Anesthesia Patient Safety Podcast

#266 Protecting the Brain: Perioperative Stroke Prevention

• Anesthesia Patient Safety Foundation

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Perioperative stroke represents a rare but potentially devastating complication of anesthesia care. While occurring in less than 1% of non-cardiac surgical patients, this complication fundamentally threatens not just patient outcomes but their very identity. As Dr. Jacob Nadler poignantly notes in our podcast, "By maintaining brain health, we're preserving the essence of who our patients are—their memories, their personality, their ability to connect with friends and family."

The most significant recent development in this field comes from the 2024 joint guidelines that have dramatically shortened the recommended waiting period following stroke before elective surgery. What was once a nine-month wait has been reduced to just three months based on compelling evidence from a cohort study of 5.8 million patients showing risk stabilization after 90 days. This change has profound implications for surgical planning and patient care timelines.

Anesthesia professionals must be vigilant about key risk factors including advanced age, previous stroke history, renal dysfunction, and anemia. The podcast explores critical medication management considerations, particularly regarding anticoagulation protocols, alongside specific intraoperative targets for blood pressure and hemoglobin levels. For suspected perioperative stroke, rapid multidisciplinary intervention with emergent brain imaging, possible thrombolytics, and mechanical thrombectomy may be indicated.

For every anesthesia professional, this episode provides essential insights to help fulfill our commitment that no one shall be harmed by anesthesia care. Subscribe on Spotify or YouTube and share with colleagues to spread this vital safety information.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/266-protecting-the-brain-perioperative-stroke-prevention/

© 2025, The Anesthesia Patient Safety Foundation

Speaker 1:

You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.

Speaker 2:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are so excited to continue our conversation of the excellent articles from the June 2025 APSF newsletter. But before we dive further into the episode today, we'd like to recognize Nihon Kodan, a major corporate supporter of APSF. Nihon Kodan has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, nihon Kodan. We wouldn't be able to do all that we do without you. Our featured article today is Perioperative Stroke Prevention a review of recent guidelines for non-cardiac and non-neurologic surgery by Robert Pranat and Jacob Nadler. To follow along with us, head over to apsforg and click on the newsletter heading. The first one down is the current newsletter. Then scroll down until you get to our featured article today. I will include the link in the show notes as well. We have exclusive content from one of the authors to help kick off the show today. Here he is now.

Speaker 3:

Hi, my name is Jacob Nadler and I'm chief of the neuroanesthesiology division within the Department of Anesthesiology and Perioperative Medicine at the University of Rochester in Rochester, New York.

Speaker 2:

I asked Nadler why he is so passionate about this topic. Let's take a listen to what he had to say.

Speaker 3:

I'm passionate about brain health because neurologic complications impact our patient's identity and humanity in a way that other serious perioperative complications like infection or kidney injury might not. By maintaining brain health, we're preserving the essence of who our patients are their memories, their personality, their ability to connect with their friends and family. To me, brain health is not just a medical concern, but a deeply personal and philosophical one. This area offers tangible opportunities to avoid what I see as really existential complications.

Speaker 2:

Thank you so much to Nadler for contributing to the show today and helping to highlight how important this topic is for anesthesia professionals. The stakes are quite high and we need to remain vigilant to help keep our patients safe during anesthesia care. Now it's time to get into the article, and we'll get started with the definition. Perioperative stroke is a brain infarction of ischemic or hemorrhagic etiology that occurs during surgery or within 30 days postoperatively. The good news is that this is an uncommon event and may occur in between 0.1 and 0.7 percent of patients undergoing non-cardiac surgery, according to data from the American College of Surgeons National Surgical Quality Improvement Program. Further investigation into perioperative stroke has revealed the following the greatest risk factors for post-operative stroke include history of stroke, including transient ischemic attack, advanced age, anemia with a hematocrit less than 27% and renal dysfunction. The most common time frame was between postoperative days 2 and 9. The surgeries with the highest risk were emergency surgery, vascular surgery, including carotid endarterectomy and thoracic endovascular, aortic repair and brain surgery. The majority of perioperative stroke events in non-cardiac and non-neurological surgery are due to ischemia, which may be from hypotension and low flow states previously unknown large artery stenosis, anemia-associated tissue hypoxia, thrombus fat or foreign material embolism, enhanced coagulability or thrombosis in the setting of systemic inflammation and or recent discontinuation of antithrombotic medications. There is an opportunity for enhanced education when it comes to diagnosis and management of perioperative stroke for patients and clinicians. In addition, risk factors may be under-recognized during the preoperative period. There is a study of Canadian anesthesiologists that identified knowledge gaps in anesthesia professionals related to perioperative stroke. Survey study revealed that less than half of the respondents correctly identified the overall incidence of stroke in the perioperative time period and only a quarter knew that thrombosis was the most common etiology. In addition, 64% of respondents believe that the overall risk of dying from perioperative stroke is rare, but the actual stroke-associated mortality rate is quite high, at 25 to 87 percent. For most of the respondents, there was a disconnect between knowledge about perioperative stroke and confidence providing care to patients at high risk for stroke. We hope that you will check out the whole study and I will include the citation in the show notes as well.

