britiany sheard-caple, md faculty mentor: anthony edelman, … · varied based on etiology adams...

How low can you go?

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

Adapted from Moore LE. What’s New in Stroke 2018 for the Anesthesiologist . Powerpoint, 2018.

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

MRI• MRI next day obtained revealed Multifocal areas of ischemia

in the left MCA distribution

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


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


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


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


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


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.


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


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.


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

Questions

britiany sheard-caple, md faculty mentor: anthony edelman, … · varied based on etiology adams...

Documents