© Springer International Publishing Switzerland 2015
Molly Blackley Jackson, Somnath Mookherjee and Nason P. Hamlin (eds.)The Perioperative Medicine Consult Handbook10.1007/978-3-319-09366-6_2424. Cerebrovascular Disease
(1)
Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
Background
Stroke is an uncommon but feared complication of surgery. The observed stroke rate is 0.3–3.5 % in general surgery patients, varying by age and other comorbidities [1]. Approximately one-third of postoperative strokes are embolic [2, 3]. A history of cerebrovascular disease is a risk factor for perioperative cerebrovascular and cardiovascular complications.
Preoperative Evaluation
Risk Stratification: General Considerations
Prior stroke is a major risk factor: One retrospective surgical series of patients with a history of previous stroke found a 2.9 % incidence of postoperative stroke [4]. A case–control study found that history of previous stroke was the most significant risk factor for postoperative stroke [5]. Other possible risk factors include age (not independent, but as a marker of other cardiovascular disease), female gender, hypertension, diabetes, creatinine >2, smoking, chronic obstructive pulmonary disease, peripheral vascular disease, left ventricular ejection fraction <40 %, coronary artery disease, heart failure, and symptomatic carotid stenosis [2].
Medical consultants often evaluate patients who have had a recent cerebrovascular event being considered for surgery:
Recommendations to delay elective surgery following a cerebrovascular accident (CVA) or transient ischemic attack (TIA) vary widely, from 2 weeks to 3 months [1].
Each case should be individually evaluated with regard to the type and urgency of the surgery, the patient’s comorbidities as a whole, and the extent to which the TIA/CVA symptoms are stable, have been fully evaluated, and intervened upon if appropriate (e.g., carotid endarterectomy [CEA] for recurrent TIA/CVA due to a carotid lesion).
Patients whose stroke risk factors have been maximally treated without escalating symptoms are likely to be at lower risk.
Discussion with the patient’s neurologist regarding risk factor optimization is recommended.
Physical Examination
General cardiovascular examination and neurologic examination is indicated preoperatively for patients at risk for perioperative stroke [6]. If a carotid bruit is detected, the patient should be questioned for signs, symptoms, or history of TIA/CVA. Patients with truly asymptomatic, incidentally found carotid bruits do not require further workup prior to surgery:
There is a poor correlation between asymptomatic bruits and significant carotid disease [7].
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