Occlusive Cerebrovascular Disease

Worldwide, 15 million people suffer a stroke each year.

Prevalence of stroke in USA: Approximately 3%.

Incidence of stroke in USA: 795,000 annually, including 600,000 new cases and 115,000 recurrences.

China has the highest rates of mortality (19.9%), followed by Africa and South America.

Risks for stroke:

• Cardiac and carotid surgery: CABG = 1–5%; CEA < 3%

• Noncardiac surgery: Major general surgery 0.08–0.7%; orthopedic 0.2–0.9%; major peripheral vascular reconstruction = 0.3–3%

Cerebral ischemia

Myocardial ischemia (CAD, the leading cause of morbidity following CEA)

Cognitive decline (long-term effects of poor perfusion)

Control of coexisting Htn, DM, CAD, and OSA

Two main clinical presentations:

• Pts with known occlusive CVD undergoing carotid or cerebral revascularization; risk factors include CAD/CHF; stroke in evolution, frequent TIAs; severe Htn; stenosis; COPD; OSA, diabetes, and poor cerebral collateral flow; age >70 y; and intraluminal thrombus. Criteria for pt selection and acceptable periop morbidity and mortality rates are now well established for CEA and carotid stenting.

• Pts with known or possible CVD presenting for other surgery; risk factors vary with age and type of surgery. The peak incidence of periop stroke is on postop d 2, and the median is between 2–9 d. Periop stroke carries higher mortality than stroke does in nonsurgical settings (26% vs. 12.2%). In pts with previous stroke, mortality rate after periop stroke is around 87%.