Journal of Anesthesia and Perioperative Medicine

Review Article

Approach to Risk Management of Perioperative Stroke

Sunny S. Chiao, and Zhi-Yi Zuo

ABSTRACT

From Department of Anesthesiology,
University of Virginia, Charlottesville,
Virginia, USA.
Correspondence to Dr. Zhi- Yi Zuo at
zz3c@virginia.edu.
Citation: Sunny S. Chiao, Zhi- Yi Zuo.
Approach to risk management of
perioperative stroke. J Anesth Periop-
er Med 2015; 2: 268-76.
Aim of review: Perioperative stroke is a rare, but potentially devastating complica-
tion. This review is performed to draw attention of perioperative care providers to
this complication and improve their understanding on the risk factors for periopera-
tive stroke so that better management of patients with risk factors can be achieved.
Method: Literature was searched and reviewed to identify articles on risk factors of
perioperative stroke and management of these risk factors.
Recent findings: Stroke rates are as high as 6% after cardiac, neurosurgical, and vas-
cular surgery, and are lower (<1%) after general surgery. Perioperative stroke is most-
ly ischemic. Risk factors that are not modifiable include increasing age and female
gender. Morbidities that increase the risk for perioperative stroke include renal fail-
ure, history of stroke or transient ischemic attack, diabetes mellitus, atrial fibrillation,
congestive heart failure, smoking status, emergency surgery, carotid stenosis, and val-
vular cardiac disease. Modifiable factors for perioperative stroke during periopera-
tive period include judicious use of antithrombotic therapy and beta-blockers, avoid-
ance of hypotension and maintenance of normal blood glucose levels.
Summary: Many risk factors for perioperative stroke have been revealed. Careful
management of the modifiable risk factors may reduce the occurrence of periopera-
tive stroke.

S
troke is an acute cerebral vascular
event leading to brain tissue injury.
It can be diagnosed based on pathol-
ogy, imaging, or clinical symptomatolo-
gy (1). The annual rate of stroke related
death has declined over the last decade.
Annually in the USA, about 795,000
people experience new or recurrent
stroke; about 610,000 are first events
and 185,000 are recurrent events. In
2011, stroke was the fourth leading
cause of death in the United States ac-
counting for about 1 in every 20 deaths
from all causes (2).
The incidence of perioperative stroke
(usually defined as stroke within 30
days after surgery) varies widely depend-
ing on the types of surgical procedure.
The risk is highest in cardiac, neurosur-
gical, and vascular surgery (0.6- 5.4% )
(3-6), and is significantly less after gener-
al surgery, where the incidence is 0.08-
0.7% (Table 1) (7-9). Besides the neuro-
logical deficit experienced by an individ-
ual after stroke, perioperative stroke is
associated with longer hospital stays
and higher disability, discharge to long
term care facilities, and risk of mortality
(2, 5, 7, 8). Perioperative stroke also is
associated with much higher mortality
(26%- 87% ) (10) as compared with
stroke mortality in the non- periopera-
tive setting (16%-23%) (10-12).
This article will review pathophysiol-
ogy and identify risk factors for periop-
erative stroke, and make recommenda-
tions regarding perioperative optimiza-
tion of at- risk patients to minimize inci-
dence, morbidity, and mortality of peri-
operative stroke.

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Sunny S. Chiao et al.
Pathophysiological Conditions for
Perioperative Stroke
Acute stroke can be divided into two subtypes:
ischemic and hemorrhagic stroke. Cerebral isch-
emia can occur from reductions in blood flow;
infarction can occur within 4- 10 minutes with
complete cessation of blood flow to the brain tis-
sues (22). The majority of perioperative strokes
are ischemic, rather than hemorrhagic, in nature
(23, 24). Conditions for increased risk of periop-
erative ischemic stroke include cerebral athero-
thrombosis, atrial fibrillation, hypotension, hy-
percoagulability, paradoxical embolism, and
cerebrovascular dissection (25). Hemorrhagic
stroke includes intracerebral hemorrhage and
subarachnoid hemorrhage (26). Patients with un-
controlled hypertension or on anticoagulants
are at high risk of hemorrhagic stroke. Obesity,
age, male gender, high alcohol intake, smoking
behavior and diabetes are other risk factors for
hemorrhagic stroke (26- 28). Hemorrhagic
stroke exerts its damaging effects either by pres-
sure effects on surrounding tissue, or by direct
toxic effects of blood on neuronal tissue (27).
