AHA statement outlines perioperative stroke prevention, management strategies
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Perioperative stroke, a major complication of cardiac and thoracic aortic surgeries, has many possible origins, which can make prediction and prevention difficult, according to a new scientific statement.
According to an American Heart Association scientific statement published in Circulation, perioperative stroke is associated with a five- to 10-fold higher risk for in-hospital mortality, elevated cost, increased hospital stay and risk of cognitive decline at 1 year after surgery. In addition, perioperative stroke survivors often experience poor functional outcomes.
The statement outlined steps for stroke prevention during surgery, early diagnosis and treatment of perioperative stroke.
“Stroke has been shown to be the most feared complication. Most patients would prefer to die during the operation rather than have a stroke, and this is very understandable. Clearly, it is a target for us physicians to improve and to provide better results, lower the risk for stroke and provide better treatment of this complication when it happens. This is probably the most important complication after cardiac surgery,” Mario F.L. Gaudino, MD, FEBCTS, Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery at Weill Cornell Medicine and chair of the writing group for the scientific statement, told Healio. “Over the last decade, there has been some very important progress and not only from the surgeon perspective, but also from the perspective of the diagnosis and treatment of stroke at a very early postoperative stage. So, the AHA decided it was a good idea to provide a document that summarizes this recent progress, oriented in a way that can be useful in clinical practice. It is a short document that is relatively easy to consult that does not require a three-page index like some guidelines.”
Prevention during surgery
The scientific statement recommended various measures for the intraoperative prevention of stroke, including:
- use of intraoperative neuromonitoring;
- use of epiaortic scanning;
- maintaining a mean arterial pressure of 60 mm Hg to 65 mm Hg during cardiopulmonary bypass;
- use of a transfusion trigger between 7.5 g/dL and 8 g/dL;
- minimizing hemodilution;
- using active perfusion techniques in aortic surgeries with longer circulatory arrest time;
- considering, at the time of surgery, left atrial appendage ligation or atrial fibrillation ablation; and
- in the presence of thrombus, considering surgical thrombectomy or delay of surgery with anticoagulation.
“If surgery is urgent or emergent, guidelines recommend intraoperative anticoagulation with bivalirudin, heparin after treatment with plasma exchange, or heparin in combination with a potent antiplatelet agent,” Gaudino and colleagues wrote. “For patients with less acute heparin-induced thrombocytopenia ... scheduled for cardiac surgery, guidelines suggest intraoperative anticoagulation with heparin.”
Early diagnosis
For the early diagnosis of stroke, the writing committee recommended clinicians perform routine neurologic examinations that include measurements of arousal, speech and motor findings. Due to lingering effects of anesthesia, quick assessment might be difficult, therefore they suggested fast-tracking care with the use of low-dose opioid-based general anesthesia and short-acting anesthetics in high-risk patients.
“Patients suspected of having a stroke are best evaluated with a noncontrast CT of the head to rule out intracerebral hemorrhage and characterize any signs of early ischemia if present,” the committee wrote. “Noncontrast CT of the head has a limited sensitivity in detecting early stroke (< 6 hours), when ischemic changes could be evolving.”
Moreover, in the initial imaging assessment, CT angiography may be included upon suspicion of large-vessel occlusion that could me managed with mechanical thrombectomy, according to the statement.
Management of perioperative stroke
The writing committee recommended the following steps for rapid treatment in the event of perioperative stroke:
- Transfer the patient to an intensive care setting.
- Optimize cerebral oxygenation and perfusion.
- Consider performing thrombolysis and thrombectomy.
- Conduct screenings that include speech, swallow and depression evaluations in addition to deep vein thrombolysis prophylaxis and evaluation for rehabilitation.
“Is it a collaborative effort. Ideally, you must have a stroke team for cardiac surgery in place. You cannot try to figure it out during the surgery,” Gaudino said in an interview. “When you suspect that there is a stroke, you have to call where the patient is supposed to be going. All of these need to be predefined, there must be protocols in place, and there must be an existing infrastructure that can be activated the moment there is a suspicion that something is going wrong and that there has been a stroke. I would be the happiest person if this document were useless and if every hospital in the country had a system like that in place. Unfortunately, I do not think that this is the case, and so the document is supposed to either guide or help a hospital that would want to build something like that.”
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