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Transcript of Britiany Sheard-Caple, MD Faculty Mentor: Anthony Edelman, … · varied based on etiology Adams...
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Britiany Sheard-Caple, MD
Faculty Mentor: Anthony Edelman, MD, MBA
Department of Anesthesiology
University of Michigan
Outline
• Case presentation
• Perioperative stroke: incidence and
pathophysiology
• Management of stroke risk factors
• Management of acute perioperative
stroke
Case Background65 year old female ASA 3 presenting for a
left total hip arthroplasty
• PMH
–Hx right breast cancer
–Diabetes Mellitus type 2
Hyperlipidemia
–Severe osteoarthritis
–Depression
Case BackgroundPMH
–Hypertension
•chart review 110s/50s-60s
–Hx right lacunar infarct
–“Mild carotid disease”
Case Background
• PSH: Breast lumpectomy, mastectomy,
appendectomy, ankle pinning, tubal ligation
• Social: former smoker, former alcohol abuse
Case Background
• Medications: aspirin, atorvastatin,
triamterene-hydrochlorothiazide,
fluoxetine, metformin, gabapentin,
ibuprofen, hydrocodone-acetaminophen,
trazadone
• Allergies: NKA
• Anes: No documented issues with
previous GAs in the past
Case Background-Preop• Vitals: T-36.6; BP-133/59; HR-59; Sat-98%
• Exam: BMI-27. 74kg; 65 inches
• Airway: Unremarkable, Mallampati I
• Labs: Hgb/Hct-13.2/39.1; plt-139; normal
coags; POC glucose-92
Intraoperative• Premedication: 1mg Midazolam
• Uneventful placement of spinal
• Sedation: Fentanyl IVP and Propofol
infusion
First BP reading:
174/83
Last BP
reading:
101/51
Incision @ 1330
Propofol stopped + 50mcg Fentanyl IVP @1450
Surgical dressing complete @1458
Transported to PACU @1512
Post Operative
• Arrived to PACU @ 1518
• Vitals: T-36.8; BP- 115/55; P-76; SaO2-99 on
nasal cannula; RR-14
• Exam– Dysarthric and aphasic with right facial droop
– 2/5 strength in RUE
– Unable to move lower extremities
**Stroke pager activated**– NIHSS score 16 on initial assessment by
Neurology
Post Operative Imaging
• Non-contrast Head CT– No acute intracranial abnormality
– No acute cervical fracture or traumatic malalignment
• CTA– Severe atherosclerotic calcification involving bilateral
cavernous and segments of the intracranial ICA leading
to 50-60% stenosis
– Chronic right lacunar infarct involving right caudate
lobe re-demonstrated. “Please consider MRI for
assessment”
Post Operative
• Not an IV tPA candidate
• No thrombectomy offered
• Transferred to Neurology inpatient
Perioperative Stroke:
Incidence
Sunny S. Chiao, Zhi-Yi Zuo. Approach to risk management of perioperative stroke. J Anesth Perioper Med 2015; 2: 268-
76. doi: 10.24015/JAPM.2015.0036
Perioperative Stroke: Timing
• Majority of perioperative strokes occur
after the second post operative day
– In 2016 observational study by Vlisides et. al,
strokes occurred between POD 0 and 1
• According to 2011 review article by Ng et al.,
looking at perioperative stroke, only 5.8% thought
the stroke occurred during surgery
Vlisides PE, Mashour GA,. Didier TJ, Shanks A, Weightman A, Gelb AW, Moore LE. Recognition and Management of Perioperative Stroke in
Hospitalized Patients. A &A Case Rep. 2016 Aug 1;7(3):55-6.
Ng JL, Chan MT, Gelb AW. Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology. 2011;115:879–90
Perioperative stroke:
Risk Factors
Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.
Anesthesiology. 2011;114:1289–96
Risk Index Classification
Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.