Common etiologies of ischemic stroke in-
clude thromboembolism induced by surgery or
secondary to atrial fibrillation, and cerebral hy-
poperfusion secondary to carotid stenosis. Atrial
fibrillation likely contributes to acute stroke in
two ways: either through embolism of cardiac
thrombus, or through global hypoperfusion and
cerebral ischemia induced by rapid ventricular
response and hypotension (9). Less common
causes of stroke have been reported to be air,
fat, or paradoxical embolism, arterial dissection
of neck arteries, cardiac valvular diseases, hyper-
coagulable states, and abrupt cessation of antico-
agulation or antiplatelet therapies (7, 9). Water-
shed infarcts can occur in the absence of physi-
cal arterial obstruction at the junction between
two major arterial distributions, and are thought
to be secondary to decreased perfusion to the
distal territory of the artery and resultant isch-
emia (29). In any case, the shared commonality
is altered cerebral circulation resulting in neuro-
nal cell injury or death. Transient ischemic at-
tack (TIA) is a fleeting "version" of stroke, with
no residual deficits.
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Risk Management of Perioperative Stroke
Table 1. Incidence of Perioperative Stroke by Surgery Type (%).
Surgery type Stroke risk (%) References
General surgery 0.08-1.0 Bateman, 2009 (9)
Orthopedic surgery 0.2-0.9 Bateman, 2009 (9)
Non-carotid major vascular surgery 0.6 Sharifpour, 2013 (5)
Head and neck surgery 0.2-4.8 Nosan, 1993 (13);
Thompson, 2004 (14)
Carotid endarterectomy 1.4 Gupta, 2011 (15)
Coronary artery bypass grafting 1.2-2.3 Sezai, 2015 (16)
Valve surgery 1.4-6.5 O'Brien, 2009 (17);
Biancari, 2013 (18, 19)
Thoracic endovascular aortic surgery 3.8 Ullery, 2012 (20)
Open thoracic aortic surgery 5.4-5. 8 Quintana, 2014 (4);
Higgins, 2014 (21)
Etiology for hemorrhagic stroke includes in-
tracranial aneurysm and arteriovenous malfor-
mations. These vascular diseases weaken blood
vessel walls that are easy to be ruptured. Howev-
er, uncontrolled hypertension and illegal drug
use can induce rupture of vessels without these
changes (26, 27, 30).
Risk Factors and Risk Optimization
Many risk factors for perioperative stroke have
been identified (Table 2), although some of the
most commonly identified ones are unfortunate-
ly unmodifiable. These unmodifiable factors in-
clude increasing age and female gender (5, 8, 9,
12, 24, 31, 32). Other independent risk factors
include previous history of stroke or TIA, renal
failure, diabetes mellitus, atrial fibrillation, con-
gestive heart failure, smoking status, emergency
surgery, and cardiac valvular disease (5, 8, 9, 12,
24, 31). Additional described risk factors in-
clude intraoperative complications including hy-
potension, cardiac arrhythmias or rate derange-
ments, hyperglycemia, dehydration, and acute
blood loss or anemia. We will focus our discus-
sion on modifiable risk factors.
Age
Bateman et al. (9) studied 371,641 patients iden-
tifying acute ischemic stroke (AIS) in the periop-
erative setting for non- cardiac and nonvascular
surgery. The rate of AIS in all patients with hemi-
colectomy was 0.7% , total hip replacement was
0.2% , and lobectomy/segmental lung resection
was 0.6% . These rates rose to 1.0% , 0.3% , and
0.8% , respectively, in patients older than 65
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Journal of Anesthesia and Perioperative Medicine Review Article

Table 2. Identified Independent Predictors of Perioperative Stroke.

