ANAESTHESIA FOR PATIENTS WITH

PRIOR
CEREBRO-VASCULAR STROKE
• Stroke is second most common cause of death worldwide (11.8 % of
all deaths).
• Third most common cause of disability (4.5 % ).

• More than 80% strokes are Ischaemic.

• Majority of Ischaemic stroke patients are older with multiple co-
morbid conditions.
• Increasing number of these patients present for elective and
emergency surgeries.
• History of stroke is major risk factor for increased peri-operative
morbidity and mortality in non- cardiac surgery.
(Reference : Lee et al )
PATHOPHYSIOLOGY
• In an acute Ischaemic stroke,cerebral autoregulation is impaired for 1
to 3 months.
• Cerebral perfusion is affected even by minor cardiovascular changes.

• The vasomotor reactivity is also impaired for approximately 3 months.

• Anaesthesia and surgery, because of its stress response,changing
volume status,poly pharmacy may significantly affect the outcome
and peri-operative morbidity and mortality.
• Extensive guidelines are available regarding anaesthesia risk and
assessment in patients with prior cardiac diseases.
( AMERICAN SOCIETY OF ANAESTHESIA , AMERICAN HEART
ASSOCIATION )
• There is paucity of literature regarding peri-operative assessment,
optimization, management, complications in patients with prior
stroke.
• The timing of surgery in patients with recent Ischaemic stroke is
important but inadequately addressed issue.
STUDY PUBLISHED IN JAMA 2014
• Time elapsed after Ischaemic stroke and risk of adverse
cardiovascular events and mortality following elective non-cardiac
surgery.
• Danish National Cohort Study ( 2005-2011 ) includes all patients 20
years and older undergoing Elective non-cardiac surgeries.
• Records are obtained from National Registry.
Time elapsed between stroke and surgery and their outcome was
studied.
Risk for Major Acute Cardiovascular Events
(MACE )
Includes
• Ischaemic stroke
• Acute Myocardial Infarction
• Cardiovascular mortality
• All-cause mortality upto 30 days after surgery
• The study included a large,unselected patient population for wide
range of surgeries.
RESULTS
DISCUSSION
• The study included all elective surgeries in DENMARK ( 2005-2011 ).
• Prior ischaemic stroke, irrespective of time between ischaemic stroke
and surgery, was associated with adjusted 1.8 fold increased relative
risk of 30-day mortality, and 4.8 fold increased risk of 30-day MACE
compared with patients without prior stroke.
• A strong time dependant relationship existed between prior stroke
and adverse outcome with patients experiencing stroke less than 3
months prior to surgery.
• The risk stabilized after approximately 9 months after stroke.
• Increased Relative risk associated with prior stroke was found to be
of at least similar magnitude in low , intermediate and high risk
surgeries.
• The observational nature of the study makes it impossible to have
detailed data about medication, disease severity of various organs
and systems.
• The study was predominantly undertaken in white population. Their
generalization to other countries and non-white population is
unknown.
• The findings need to be confirmed by further studies, but may
warrant consideration in future peri-operative guidelines.