Anesthesiology. 2011;114:1289–96
Perioperative Stroke:
Pathophysiology
• Ischemic or Hemorrhagic
– In non-cardiac, non-neurological surgery
according to Ng et al. 2011 perioperative
stroke review:
• Hemorrhagic is less than 6% cause of stroke
• Ischemic can be further classified by
presenting signs/symptoms or by etiology
Ng JL, Chan MT, Gelb AW. Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology. 2011;115:879–90
Trial of Org 10272 in Acute Stroke
Treatment (TOAST study)
• Standardized classification of ischemic
subtypes
• Based on fact that outcomes,
treatment, and risk of recurrent stroke
varied based on etiology
Adams HP, Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter
clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24:35–41
TOAST study classification
Adapted from Vlisides PE. Neurologic Outcomes of Major Surgery. Powerpoint (2018).
Pathways of Ischemic
Stroke• Pathways described by Vlisides et al., as
contributing to perioperative ischemic
stroke include
– Thrombosis
– Embolism
– Anemic tissue hypoxia
– Cerebral hypoperfusion
• Watershed areas hypoxic ischemic infarct
Vlisides PE, Mashour GE. Perioperative Stroke. Can J Anaesth. 2016 Feb; 63(2): 193–204.
Pathophysiology:
Cerebrovascular thrombosis
Bernhard Riedel B, Rafat N, Browne K, Burbury K, Schier R. Perioperative Implications of Vascular Endothelial Dysfunction:
Current Understanding of this Critical Sensor-Effector Organ. Current Anesthesiology Reports. Sept 2013, Volume 3, Issue 3,
pp 151–161.
An Approach to Intraoperative
Management: Risk factors
Vlisides PE, Mashour GE. Perioperative Stroke. Can J Anaesth. 2016 Feb; 63(2): 193–204.
Antiplatelet therapy in the
perioperative period• POISE-2 trial
• Aspirin before surgery and throughout the early postsurgical
period increased the risk of major bleeding
• Withholding aspirin after chronic use was not associated with
an increase in thrombotic events
• Subgroup analysis revealed reduced incidence of stroke in
patients who initiated aspirin during the study
Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, et al., for the POISE Study Group: Effects of extended-
release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet
2008; 371:1839–47.
POISE-2 Trial
Gerstein NS, Carey MC, Cigarroa JE, Schulman PM: Perioperative aspirin management after POISE-2: some answers, but
questions remain. Anesth Analg 2015; 120:570–5.
Antiplatelet therapy in the
perioperative period
American College of Chest Physicians (ACCP)
recommends continuing ASA perioperatively in
patients at moderate to high risk of thrombotic events
undergoing non-cardiac surgery
Douketis JD1, Spyropoulos AC2, Spencer FA1, Mayr M3, Jaffer AK4, Eckman MH5, Dunn AS6, Kunz R7. 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 Feb;141(2 Suppl):e326S-e350S. doi: 10.1378/chest.11-2298.
Bridge trial
Conclusion: Forgoing bridging non-inferior to
bridging group (0.4 vs 0.3%) for thromboembolic
events and decreased risk of bleeding
Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. The New England journal of
medicine. 2015;373(9):823-833.
An Approach to Intraoperative
Management: Risk factors
Vlisides PE, Mashour GE. Perioperative Stroke. Can J Anaesth. 2016 Feb; 63(2): 193–204.
Perioperative Stroke after
Total Joint Arthroplasty
Conclusion: General (versus regional)
anesthesia is a significant risk factor of
perioperative stroke
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):2095-101
Regional Anesthesia and
perioperative stroke
Conclusion: When neuraxial anesthesia was
used, 30-day mortality was significantly lower.
Memtsoudis SG, Sun X, Chiu Y-L, et al. Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic
Patients. Anesthesiology. 2013;118(5):1046-1058.9
Regional Anesthesia and
perioperative stroke
Memtsoudis SG, Sun X, Chiu Y-L, et al. Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic
Patients. Anesthesiology. 2013;118(5):1046-1058.9
Regional anesthesia and
perioperative stroke
Regional provides the benefit of “intra-
procedural clinical neurological evaluation”
Z. H. Anastasian; Anaesthetic management of the patient with acute ischaemic stroke, BJA: British Journal of Anaesthesia,
Volume 113, Issue suppl_2, 1 December 2014, Pages ii9–ii16.