Speaker 2:

One question that comes up in preoperative anesthesia clinics around the world is related to the timing of elective surgery for patients who have had a prior stroke. We know that patients with a history of stroke have a higher risk for complications, including perioperative stroke, but this risk decreases over time. Let's look into the literature database that found the greatest risk for ischemic stroke and cardiovascular death was within the first three months following the initial event. For patients undergoing elective surgery, this risk appeared to level off at about nine months. The 2021 American Stroke Association American Heart Association guidelines incorporated this data and recommended delaying elective surgery following stroke for nine months, with consideration for surgery after six months if the benefit outweighed the risk of waiting. Fast forward to the 2022 study by Glantz and colleagues published in JAMA Surgery Association of Time Elapsed Since Ischemic Stroke with Risk of Recurrent Stroke in Older Patients Undergoing Elective Non-Neurological Non-Cardiac Surgery. This is a cohort study of 5.8 million patients that revealed that the risk of stroke and death leveled off after only 90 days between a previous stroke and elective surgery. These results led to new guidelines. In 2024, a joint guideline by the AHA, asa and other international societies for perioperative cardiovascular management of patients undergoing non-cardiac surgery was published. The updated guidelines recommended that patients wait at least three months after stroke before undergoing non-cardiac surgery to help decrease the risk of recurrent stroke and or major adverse cardiovascular events. I just want to highlight this recommendation for all anesthesia professionals who may find themselves being asked how long to wait to schedule surgery for patients who have had a stroke. According to the latest guidelines, it is appropriate to wait at least three months after the stroke. You can help your entire department stay up to date with the most recent guidelines.

Speaker 2:

Speaking of preoperative recommendations, we have more to talk about. Let's review the guidelines for the prevention of perioperative stroke published by the ASA and AHA in 2021 and the Society of Neuroscience and Anesthesiology in Critical Care, or SNAC, in 2020. Preoperative recommendations highlight a multidisciplinary approach to preoperative testing and optimization and appropriate medication management, especially when it comes to beta blockers and anticoagulation. Before we go through the recommendations that are listed in Table 1, I want to highlight some of the differences between these two published guidelines. The SNAC guidelines advise caution with the use of interoperative metoprolol, since it has been associated with perioperative stroke with considerations for using other beta blockers. The ASA-AHA guidelines recommend continuing beta blockers.

Speaker 2:

Other key differences come from the ASA-AHA guidelines pertaining to the increased risk for perioperative stroke in patients with a Peyton-Ferramen ovale, the use of web-based American College of Surgeons surgical risk calculator and carotid artery revascularization for patients with symptomatic carotid artery stenosis greater than 70% before elective surgery. The guidelines are also different in the management of patients taking vitamin K antagonists, but both agree that for patients at high risk for thromboembolic complications, bridging with either therapeutic low molecular weight heparin or intravenous heparin is appropriate. There is further agreement that aspirin, warfarin and direct oral anticoagulants should be held before elective surgery, depending on the bleeding risk, and restarted shortly after surgery, with heparin bridging only required for high thromboembolic risk cases. Make sure to continue aspirin for patients who have undergone percutaneous coronary interventions. Statin therapy may not reduce the risk of stroke, but may improve other outcomes.

