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Stroke

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Ross Hanrahan
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Assessing Perioperative Stroke Risk

Baseline Risk

In the POISE-2 cohort of patients with moderately elevated cardiovascular risk, perioperative stroke occurred in 0.35% of patients within the 30 days following surgery (1 in 286)1. In ~38000 patients undergoing non-carotid major vascular surgery, perioperative stroke occurred in 0.6% of patients (1 in 166)2.

Previous Stroke

Previous stroke is the most significant risk factor for perioperative stroke, and is associated with a 16 fold increased risk in the 30 days following surgery3.
Risk of Perioperative Stroke AS Compared to Patients with NO History of Stroke

Risk Factors for Perioperative Stroke

Time Since Previous Stroke

30 Day OR for Ischaemic Stroke

< 3 Months Prior

67.6

3 - < 6 Months Prior

24.02

6 - < 12 Months Prior

10.39

≥ 12 Months Prior

8.17

Any History of Stroke

16.24

Recency of Previous Stroke

Recency of the previous stroke compounds this risk substantially, with patients undergoing surgery within 3 months of a stroke suffering ~12% risk of perioperative stroke in the subsequent surgery.

These patients are also at substantially increased risk of major adverse cardiac events (MACE) and death..

30 Day Perioperative Risk of Stroke and MI According to Time Elapsed Between Stroke and Surgery

A Danish cohort study of ~400,000 patients concluded that the period of increased risk extends to around 9 months following the initial stroke.

Risk beyond that period remains elevated compared to patients without a history of stroke, but does not appear to decline further over time.

Association Between Time Elapsed Since Stroke and 30 Day Risk of Ischaemic Stroke, Major Adverse Cardiac Events (MACE) and Mortality.

Odds Ratios relative to Reference of Study Median Duration between Stroke and Surgery (665 Days)

The 2020 SNACC Guidelines have adopted these findings and advise considering delay of elective surgery until 9 months following stroke4.
WHERE POSSIBLE, SURGERY SHOULD BE DELAYED UNTIL 9 MONTHS HAVE ELAPSED FOLLOWING STROKE

Patient Risk Factors for Perioperative Stroke

Perioperative Stroke shares many of the same risk factors as perioperative MACE.

The following patient risk factors should be considered when weighing individual patent risk.

Risk Factors for Perioperative Stroke

Risk Factor

30 Day OR for Ischaemic Stroke

Emergency Surgery

~ 8

Postoperative Hypotension

~ 5

MI Within 6 Months

3.8

Renal Failure

2.98

Patent Foramen Ovale

2.6

History of Hypertension

2.0

Atrial Fibrilation

1.95

COPD

1.8

Valvular Heart Disease

1.54

Smoking

1.5

Surgical Risk Factors for Perioperative Stroke

Risk of perioperative stroke has been shown to vary by type of surgery5.  The below graph compared Odds Risk for perioperative stroke as compared to a reference of patients undergoing general surgery procedures.

Relative Risk of Perioperative Stroke in Different Surgical Procedures

Perioperative Stroke Risk Calculators

A specific risk score for prediction of perioperative stroke risk was developed by Mashour in 20116 and can be calculated below.
However, a recent analysis7 found that the MICA (GUPTA) Cardiovascular Risk Score (though developed to assess cardiovascular risk) was more discriminative than the Mashour score for of perioperative stroke prediction (AUC 0.833 vs 0.773). The MICA score cannot quantify stroke risk, but is still useful in identifying patients at increased risk. Both calculators are available below

High cardiovascular risk on the MICA score indicates an increased risk of perioperative stroke.

Other Things to Consider in at Risk Patients

Bridge patients with AF and a high CHAD2SVASC risk, Consider bridging moderate risk patients

Continue beta-blockers and statins in patients already on them

Regional anaesthesia may have some small benefit

propofol and volatile do not seem to a have significantly different risk

maintain baseline MAP

maintain normocapnoea (avoid hypocapnoea which may increase cerebrovascular resistance)

maintain BGL 7.2-10.0mmol

Intraoperative Hypotension (time spent with MAP more than 30% below baseline) is associated with risk of post-operative stroke8

References

  1. Aspirin in Patients Undergoing Noncardiac Surgery - POISE-2 - NEJM 2014
  2. Incidence, Predictors, and Outcomes of Perioperative Stroke in Noncarotid Major Vascular Surgery - Anesth Analg 2013
  3. Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Non-Cardiac Surgery - JAMA 2014
  4. Perioperative Care of Patients at High Risk of Stroke During or After Non-Cardac, Non-Neurological Surgery - 2020 SNACC Guidelines - J Neurosurg Anaesthesiol 2020
  5. Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery - GUPTA - CVA - JAMA 2017
  6. Perioperative stroke and Associated Mortality after Noncardiac, Nonneurologic Surgery - Anesthesiology 2011
  7. Cardiovascular Risk Scores to Predict Perioperative Stroke in Noncardiac Surgery - Stroke 2019
  8. Intraoperative Hypotension and Perioperative Ischaemic Stroke after General Surgery - Anesthesiology 2012
  9. Perioperative Stroke After Non-Cardiac, Non-Neurological Surgery - BJA Education 2020
  10. Perioperative Care of Patients at High Risk for Stroke During or After Non-Cardiac Surgery - J Neurosurg Anesthesiol 2014
  11. Cardiovascular Risk Scores to Predict Perioperative Stroke in Noncardiac Surgery - Stroke 2019
  12. Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery - GUPTA - CVA - JAMA 2017
  13. Perioperative stroke and Associated Mortality after Noncardiac, Nonneurologic Surgery - Anesthesiology 2011
  14. Development and Validation of a Prediction Model for Stroke Cardiac and Mortality Risk After Non-Cardiac Surgery - JAMA 2021
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