Perioperative stroke is an uncommon event associated with significant morbidity and mortality. Neurologists are often called to assess potential stroke risk factors to advice on prophylactic medical or surgical measures, which could decrease risk of this dreaded complication.
The decision to continue or just temporarily hold antiplatelet medications perioperatively in patients with known risk factors depends on the type of surgery. If on oral anticoagulation, the majority of patients should be considered for bridging therapy with heparin or low-molecular-weight-heparin. If an acute perioperative stroke occurs and standard intravenous rt-PA (Alteplase) is contraindicated, a neurointerventional procedure should be considered. Some studies demonstrate that the concept of neuroprotection, ie, using statin and β-adrenergic receptor antagonists, in the perioperative setting could be beneficial. Carotid stenosis is associated with an increased risk of stroke, however, there is no evidence that the increased risk is sufficient to mandate prophylactic carotid endarterectomy before general surgical procedures. When both coronary and extracranial carotid artery stenoses exist, symptomatic lesions should be treated first in a staged procedure. The approach to asymptomatic patients should depend on the degree of the stenosis.
Perioperative stroke can be a serious complication. Hence, neurologists should assess the patient's risk factors and advice on possible prophylaxis and management of antiplatelet or anticoagulation medications. In this review, we provide several algorithms and recommendations to prevent and treat perioperative stroke.
From the *Department of Neurology and †Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI.
Reprints: Michel T. Torbey, MD, MPH, FAHA, Associate Professor of Neurology and Neurosurgery, Director, Stroke Critical Care Program, Director, Neurointensive Care Unit 9200 W. Wisconsin Ave. Milwaukee, WI 53226. E-mail: Mtorbey@mcw.edu.