Intraoperative Hypotension
and Stroke
Conclusion: Mean blood pressure decreased more
than 30% from baseline statistically significantly
associated with the occurrence of a postoperative stroke
Jilles B. Bijker, Suzanne Persoon, Linda M. Peelen, Karel G. M. Moons, Cor J. Kalkman, L. Jaap Kappelle, Wilton A. van Klei;
Intraoperative Hypotension and Perioperative Ischemic Stroke after General Surgery: A Nested Case-control Study. Anesthesiology
2012;116(3):658-664.
Intraoperative Hypotension
and Stroke
George A. Mashour, Milad Sharifpour, Robert E. Freundlich, Kevin K. Tremper, Amy Shanks, Brahmajee K. Nallamothu, Phillip E.
Vlisides, Adam Weightman, Lisa Matlen, Janna Merte, Sachin Kheterpal; Perioperative Metoprolol and Risk of Stroke after Noncardiac
Surgery. Anesthesiology 2013;119(6):1340-1346. doi: 10.1097/ALN.0b013e318295a25f
Intraoperative Hypotension
and Stroke
Conclusion: There was no association between
stroke and mild intraoperative hypotension.
Hsieh JK, Dalton JE, Yang D, Farag ES, Sessler DI, Kurz AM: The association between mild intraoperative hypotension and
stroke in general surgery patients. Anesth Analg 2016; 123:933–9.
Intraoperative Hypotension
and Stroke
Conclusion: “unusually” low blood pressure can
eventually result in neurodamage, but threshold
unclear
Bijker, JB, Gelb AW. Review article: The role of hypotension in perioperative stroke. Can J Anesth/J Can Anesth
(2013) 60: 159
Summary from studies
• Hypotension=unclear
• Anticoagulation=unclear
• GA vs Regional=benefit seen in
joints only
Further work to be done!
Acute Perioperative Stroke
• “Time is Brain”
• Imaging
– Non-contrast CT
• Pharmacological
– IV tPA
• only FDA-approved therapy for acute ischemic
stroke
• IV tPA
• Dose: 0.9mg/kg over 60 mins with
max dose of 90mg
Management of Stroke Patients. (2013). In M. Torbey & M. Selim (Eds.), The Stroke Book (pp. 175-256). Cambridge: Cambridge
University Press. doi:10.1017/CBO9781139344296.012
Acute Perioperative Stroke• Interventional
Nogueira RG et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018 Jan 4;378(1):11-
21. doi: 10.1056/NEJMoa1706442.
Albers GW et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging N Engl J Med 2018; 378:708-718
DOI: 10.1056/NEJMoa1713973
Acute Perioperative Stroke
Prevention • A summary of recommendations by Mashour et al.,
Journal of Neurosurgical Anesthesiology:
– No clear data on ventilation strategies but hypocapnia
should be avoided
– Glucose monitoring is recommended
– Beta blocker use with anemia <9.0 gm/dl has an
association with stroke
– Although correlation is still not defined, intraoperative
hypotension should be avoided in patients at high risk
Mashour, G. A., Moore, L. E., Lele, A. V., Robicsek, S. A., & Gelb, A. W. (2014). 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. Journal of
Neurosurgical Anesthesiology, 26(4), 273-285.
Post operative course• Admitted to Neurology for 9 days before
transfer to inpatient rehab
• Final diagnosis upon discharge, “ left
MCA distribution ischemic stroke of
unclear etiology”
Post operative course
• Physical, Occupational,
Psychotherapy and Speech Therapy
– Regaining strength
– Speech improved
– Ongoing mood/adjustment difficulties
Summary• Perioperative stroke is a rare but
debilitating complication that can occur
• Identifying patients with risk factors and
develop as treatment plan
• Have open, clear communication with
surgical team regarding patient concerns
• Time between recognition of stroke and
treatment is critical and can improve
outcomes