compared with Local Anaesthesia for carotid surgery (GALA) trial. Br J Anaesth 2012; 109 (03) 361-367
• 75 Myles PS, Leslie K, Chan MTV. et al; ANZCA Trials Group for the ENIGMA-II investigators. The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet 2014; 384 9952 1446-1454
• 76 Whalin MK, Lopian S, Wyatt K. et al. Dexmedetomidine: a safe alternative to general anesthesia for endovascular stroke treatment. J Neurointerv Surg 2014; 6 (04) 270-275
• 77 John S, Somal J, Thebo U. et al. Safety and hemodynamic profile of propofol and dexmedetomidine anesthesia during intra-arterial acute stroke therapy. J Stroke Cerebrovasc Dis 2015; 24 (10) 2397-2403
• 78 Treurniet KM, Berkhemer OA, Immink RV. et al; MR CLEAN investigators. A decrease in blood pressure is associated with unfavorable outcome in patients undergoing thrombectomy under general anesthesia. J Neurointerv Surg 2018; 10 (02) 107-111
• 79 Bijker JB, Persoon S, Peelen LM. et al. Intraoperative hypotension and perioperative ischemic stroke after general surgery: a nested case-control study. Anesthesiology 2012; 116 (03) 658-664
• 80 Meng L, Gelb AW. Regulation of cerebral autoregulation by carbon dioxide. Anesthesiology 2015; 122 (01) 196-205
• 81 Smith JS, Roizen MF, Cahalan MK. et al. Does anesthetic technique make a difference? Augmentation of systolic blood pressure during carotid endarterectomy: effects of phenylephrine versus light anesthesia and of isoflurane versus halothane on the incidence of myocardial ischemia. Anesthesiology 1988; 69 (06) 846-853
• 82 Cullen DJ, Kirby RR. Beach chair position may decrease cerebral perfusion: Catastrophic outcomes have occured. APSF Newsl 2007; 22: 25-27
• 83 Gelb AW, Cowie DA. Perioperative stroke prevention. Anesth Analg 2001; 92: 46-53
• 84 Hare GM, Tsui AK, McLaren AT, Ragoonanan TE, Yu J, Mazer CD. Anemia and cerebral outcomes: many questions, fewer answers. Anesth Analg 2008; 107 (04) 1356-1370
• 85 Giuffrida S, Carpinteri G, Modica D. et al. Focal neurological deficit in acute anemia: case reports and review of the literature. World J Neurosci 2013; 3: 53-56
• 86 Kimberly WT, Wu O, Arsava EM. et al. Lower hemoglobin correlates with larger stroke volumes in acute ischemic stroke. Cerebrovasc Dis Extra 2011; 1 (01) 44-53
• 87 Gandhi GY, Nuttall GA, Abel MD. et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med 2007; 146 (04) 233-243
• 88 Bellolio MF, Gilmore RM, Ganti L. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 2014; (01) CD005346
• 89 Zietemann V, Wollenweber FA, Bayer-Karpinska A, Biessels GJ, Dichgans M. Peripheral glucose levels and cognitive outcome after ischemic stroke—results from the Munich Stroke Cohort. Eur Stroke J 2016; 1: 51-60
• 90 Epstein AE, Alexander JC, Gutterman DD, Maisel W, Wharton JM. American College of Chest Physicians. Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest 2005; 128 (02) Suppl 24S-27S
• 91 Fogarty MackP. Intracranial haemorrhage: therapeutic interventions and anaesthetic management. Br J Anaesth 2014; 113 (Suppl. 02) ii17-ii25
• 92 Huhtakangas J, Löppönen P, Tetri S. et al. Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study. Stroke 2013; 44 (03) 585-590