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Stroke Related to Surgery and Other Procedures


Key Points

  • Periprocedural stroke accounts for at least 5% of the approximately 800,000 strokes that occur each year in the United States, although these events are likely underreported.

  • Stroke can occur after a wide range of surgeries, and when it occurs, it is associated with substantial morbidity, mortality, and cost.

  • Surgeries with high risk of periprocedural stroke include carotid revascularization, intracranial vascular procedures, cardiac valve surgery, thoracic aortic procedures, and coronary artery bypass grafting (CABG).

  • In general, predictors of periprocedural stroke are similar to predictors of stroke in the general population and include advanced age, history of prior stroke, and/or history of other vascular disease.

  • Carotid screening prior to high-risk surgeries, including CABG, may not be helpful and, if performed at all, should be limited to selected high-risk patients. The utility of combined carotid revascularization and CABG is uncertain, but, based on current evidence, is not likely to be beneficial for most neurologically asymptomatic patients.

  • Stopping antithrombotic therapy in the periprocedural period may be associated with an increased risk of stroke. Although the absolute risk is generally low if the duration of withholding antithrombotic medications is brief, the sequelae of a stroke can be severe. For dental and dermatologic procedures, continuation of antithrombotic therapy, including aspirin and warfarin, is likely safe. Optimal management for more invasive procedures is less certain.

  • Major surgery within 14 days is a contraindication to intravenous recombinant tissue plasminogen activator (rt-PA). Patients who have had minor procedures at a readily compressible site, such as percutaneous coronary intervention, may still be treated. Thrombolysis after more significant transcatheter procedures such as valve replacement, with a known risk for silent embolic injury, is of uncertain safety. Endovascular treatment, with mechanical thrombectomy, should be considered after any invasive procedures regardless of whether rt-PA is given.

Introduction

Many surgical and endovascular procedures place the central nervous system at direct risk of ischemic injury, particularly in high-risk patients. When they occur, periprocedural strokes are associated with a dramatic increase in morbidity, mortality, and healthcare costs. For example, stroke complicating cardiac surgery has been reported to double the duration and cost of hospitalization, increase the mortality rate 5–10-fold, and leave the majority of survivors with significant disability.

The risk of periprocedural stroke depends in part on the intervention being performed. Stroke after general surgery and vascular surgery (excluding the great vessels and thoracic aorta) is estimated to be less than 1%. Stroke risk after cardiac catheterization is also low, with estimates ranging from 0.1% to 0.4%, although rates are likely higher after valvuloplasty and electrophysiologic ablation procedures. The risk of stroke is significantly higher during cardiac surgery, carotid revascularization, cerebrovascular procedures, and thoracic or thoracoabdominal aortic repairs. , , Among cardiac surgical procedures, coronary artery bypass graft (CABG) has been reported to have a stroke risk of 1%–4%. , When compared with percutaneous coronary intervention, CABG has a higher rate of stroke. Although CABG patients are more likely to have multivessel coronary disease and diffuse atherosclerosis, observed differences are not explained solely by patient selection. Valve procedures are higher risk than CABG, and multivalve or combined CABG plus valve replacement are highest of all. Compared with traditional surgical aortic valve replacement, randomized trials of transcutaneous aortic valve replacement (TAVR) have yielded mixed results, with various studies finding higher, similar, or lower risks of stroke between the two procedures. Early trials of TAVR were limited to nonoperable and high-risk populations. , More recently, randomized studies in both intermediate- and low-risk subjects have shown similar or lower stroke rates with TAVR compared with surgical aortic valve replacement. Procedures involving the extracranial carotid arteries and intracranial vessels are particularly high risk for stroke. Multiple randomized trials of carotid revascularization have demonstrated a higher risk of stroke with stenting compared with endarterectomy, although the endovascular procedure does have a lower risk of myocardial infarction. , Table 34.1 presents a list of common cardiovascular and cerebrovascular procedures, a range of risks for neurologic ischemia quoted from the literature, and an estimated number of procedures performed annually in the United States. Taken together, these estimates suggest that periprocedural stroke accounts for at least 5% of the approximately 800,000 strokes that occur each year in the United States.

TABLE 34.1
Common Procedures and the Reported Risk for Neurologic Ischemic Complications.
Procedure Ischemic Neurologic Complication Rate Estimated Annual Number of Procedures in the United States , ,
Cardiac catheterization , Stroke in 0.2%–0.5% 1,000,000
Coronary artery bypass grafting , Stroke in 1%–4% 450,000
Asymptomatic CEA or stenting Stroke in 1%–3% 100,000
Symptomatic CEA or stenting , Stroke in 4%–10% 70,000
Cerebral aneurysm clipping or coiling Stroke in 6%–10% 20,000
Intracranial stenting , Stroke in 9%–15% 500
Cardiac valve replacement , , , Stroke in 2%–17% 100,000
Descending thoracic aorta and thoracoabdominal aorta repair , , Stroke in 1.4%–8.7%
Spinal infarct in 3.8%–23%		 20,000
CEA, Carotid endarterectomy.

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