Perioperative stroke

More recent reports conclude that early CEA after a nondisabling ischemic stroke can be performed with perioperative mortality and stroke rates comparable to those of delayed CEA. In a subgroup analysis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators, 42 patients who underwent early CEA (<30 days after stroke) were compared with 58 patients who underwent delayed CEA (>30 days), and no overall difference was demonstrated in the perioperative stroke rate (4.8% vs. 5.2%). Another recent prospective randomized study of 86 patients showed no difference in either perioperative stroke (2% in both groups) or survival rates (mean 23 months follow-up) between patients randomized to early or delayed CEA. ... 

Index functional status 30 d after stroke. The results showed that only the severity of neurological deficit predicted greater 30-d mortality in these patients. Patients with hyperthermia on the first day of hospitalization had increased mortality and worse functional status at 30 d, but increased temperature was not an independent predictor of mortality 30 d after PICH. In a study to assess typical early onset complications following ischemic stroke, Weimar et al. (5) looked at a cohort of 3866 patients from 14 neurology departments with an acute stroke unit. In the first week following admission, increased intracranial pressure (ICP) and recurrent cerebral ischemia were the most frequent complications, along with fever, severe hypertension, and pneumonia. Similar concerns are also found in cardiac surgery patients in whom perioperative stroke occurred (6). 

One particular variation, eversion endarterectomy, is becoming increasingly popular (Loftus and Quest 1987 Darling et al. 1996 Cao et al. 1998 Brothers 2005). A systematic review of five randomized controlled trials (2590 operations) compared eversion endarterectomy versus conventional endarterectomy performed either with primary closure or patch angioplasty (Cao et al. 2004). Overall, there was no significant difference in the rates of perioperative stroke, stroke or death, and local complication rates, but the absolute risks were rather low (risk of stroke or death was 1.7% with eversion and 2.6% with conventional endarterectomy). 

Riles TS, Imparato AM, Jacobowitz GR et at (1994). The cause of perioperative stroke after carotid endarterectomy. Journal of Vascular Surgery 19 206-216... 

Pooling data from 20 reports encompassing 313 patients, there was a perioperative stroke risk of 1.3% and death rate of 0.3%. However, the rate of restenosis during a mean of 14 months of follow-up was still approximately 25%, albeit usually asymptomatic. 

Only a few serious attempts have been made to sort out which other patient-related factors affect perioperative stroke risk, and then which factors are independent from each other so they can be used in combination to predict surgical risk in individuals (Sundt et al. 1975 McCrory et al. 1993 Goldstein et al. 1994 Riles et al. 1994 Golledge et al. 1996 Kucey et al. 1998 Ferguson et al. 1999). Risk factors almost certainly include hypertension, peripheral... 

Wu CL, Francisco DR, Benesch CG. Perioperative stroke associated with postoperative epidural analgesia. J Chn Anesth 2000 12(l) 61-3. 

Gutierrez IZ, Barone DL, Makula PA, Currier C. The risk of perioperative stroke in patients with asymptomatic carotid bruits undergoing peripheral vascular surgery. Am Surg 1987 Sep 53(9) 487-9. 

C. Pennekamp, M. Bots, L. Kappelle, et al.. The Value of Near-Infrared Spectroscopy Measured Cerebral Oximetry during Carotid Endarterectomy in Perioperative Stroke Prevention A Review, Eur.. Vase. Endovasc. Surg., 38, 539 (2009). 

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