Predictors Odds ratio Confidence intervals Reference
Age
Age (per 10 years) 1.43 1.35-1.51 Bateman, 2009 (9)
Age (per additional year) 1.02 1.01-1.04 Sharifpour, 2013 (5)
Age 50-69 4.7 1.8-12.4 Kikura, 2008 (31)
Age 70+ 23.6 9.6-58.1 Kikura, 2008 (31)
Age (per 10 years) 2.5 1.01-3.2 Biteker, 2014 (12)
Age ≥62 years 3.9* 3.0-5.0 Mashour, 2011 (8)
Renal disease
Renal disease 2.98 2.52-3.54 Bateman, 2009 (9)
Acute renal failure 3.6* 2.3-5.8 Mashour, 2011 (8)
Dialysis dependence 2.3* 1.6-3.4 Mashour, 2011 (8)
History of kidney disease (creatine≥2) 1.3 0.8-2.3 Kikura, 2008 (31)
History of stroke, TIA, cerebrovascular disease
History of previous stroke or TIA 1.64 1.25-2.14 Bateman, 2009 (9)
History of previous stroke or TIA 3.6 1.2-4.8 Biteker, 2014 (12)
History of cerebrovascular disease 7.1 4.6-11.0 Kikura, 2008 (31)
History of stroke, TIA, or hemiplegia 1.72 1.29-2.30 Sharifpour, 2013 (5)
Previous cerebrovascular disease 12.57* 2.14-73.7 Limburg, 1998 (24)
Gender
Female gender 1.21 1.07-1.36 Bateman, 2009 (9)
Female gender 1.47 1.12-1.93 Sharifpour, 2013 (5)
Female gender 1.2 0.8-1.7 Kikura, 2008 (31)
Other diseases or history
Valvular disease 1.54 1.25-1.90 Bateman, 2009 (9)
Diabetes 1.18 1.01-1.39 Bateman, 2009 (9)
Current smoker 1.5 1.1-1.9 Mashour, 2011 (8)
History of cardiac disease 1.42 1.07-1.87 Sharifpour, 2013 (5)
Chronic obstructive pulmonary disease 7.51* 1.87-30.12 Limburg, 1998 (24)
Peripheral vascular disease 5.35* 1.25-22.94 Limburg, 1998 (24)
Hypertension 1.5 0.9-2.4 Kikura, 2008 (31)
Atrial fibrillation 5.5 2.8-10.9 Kikura, 2008 (31)
Atrial fibrillation 1.95 1.69-2.26 Bateman, 2009 (9)
History of ischemic heart disease 2.3 1.3-4.1 Kikura, 2008 (31)
*Adjusted Odds Ratio

years. Kikura et al. (31) identified a 4.7- fold in-
creased risk of perioperative stroke after the age
of 50, and a 23.6-fold increased risk of perioper-
ative stroke after the age of 70, as compared
with patients younger than 50 years old.
Stroke History
All patients with a history of cerebrovascular ac-
cident or TIA should be considered high risk for
recurrent stroke. Patients with stroke history
have a higher risk of perioperative stroke after
coronary artery bypass grafting (CABG) (33). A
cohort study of 1,426,795 patients undergoing
major non- neurological surgery with a history
of stroke within a 24- month period prior to
their surgery found increased morbidity (pneu-
monia, sepsis, renal failure, acute myocardial in-
farction [MI], and pulmonary embolism) and 30
day in- hospital mortality (adjusted risk ratio
[RR] 1.79, 95% confidence interval [CI] 1.61-
1.99), especially in patients with previous intra-
cerebral hemorrhage (RR 3.41, CI 2.97- 3.91)
and patients with stroke 1-6 months prior to sur-
gery (RR 3.31, CI 2.91-3.71) (34). A Danish co-
hort analysis of 481,183 adults undergoing elec-
tive non- cardiac surgery found a dramatic in-
crease in major adverse cardiovascular events, in-
cluding ischemic stroke, acute MI, cardiovascu-
lar mortality, and all- cause mortality in patients
with a history of stroke. This increase was most-

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Sunny S. Chiao et al.
ly marked in patients with stroke less than 3
months prior to surgery, but was still elevated
up to 12 months or more after stroke (35). Inter-
estingly, these conclusions are contradicted by a
study of patients undergoing total hip or knee
replacement or abdominal aortic aneurysm re-
pair within 6 months of recent stroke. This
study found no relationship between timing of
surgery after recent stroke and perioperative
mortality (36).
