Cerebrovascular Accident (Stroke / CVA)
Anesthesia Implications
Anesthesia Implications
Wait 3 months – Studies indicate that patients that have had a stroke within the last 3 months are at greater risk for major cardiovascular events and have a higher 30-day mortality rate. Therefore, elective surgery should be delayed for 3 months after the stroke where feasible.
High risk for another stroke – If a patient has had a stroke, they are far more likely than the general population to experience another. The highest risk is within the first month.
Choice of anesthetic – Autoregulation is impaired in the days following a stroke – so even modest changes in blood pressure could have drastic affects on cerebral perfusion. It is predicted that this lasts for 1-3 months following a stroke. Furthermore, ischemic tissue affected by a stroke has undergone inflammatory processes and is especially susceptible to further damage by the hemodynamic changes experienced during anesthetic intervention. Clinical trials are ongoing to establish a particular anesthetic technique as the preferred or safest. For the present, safeguard against drastic changes in hemodynamic parameters.
Preoperatively assess – document thoroughly weakness and/or residual affects of the stroke.
High risk surgeries – The highest risk surgeries for a patient to experience a stroke intraoperatively are cardiac, carotid, and neurological surgeries.
Pathophysiology
This condition is characterized by a neurological deficit which follows an ischemic or hemorrhagic problem. Ischemic events occur as a result of a embolism or thrombosis. Trauma, vascular malformation, and coagulopathy are the primary culprits for hemorrhagic problems. The vast majority of strokes are classified as ischemic.
Very Common – 3% of adults in the United States have experienced a stroke.
Inherited risk factors include age, prior history of a CVA, family history of a CVA, black race, male, and sickle cell disease.
Modifiable risk factors include hypertension, tobacco use, diabetes, carotid artery disease, atrial fibrillation, heart failure, high cholesterol, obesity, and sedentary lifestyle.
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Mehdi. Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery. Clinical Medicine. 2016.
American Heart Association (AHA). 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. 2015.
