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Chapter 35 - Cerebrovascular disease

from Section 11 - Neurology

Published online by Cambridge University Press:  05 September 2013

By
Kumiko Owada ,
Duncan Borland  and
Michael Frankel
Edited by
Michael F. Lubin ,
Thomas F. Dodson  and
Neil H. Winawer
Michael F. Lubin
Affiliation:
Emory University, Atlanta
Thomas F. Dodson
Affiliation:
Emory University, Atlanta
Neil H. Winawer
Affiliation:
Emory University, Atlanta
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Summary

Introduction

Stroke affects 795,000 people each year in the USA and is a leading cause of long-term disability in the adult population. The impact of stroke on society is large not only because of the medical cost of acute care but also due to the cost of long-term disability. Stroke also has a significant impact on individual quality of life. In the past decade there have been considerable advances in treatment and prevention of stroke. Some of the incidence of stroke is associated directly or indirectly with surgical procedures. This chapter will review the mechanisms of stroke associated with surgical procedures and the issues surrounding management of stroke relevant to surgical patients.

Pathophysiology

Stroke can be divided into two types; ischemic and hemorrhagic. Ischemic stroke comprises about 87% of all strokes. Hypoperfusion in the brain tissue associated with either arterial occlusion or decreased blood flow causes ischemia that will progress with time to infarction. The concept of “penumbra” represents brain tissue which suffers from acute hypoperfusion but has yet to suffer cell death. The penumbra represents salvageable brain tissue that may be amenable to reperfusion therapy. Available therapeutic modalities for acute stroke focused on salvaging penumbra are discussed in the section below.

Type
Chapter
Information
Medical Management of the Surgical Patient
A Textbook of Perioperative Medicine
 , pp. 387 - 395
Publisher: Cambridge University Press
Print publication year: 2013