It has been shown that after AIS, cerebrovas-
cular autoregulation is deranged and may rely
on systemic blood pressure to maintain ade-
quate cerebral perfusion (37, 38). This impair-
ment of autoregulation peaks within the first 5
days after stroke and with recovery over the
next 3 months (37).
Renal Disease
Mashour et al. (8) identified acute renal failure
as an independent risk factor for perioperative
stroke in non- cardiac, non- neurologic surgeries
(odds ratio [OR] 3.6, CI 2.3-5.8) as well as dialy-
sis dependence (OR 2.3, CI 1.6- 3.4). Bateman
et al. (9) also identified renal disease as an inde-
pendent risk factor for perioperative stroke (OR
2.98, CI 2.52- 3.54). In patients undergoing ca-
rotid endarterectomy, moderate to severe chron-
ic renal insufficiency is strongly associated with
higher rates of both stroke and five-year mortali-
ty (39, 40). Postoperative blood urea nitrogen in-
crease is found to be associated with periopera-
tive stroke in cardiac surgical patients (41).
Atrial Fibrillation
Atrial fibrillation may be intermittent or continu-
ous in nature, and has been found to be a comor-
bid in 27.6% of the patients with postoperative
strokes. It is associated with up to 5.5- fold in-
creased risk of stroke (9, 31). Postoperative atri-
al fibrillation is the most consistent independent
variable for stroke after CABG (42). New onset
of perioperative atrial fibrillation has also been
associated with an increased long-term (within 1
year) risk of subsequent stroke in patients with
cardiac or non-cardiac surgery (9, 43). Anticoag-
ulation in this population to reduce stroke risk
is a common practice, and the benefit of continu-
ing anticoagulation in the perioperative setting
is offset by the risk of surgical site bleeding.
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Risk Management of Perioperative Stroke
Symptomatic Carotid Stenosis
Carotid stenosis may be diagnosed on symptoms
or clinical examination. In the non-operative set-
ting, symptomatically severe carotid stenosis (>
70% stenosis), the rate of recurrent stroke after
onset of TIA or minor stroke is between 2-7.5%
within the first month (44). It is reasonable to
perform carotid endarterectomy or stenting in
symptomatic patients (i.e. following ischemic
stroke or TIA) within 6 months if the severity of
internal carotid artery stenosis is greater than
70% by imaging, or more than 50% by catheter
angiography. Asymptomatic patients with great-
er than 70% stenosis of the internal carotid ar-
tery are also candidates for intervention (45).
In general, optimization of other comorbidi-
ties is also important prior to elective surgeries,
such as control of hypertension and hyperglyce-
mia. Medical management to reduce risk factors
for stroke includes smoking cessation, blood
pressure control, anticoagulation for atrial fibril-
lation, and anti-hyperlipidemic medications.
Antithrombotic Therapy
Antithrombotic therapies (anticoagulants and an-
tiplatelet drugs) are commonly prescribed medi-
cations. The risks and benefits of withholding
these drugs perioperatively certainly need to be
balanced against the probability of surgical
bleeding, as well as the consequences of bleed-
ing. For instance, specific surgeries may not tol-
erate even minimal amounts of bleeding, such as
neurosurgical or certain ophthalmologic proce-
dures. Conversely, stopping antithrombotic ther-
apy can also result in untoward consequences.
The withdrawal of antiplatelet medications or
anticoagulants within 60 days preceding to an
AIS accounted for 5.2% of strokes occurred in a
community (46). Of these patients with with-
drawal of the anticoagulants, 62.3% were first-
ever strokes, and 47.4% occurred in the peripro-
cedural period.
Surgeries with high risk of bleeding include
cardiac surgery (CABG and valvular replace-
ment), intracranial surgery, intraspinal surgery,
major vascular surgery (aortic aneurysm repair,
peripheral artery bypass), major vascular ortho-
pedic surgery, reconstructive plastic, major can-
cer surgery, urogenital surgery, and hip surgery.
Surgeries with low risk of bleeding include den-
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Journal of Anesthesia and Perioperative Medicine
tal procedures, some ophthalmologic surgeries,
and dermatology procedures (47, 48).
