Perioperative stroke

International Surgical Outcomes Study group Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br. J. Anaesth. 117, 601–609 (2016).

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Mashour, G., Moore, L., Lele, A., Robicsek, S. & Gelb, A. 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. J. Neurosurg. Anesthesiol. 26, 273–285 (2014). An original authoritative consensus statement, endorsed by the Society for Neuroscience in Anesthesiology and Critical Care, provides evidence-based guidelines for a previously under-represented patient cohort. It offers a structured risk stratification methodology and outlines best practices for multidisciplinary teams.

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Mashour, G., Shanks, A. & Kheterpal, S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology 114, 1289–1296 (2011). This study presents comprehensive data regarding the incidence and mortality of perioperative stroke from 523,059 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent noncardiac, non-neurological surgery. This is foundational in highlighting the risk factors and significant morbidity and mortality associated with perioperative stroke.

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Wilcox, T., Smilowitz, N. R., Xia, Y. & Berger, J. S. Cardiovascular risk scores to predict perioperative stroke in noncardiac surgery. Stroke 50, 2002–2006 (2019). This study compares several scoring tools used clinically for perioperative stroke risk prediction. It reports excellent risk discrimination for perioperative stroke in patients undergoing noncardiac surgery using the myocardial infarction or cardiac arrest risk score and the American College of Surgeons surgical risk calculator.

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Messé, S. R. et al. Stroke after aortic valve surgery: results from a prospective cohort. Circulation 129, 2253–2261 (2014). This study characterizes stroke after aortic valve replacement highlighting the importance of routine neurological assessments to identify stroke and the increased mortality and length of stay associated with clinical stroke complicating aortic valve replacement.

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Aguirre, A. O. et al. Stroke management and outcomes in low-income and lower-middle-income countries: a meta-analysis of 8535 patients. J. Neurosurg. 139, 1042–1051 (2023).

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Al-Hader, R. et al. The incidence of perioperative stroke: estimate using state and national databases and systematic review. J. Stroke 21, 290–301 (2019). This study establishes a comprehensive baseline estimate for perioperative stroke incidence in the USA.

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Likosky, D. S. et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke 34, 2830–2834 (2003).

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Benesch, C. et al. Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association. Circulation 143, e923–e946 (2021). An authoritative scientific statement from the American Heart Association/American Stroke Association, it provides the most up-to-date (published in 2021) evidence-based recommendations for neurological evaluation and management to lower the risk of acute stroke in patients undergoing non-cardiac, non-neurological surgery.

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Gaudino, M. et al. Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a scientific statement from the American Heart Association. Circulation 142, e193–e209 (2020). An authoritative scientific statement from the American Heart Association, it offers evidence-based guidelines aimed at reducing the risk of perioperative stroke, specifically in cardiac and thoracic aortic operations.

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GBD 2019 Stroke Collaborators Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 20, 795–820 (2021).

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Pichlmaier, M. et al. Routine stent bridging to the supraaortic vessels in aortic arch replacement: 10-year-experience. Ann. Thorac. Surg. 113, 1491–1497 (2022).

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NeuroVISION Investigators Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study. Lancet 394, 1022–1029 (2019). A prospective, multinational cohort study of over 1,100 patients ≥65 years of age who underwent elective, high-risk noncardiac and noncarotid surgery. It reveals a 7% incidence rate of perioperative covert (or clinically silent) stroke detected via MRI and underscores the need for vigilant monitoring.

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Woldendorp, K. et al. Silent brain infarcts and early cognitive outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur. Heart J. 42, 1004–1015 (2021).

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Fanning, J. P., Wong, A. A. & Fraser, J. F. The epidemiology of silent brain infarction: a systematic review of population-based cohorts. BMC Med. 12, 119 (2014).

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Gensicke, H. et al. Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk. J. Am. Coll. Cardiol. 65, 521–529 (2015).

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Smilowitz, N. R. et al. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMA Cardiol. 2, 181–187 (2017). Among 10,581,621 hospitalizations for major noncardiac surgery, major adverse cardiovascular and cerebrovascular events are a significant source of perioperative morbidity and mortality. An increase in perioperative ischaemic stroke is seen from 2004 to 2013.

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Bateman, B., Schumacher, C., Wang, S., Shaefi, S. & Berman, M. Perioperative acute ischemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes. Anesthesiology 110, 231–238 (2009). National Inpatient Sample of 372,000 patients who underwent major intra-abdominal, orthopaedic and noncardiac thoracic surgery. Detailed study of the incidence and outcomes of acute ischaemic stroke in noncardiac surgery and nonvascular surgery.

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Vasivej, T., Sathirapanya, P. & Kongkamol, C. Incidence and risk factors of perioperative stroke in noncardiac, and nonaortic and its major branches surgery. J. Stroke Cerebrovasc. Dis. 25, 1172–1176 (2016).

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Wang, H., Li, S. L., Bai, J. & Wang, D. X. Perioperative acute ischemic stroke increases mortality after noncardiac, nonvascular, and non-neurologic surgery: a retrospective case series. J. Cardiothorac. Vasc. Anesth. 33, 2231–2236 (2019).

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Reynolds, M. R. et al. Investigating the mechanisms of perioperative ischemic stroke in the Carotid Occlusion Surgery Study. J. Neurosurg. 119, 988–995 (2013).

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Garcia, R. M., Yoon, S., Cage, T., Potts, M. B. & Lawton, M. T. Ethnicity, race, and postoperative stroke risk among 53,593 patients with asymptomatic carotid stenosis undergoing revascularization. World Neurosurg. 108, 246–253 (2017).

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Mehdi, Z., Birns, J., Partridge, J., Bhalla, A. & Dhesi, J. Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery. Clin. Med. 16, 535–540 (2016).

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Aries, M. J. H., Elting, J. W., De Keyser, J., Kremer, B. P. H. & Vroomen, P. C. A. J. Cerebral autoregulation in stroke: a review of transcranial Doppler studies. Stroke 41, 2697–2704 (2010).

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Jørgensen, M. E. et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA 312, 269–277 (2014). By rigorously quantifying the time-dependent risk factors related to major adverse cardiovascular events and mortality in patients with prior ischaemic stroke, this study finds that the timing of surgery in patients with recent ischaemic stroke is an important and inadequately addressed issue.

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Andreasen, C. et al. Association of timing of aortic valve replacement surgery after stroke with risk of recurrent stroke and mortality. JAMA Cardiol. 3, 506–513 (2018). This study demonstrated association between the time elapsed from previous stroke (especially <3 months) and surgical aortic valve replacement with the risk of recurrent perioperative stroke, major adverse events (MACE) and mortality.

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Christiansen, M. N. et al. Risks of cardiovascular adverse events and death in patients with previous stroke undergoing emergency noncardiac, nonintracranial surgery: the importance of operative timing. Anesthesiology 127, 9–19 (2017).

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Glance, L. G. et al. Association of time elapsed since ischemic stroke with risk of recurrent stroke in older patients undergoing elective nonneurologic, noncardiac surgery. JAMA Surg. 157, e222236 (2022). There is limited information on which to base decisions for how long to delay elective non-neurological and noncardiac surgery in patients with a history of stroke. This study suggests that the risk plateaus after 90 days between a previous stroke and elective surgery.

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Musleh, R. et al. Surgical timing in patients with infective endocarditis and with intracranial hemorrhage: a systematic review and meta-analysis. J. Am. Heart Assoc. 11, e024401 (2022).

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