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References

Easton, JD, Saver, JL, Albers, GW et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40: 2276–93.CrossRefGoogle ScholarPubMed
Bash, S, Villablanca, JP, Jahan, R et al. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol 2005; 26: 1012–21.Google ScholarPubMed
Frankel, MR, Chimowitz, M.Acute stroke. In Emergency Neurology, Principles and Practice. Cambridge: Cambridge University Press; 1999.Google Scholar
Del Zoppo, GJ, Saver, JL, Jauch, EC et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40: 2945–8.CrossRefGoogle ScholarPubMed
Furlan, A, Higashida, R, Wechsler, L et al. Intra-arterial prourokinase for acute ischemic stroke. J Am Med Assoc 1999; 282: 2003–11.CrossRefGoogle ScholarPubMed
Smith, WS, Sung, G, Starkman, S et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI Trial. Stroke 2005; 36: 1432–8.CrossRefGoogle ScholarPubMed
Bose, A, Henkes, H, Alfke, K et al. The Penumbra system: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol 2008; 29: 1409–13.CrossRefGoogle ScholarPubMed
Fleisher, LA, Beckman, JA, Brown, KA et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2007; 116: 1971–96.CrossRefGoogle Scholar
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: 472–8.CrossRefGoogle ScholarPubMed
Selim, M.Perioperative stroke. N Engl J Med 2007; 356: 706–13.CrossRefGoogle ScholarPubMed
Limburg, M, Wijdicks, EF, Li, H.Ischemic stroke after surgical procedures: Clinical features, neuroimaging, and risk factors. Neurology 1998; 50: 895–901.CrossRefGoogle ScholarPubMed
Hogue, CW, Murphy, SF, Schechtman, KB et al. Risk factors for early or delayed stroke after cardiac surgery. Circulation 1999; 100: 642–7.CrossRefGoogle ScholarPubMed
Filsoufi, F, Rahmanian, PB, Castillo, JG et al. Incidence, imaging analysis, and early and late outcomes of stroke after cardiac valve operation. Am J Cardiol 2008; 101: 1472–8.CrossRefGoogle ScholarPubMed
Kikura, M, Oikawa, F, Yamamoto, K et al. Myocardial infarction and cerebrovascular accident following non-cardiac surgery: differences in postoperative temporal distribution and risk factors. J Thromb Haemostasis 2008; 6: 742–8.CrossRefGoogle ScholarPubMed
Naylor, AR, Mehta, Z, Rothwell, PM et al. Carotid Artery Disease and Stroke During Coronary Artery Bypass: a Critical Review of the Literature. Eur J Vasc Endovasc Surg 2002; 23: 283–94.CrossRefGoogle ScholarPubMed
Blacker, DJ, Flemming, KD, Link, MJ et al. The preoperative cerebrovascular consultation: common cerebrovascular questions before general or cardiac surgery. Mayo Clinic Proceedings 2004; 79: 223–9.CrossRefGoogle ScholarPubMed
Kellermann, K, Jungwirth, B.Avoiding stroke during cardiac surgery. Semin Cardiothorac Vasc Anesth 2010; 14: 95–101.CrossRefGoogle ScholarPubMed
Douketis, JD, Berger, PB, Dunn, AS et al. The perioperative management of antithrombotic therapy. Chest 2008; 133 (6 Suppl): 299S–339S.CrossRefGoogle ScholarPubMed
Likosky, DS, Marrin, CA, Caplan, LR et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke 2003; 34: 2830–4.CrossRefGoogle ScholarPubMed
Puskas, JD, Williams, WH, Duke, PG et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003; 125: 797–808.CrossRefGoogle ScholarPubMed
Brizzio, ME, Zapolanski, A, Shaw, RE et al. Stroke-related mortality in coronary surgery is reduced by the off-pump approach. Annal Thorac Surg 2010; 89: 19–23.CrossRefGoogle ScholarPubMed
Sedrakyan, A, Wu, AW, Parashar, A et al. Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting: a meta-analysis of systematically reviewed trials. Supplemental Appendix I. Stroke 2006; 37: 2759–69.CrossRefGoogle Scholar
Hilker, M, Arlt, M, Keyser, A et al. Minimizing the risk of perioperative stroke by clampless off-pump bypass surgery: a retrospective observational analysis. J Cardiothorac Surg 2010; 5: 14.CrossRefGoogle ScholarPubMed
N.A.S.C.E.T. Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445–53.CrossRefGoogle Scholar
E.C.S.T.C. Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet 1991; 25, 337 (8752): 1235–43.Google Scholar
E.C.S.T.C. Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351 (9113): 1379–87.CrossRefGoogle Scholar
Nagaki, T, Sato, K, Yoshida, T et al. Benefit of carotid endarterectomy for symptomatic and asymptomatic severe carotid artery stenosis: a Markov model based on data from randomized controlled trials. J Neurosurg 2009; 111: 970–7.CrossRefGoogle ScholarPubMed
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. J Am Med Assoc 1995; 10, 273: 1421–8.Google Scholar
Mantese, VA, Timaran, CH, Chiu, D et al. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST): Stenting versus carotid endarterectomy for carotid disease. Stroke 2010; 41 (10 Suppl 1): S31–4.CrossRefGoogle ScholarPubMed