Anticoagulants are commonly used for pre-
vention of stroke in patients with atrial fibrilla-
tion. The American College of Chest Physician
(ACCP) recommendations for interruption of vi-
tamin K antagonist therapy before elective sur-
gery are dependent on balancing the risk of sur-
gical bleeding with the thromboembolic risk of
the patient. Specifically, in situations of high
bleeding risk where cessation is required, the
ACCP recommends cessation of vitamin K antag-
onist therapy 5 days prior to surgery. In the high-
risk patient (known atrial fibrillation and
CHADS score [a score system to estimate the
risk for stroke in patients with non- rheumatic
atrial fibrillation based on the existence of con-
gestive heart failure, hypertension, advanced
age, diabetes or stroke] >4, history of venous
thromboembolism, history of stroke or TIA
within 6 months, or mechanical heart valve on
anticoagulation), bridging anticoagulation is rec-
ommended (47). Otherwise, in patients at low
risk for thromboembolic events, no bridging is
recommended. Resumption of anticoagulation
therapy should occur as soon as is deemed safe
from a bleeding risk standpoint.
Anti- platelet therapy is exceedingly common,
particularly in elderly populations. These drugs
are used in both the primary and secondary pre-
vention of cardiovascular disease, and the use of
aspirin has led to a 12% reduction in serious
vascular events (mainly in reduction of non- fa-
tal MI) and absolute reduction in serious vascu-
lar events (6.7% from 8.2% per year), respec-
tively (49).
In patients at moderate-to-high risk of throm -
botic events undergoing non-cardiac surgery, the
ACCP recommends continuing aspirin perioper-
atively instead of stopping it 7- 10 days prior to
surgery (47). If interruption of anti-platelet ther-
apy is required, expert guidelines have varying
recommendations for cessation of aspirin and
clopidogrel at 5 days or 7- 10 days prior to sur-
gery (45, 47, 50).
The PeriOperative Ischemic Evaluation
(POISE)- 2 trial studied the effect of low- dose
perioperative aspirin as compared with placebo
before non- cardiac surgery on perioperative
death, nonfatal MI, and major bleeding. While
272 JAPM WWW.JAPMNET.COM
Review Article
the use of low- dose aspirin did not reduce the
rate of death or nonfatal MI, it increased the
risk of major bleeding (hazard ratio [HR], 1.23;
95% CI, 1.01 to 1.49) (51). The POISE- 2 trial
also found that discontinuing aspirin three or
more days prior to surgery may decrease the
risk of major bleeding, and that withholding as-
pirin after chronic use was not associated with
an increase in thrombotic events (51). Resump-
tion of anti- platelet therapy must be carefully
considered to minimize the risk of surgical
bleeding. In general, it is reasonable to restart
aspirin after surgery when the risk of bleeding is
significantly decreased. In one study, the abso-
lute increase in risk of bleeding was 0.3% when
aspirin was restarted at day 8 as compared with
placebo (51).
Prediction Models of Perioperative Stroke
Charlesworth et al. (52) used data of 33,062 pa-
tients to develop a prediction model for stroke
after CABG. The factors used to calculate the
risk for perioperative stroke include age, gender,
surgery urgency, diabetes, cardiac function, re-
nal function and vascular disease. They came up
a very accurate prediction formula for periopera-
tive stroke. Goodney et al. (53) built up a predic-
tion model based on the data of 3092 patients
with carotid endarterectomy. The risk factors
for perioperative stroke are age >70 years, con-
tralateral internal carotid artery occlusion, con-
gestive heart failure, emergency surgery and his-
tory of ipsilateral stroke. Patients with none or
one of these risk factors have <1% chance of
perioperative stroke or death. Patients who have
three or more risk factors have nearly 5%
chance of death or stroke.
Intraoperative Management
Hypotension
Cerebral autoregulation of blood flow is vital to
maintain relatively constant cerebral blood flow
over changes in arterial blood pressure. It is typi-
cally preserved when mean arterial blood pres-
sures are between 50 to 150 mm Hg (54). The
intraoperative period is known to have high
rates of hypotension, but clearly, not every pa-
tient experiencing hypotension goes on to devel-
op stroke. Surgery in the seated position is desir-
September, 2015 Volume 2 Number 5
Sunny S. Chiao et al.
able for certain surgeries for better access and
exposure to the surgical field, but can lead to ce-
rebral hypoperfusion despite adequate systemic
blood pressure. The consequences of this postur-
al hypotension first attracted attention after a
case series identifying four neurologic injuries
with ischemic watershed brain infarcts after or-
thopedic surgery in the seated position (55). A
subsequent prospective study of patients under-
going elective surgery in the beach chair posi-
tion was performed, in which 60 patients were
randomized to either general anesthesia or re-
gional anesthesia with monitored anesthesia
care. Baseline mean arterial pressure and cere-
bral oxygen saturations were measured during
surgery, and both mean arterial pressure and ce-
rebral oxygen saturations were found to be low -
er in the general anesthesia group as compared
with the regional anesthesia and sedation group
(56). Neuromonitoring can be considered for
early detection of decrease in cerebral blood
flow (57).
Neurologic injury secondary to cerebral hypo-
tension is very rare. However, careful attention
should be paid to both the systemic mean arteri-
al pressure and also to cerebral perfusion pres-
sure, which may be significantly different from
systemic arterial pressure in certain surgical posi-
tions. Clinically significant hypotension, as de-
fined by a decrease of more than 30% from base-
line blood pressure (58), possibly plays a role in
perioperative stroke (8, 59), although a case con-
trol study of 61 patients with ischemic strokes
did not find any such association between intra-
operative hypotension and development of isch-
emic stroke (24), and no ischemic stroke events
occurred in a review of 4169 patients undergo-
ing elective shoulder surgery in the seated posi-
tion under regional anesthesia and sedation, de-
spite high rates of intraoperative hypotension
(47% ) and at least a 30% decrease in mean arte-
rial pressure in 30% of patients (60).
Normoglycemia
Although intensive glucose control has not been
conclusively identified as protective against
stroke development (61), hyperglycemia is
known to worsen brain injury and lead to in-
creased mortality after periods of cerebral isch-
emia (62- 64). A phase III multicenter trial, the
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Risk Management of Perioperative Stroke
Stroke Hyperglycemia Insulin Network Effect
(SHINE), is currently underway to compare
standard of care glucose control with intensive
glucose control in hyperglycemic AIS patients
(65). Current expert consensus recommends
treating hyperglycemia greater than 150 mg/dl,
with a target glucose range of 60- 180 mg/dl
(57, 66).
Anesthetic Technique
Patients undergoing certain surgeries may be eli-
gible for either general anesthesia or neuraxial
techniques with sedation. A study of 2,807 pa-
tients undergoing transfemoral aortic valve im -
plantation under either local anesthesia or gener-
al anesthesia demonstrated no significant differ-
ence between rates of MI, major stroke, or in-
hospital mortality. However, an observational
study of 18,745 patients undergoing primary or
revision total hip or knee arthroplasty, identified
general anesthesia as an independent predictor
of postoperative stroke (OR 3.54, 95% CI 1.01-
12.39) (67). A multicenter analysis of 382,236
patients undergoing primary hip or knee arthro-
plasty identified neuraxial anesthesia as the anes-
thetic associated with the most favorable compli-
cation risk profile. The neuraxial group was as-
sociated with a stroke incidence of 0.07% , as
compared with the combined neuraxial/general
anesthesia group (0.12% ) and the general anes-
thesia alone group (0.13% ). Thirty- day mortali-
ty was also higher in the general anesthesia
group as compared with neuraxial or neuraxial/
general anesthesia group (adjusted OR of 1.83,
95% CI 1.08- 3.1, and 1.70, 95% CI 1.06- 2.74,
respectively) (68).
Perhaps some of these findings can be ex-
plained by higher incidence of hypotension and
decreased cerebral perfusion pressure and cere-
bral saturations (56), or by delayed detection of
hypoperfusion to the brain under general anes-
thesia.
Volatile anesthetics have been demonstrated
to provide neuroprotection against brain hypox-
ic- ischemic injury in animal models. However,
no convincing clinical studies demonstrate this
benefit in humans to date (69).