Chaturvedi, S, Yadav, JS.The role of antiplatelet therapy in carotid stenting for ischemic stroke prevention. Stroke 2006; 37: 1572–7.CrossRefGoogle ScholarPubMed
Bhatt, DL, Kapadia, SR, Bajzer, CT et al. Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol 2001; 13: 767–71.Google ScholarPubMed
Kam, PC, Calcroft, RM.Peri-operative stroke in general surgical patients. Anaesthesia 1997; 52: 879–83.CrossRefGoogle ScholarPubMed
Almassi, GH, Schowalter, T, Nicolosi, AC et al. Atrial fibrillation after cardiac surgery: a major morbid event?Ann Surg 1997; 226: 501–13.CrossRefGoogle ScholarPubMed
Lahtinen, J, Biancari, F, Salmela, E et al. Postoperative atrial fibrillation is a major cause of stroke after on-pump coronary artery bypass surgery. Ann Thorac Surg 2004; 77: 1241–4.CrossRefGoogle ScholarPubMed
Epstein, AE, Alexander, JC, Gutterman, DD et al. Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest 2005; 128 (2 Suppl): 24S–7S.CrossRefGoogle ScholarPubMed
Chalela, JA, Katzan, I, Liebeskind, DS et al. Safety of intra-arterial thrombolysis in the postoperative period. Stroke 2001; 32: 1365–9.CrossRefGoogle ScholarPubMed
Albers, GW, Amarenco, P, Easton, JD et al. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 2001; 119 (1 Suppl): 300S–20S.CrossRefGoogle ScholarPubMed
Taylor, DW, Barnett, HJ, Haynes, RB et al. Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. Lancet 1999; 353(9171): 2179–84.CrossRefGoogle ScholarPubMed
Albers, GW, Amarenco, P, Easton, JD et al. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (6 Suppl): 630S–69S.CrossRefGoogle Scholar
CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348(9038): 1329–39.CrossRefGoogle Scholar
Diener, HC, Bogousslavsky, J, Brass, LM et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364 (9431): 331–7.CrossRefGoogle ScholarPubMed
Diener, HC, Cunha, L, Forbes, C et al. European Stroke Prevention Study 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143: 1–13.CrossRefGoogle ScholarPubMed
Diener, HC, Sacco, RL, Yusuf, S et al. Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebo-controlled study. Lancet Neurol 2008; 7: 875–84.CrossRefGoogle ScholarPubMed
Shinohara, Y, Katayama, Y, Uchiyama, S et al. Cilostazol for prevention of secondary stroke (CSPS 2): an aspirin-controlled, double-blind, randomised non-inferiority trial. Lancet Neurol 2010; 9: 959–68.CrossRefGoogle ScholarPubMed
Gotoh, F, Tohgi, H, Hirai, S et al. Cilostazol Stroke Prevention Study: a placebo-controlled double-blind trial for secondary prevention of cerebral infarction. J Stroke Cerebrovasc Dis 2000; 9: 147–57.CrossRefGoogle ScholarPubMed
Shinohara, Y, Gotoh, F, Tohgi, H et al. Antiplatelet cilostazol is beneficial in diabetic and/or hypertensive ischemic stroke patients. Subgroup analysis of the cilostazol stroke prevention study. Cerebrovasc Dis 2008; 26: 63–70.CrossRefGoogle ScholarPubMed
Mohr, JP, Thompson, JL, Lazar, RM et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345: 1444–51.CrossRefGoogle ScholarPubMed
Medi, C, Hankey, GJ, Freedman, SB.Stroke risk and antithrombotic strategies in atrial fibrillation. Stroke 2010; 41: 2705–13.CrossRefGoogle ScholarPubMed
Ezekowitz, MD, Wallentin, L, Connolly, SJ et al. Dabigatran and warfarin in vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation 2010; 122: 2246–53.CrossRefGoogle ScholarPubMed
Gorelick, PB.Stroke prevention therapy beyond antithrombotics: unifying mechanisms in ischemic stroke pathogenesis and implications for therapy: an invited review. Stroke 2002; 33: 862–75.CrossRefGoogle Scholar
Ridker, PM, Danielson, E, Fonseca, FA et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008; 359: 2195–207.CrossRefGoogle ScholarPubMed
Chobanian, AV, Bakris, GL, Black, HR et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. J Am Med Assoc 2003; 21, 289: 2560–72.CrossRefGoogle Scholar
Neal, B, MacMahon, S, Chapman, N; Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet 2000; 356(9246): 1955–64.Google ScholarPubMed
ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. J Am Med Assoc 2002; 288: 2981–97.CrossRefGoogle Scholar
Gorelick, PB.New horizons for stroke prevention: PROGRESS and HOPE. Lancet Neurol 2002; 1: 149–56.CrossRefGoogle ScholarPubMed
Yusuf, S, Sleight, P, Pogue, J; The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342: 145–53.Google ScholarPubMed
PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358(9287): 1033–41.CrossRefGoogle Scholar
Leenen, FH, Nwachuku, CE, Black, HR et al. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Hypertension 2006; 48: 374–84.CrossRefGoogle ScholarPubMed

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