Beta-Blockade
The 2008 POISE trial associated continuation of
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Journal of Anesthesia and Perioperative Medicine
perioperative beta- blockers with reductions in
MI, the need for coronary revascularization, as
well as a reduction in the development of atrial
fibrillation (59). However, there was an in-
creased risk of clinically significant hypotension
(HR 1.55, CI 1.38-1.74), and bradycardia, over-
all mortality (metoprolol group 129 [3.1% ] vs.
placebo group 97 [2.3% ]), stroke (metoprolol
group 41 [1% ] vs. placebo group 19 [0.5% ]) in
spite of lower rates of atrial fibrillation. The risk
and benefit of perioperative beta- blockade with
metoprolol should be considered on an individu-
al basis. Withdrawal of chronic beta- blockers is
associated with increased risk of adverse cardiac
outcomes (70), and continuation of beta- block-
ade in patients on beta- blocker therapy prior to
admission has been identified as a Surgical Care
Improvement Project (SCIP) Measure by the
Joint Commission (71). One study of incidence
of perioperative stroke in a group of 57,218 pa-
tients found approximately a 4.2- fold increase
in perioperative stroke with preoperative meto-
prolol. However, the study did not find a statisti-
cally significant association of stroke with other
beta- blockers (atenolol, bisoprolol, carvedilol,
nadolol, propranolol, or sotalol), suggesting a
metoprolol specific effect (72). The use of intra-
operative metoprolol tartrate (intravenous, IV)
was associated with a 3.3- fold increased risk of
perioperative stroke; whereas IV esmolol or la-
betalol had no such association. Data suggests
that preoperative beta- blockers should not be
initiated in the immediate preoperative period,
and initiation within 7 days prior to surgery
may lead to increase in 30- day mortality (OR
1.49, CI 1.03- 2.16) without an increase in 30-
day ischemic stroke risk (50, 73).
Other Drugs
Angiotensin converting enzyme inhibitors are
commonly used to treat hypertension. Continu-
ous use of these agents, especially in combina-
tion with beta- blockers, can result in severe hy-
potension during surgery. This hypotension may
not respond that well to vasopressors (74).
Thus, angiotensin converting enzyme inhibitors
may increase the risk of perioperative stroke.
On the other hand, statins that are used to treat
hyperlipidemia have been found to provide ben-
eficial effects during the perioperative period.
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These effects include reducing perioperative
stroke in patients after vascular surgery (74, 75).
Unique Features of the Treatment of
Perioperative Stroke
Early recognition is the key to have good neuro-
logical outcome after perioperative stroke (76).
Patients under general anesthesia may not show
any signs of stroke. Fortunately, the majority of
stroke occurred after surgery when patients are
not under general anesthesia. However, sedation
can mask the presentation of stroke (77). Thus,
minimizing sedation during perioperative period
should facilitate the recognition of stroke.
Core treatment of ischemic stroke is support-
ive therapy and re- establishment of blood sup-
ply to the ischemic tissues (27, 30, 76). While
supportive therapy, such as maintaining nutri-
tion and avoiding hypotension, in the case of
perioperative stroke should be the same as for
other stroke patients, the use of intravenous tis-
sue plasminogen activator to dissolve the clots
in the vessels is relatively contraindicated within
14 days after a major surgery (30, 76). Using
catheter to mechanically remove clots may be
the method within this time window (30, 76).
The treatment of perioperative hemorrhagic
stroke may be similar to those measures used for
hemorrhagic stroke that does not occur during
perioperative period.
Conclusions
Perioperative stroke is a relatively uncommon
but debilitating event that is associated with
high morbidity, mortality, as well as extraordi-
nary intangible and financial costs. Although
many of the most common risk factors are not
modifiable, elective surgery after recent stroke
should be postponed until cerebral autoregula-
tion has improved, after a minimum of 3
months. All patients with history of stroke or
TIA should be considered high risk for repeat
stroke. Meticulous intraoperative management
may mitigate the risk of perioperative stroke. In-
traoperative hypotension should be treated, es-
pecially in patients at high risk for cerebral isch-
emia. Chronic beta- blocker therapy should be
continued in the perioperative period. The deci-
September, 2015 Volume 2 Number 5
Sunny S. Chiao et al.
sion to continue anti- platelet and anti- coagula-
tion therapy should be based on the patient's in-
dividual thromboembolic risk and risk of surgi-
cal bleeding. Serum glucose levels between 60-
180 mg/dl are ideal, with treatment recommend-
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