Speaker 2:

You may need to have a discussion with surgeons, anesthesia professionals, neurologists and other medical professionals to develop a comprehensive preoperative plan for anticoagulation management. It's time to go through table one in the article for a summary of the preoperative considerations. This is an excellent resource for anyone in a preoperative anesthesia clinic. First up, the preoperative evaluation. Here are the important considerations. All patients should be assessed for their perioperative stroke risk, specifically increased age, renal disease, history of transient ischemic attack or stroke and patent foramen ovale. Patients at higher risk of perioperative stroke should be discussed by a multidisciplinary team. Consider using the web-based ACS-SRC to assess risk.

Speaker 2:

Delay non-cardiac surgery for greater than three months following cerebrovascular event. Next up, there is a recommendation for preoperative optimization. Next up, there is a recommendation for preoperative optimization. Perform carotid artery revascularization in patients with symptomatic carotid artery stenosis of greater than 70% before elective surgery. Finally, we get to medication management, which includes the following considerations For beta blockers continue prescribed beta blockers but do not start beta blocker therapy.

Speaker 2:

For aspirin do not routinely continue aspirin solely for stroke risk reduction. Consider continuing aspirin in patients at high risk for a major adverse cardiac event, such as patients on aspirin for secondary prevention if the benefits outweigh the risk of bleeding. Aspirin should be continued if there is a history of percutaneous coronary intervention. For warfarin hold for 5-6 days before surgery. Restart 12-24 hours after surgery. Consider heparin or low molecular weight heparin bridging for high thromboembolic risk only For intermediate risk. Bridging is at the clinician's discretion and bridging is not recommended for low risk. For direct oral anticoagulants high bleeding risk surgeries hold three days prior and restart two to three days after surgery. For low bleeding risk surgeries hold two days prior and restart 24 hours after surgery. Bridging is based on clinical judgment. Regardless of the bleeding risk. Timing of resuming anticoagulants should be discussed by the multidisciplinary team.

Speaker 2:

Now it's time to head into the operating theater to talk about interoperative considerations to minimize the risk for stroke. Check out table 2 in the article to follow along. Here are the important considerations Maintain mean arterial pressures greater than 70 millimeters of mercury, especially in patients with moderate to high perioperative stroke risk. Pay careful attention to blood pressure gradients between the brain and wherever the blood pressure is being measured in order to avoid hypotension. Transfuse to a hemoglobin greater than 8 grams per deciliter in patients with recent stroke or cerebrovascular disease. And maintain the hemoglobin between 8 to 9 grams per deciliter if there is a history of recent stroke, ongoing bleeding or hemodynamic instability. In the presence of known cerebrovascular insufficiency due to occlusion or stenosis. Consider transfusion to a hemoglobin of greater than 9 if patients are taking beta blockers to help decrease the risk for perioperative stroke.

Speaker 2:

There are no specific recommendations for or against the use of regional versus general anesthesia and no recommendations against the use of nitrous oxide or volatile anesthetics versus total intravenous anesthesia. There does appear to be a benefit of regional anesthesia for joint replacement surgery, likely due to the differences in blood loss and the risk for thromboembolism. Maintain normocarbia and maintain a serum blood glucose between 130 and 180 milligrams per deciliter. We have made it out of the operating room. It's time for the post-operative recommendations. Let's turn our attention to table three. Here are the recommendations If concerned for perioperative stroke, obtain emergent brain imaging.

Speaker 2:

If there is a high suspicion for perioperative stroke on brain imaging, a multidisciplinary group discussion is warranted to recommend either intravenous thrombolytics and or the use of mechanical thrombectomy If the patient is given recombinant tissue plasminogen activator. Maintain systolic blood pressure less than 180 and diastolic blood pressure less than 105. Additional testing should include an EKG, troponins and cardiac telemetry for at least the first 24 hours. Avoid hypotension. Aim for MAP targets greater than 70 millimeters of mercury in patients at moderate to high risk of stroke. Patients at moderate to high risk of stroke.

Speaker 2:

Initiate aspirin therapy in the first 24 to 48 hours after ischemic stroke onset, but this can be delayed until after 24 hours in patients who have received TPA. Maintain serum blood glucose between 140 and 180 milligrams per deciliter. Remember this is a time when anesthesia professionals can have a big impact on keeping patients safe by providing appropriate hemodynamic monitoring and management, ventilator support and safe patient transport to imaging procedural rooms and hospital floors and intensive care units. Anesthesia professionals need to be aware of the risks for perioperative stroke and be knowledgeable about recommendations and guidelines to help decrease the risk and recognize this complication when it occurs. Here are the big takeaways Delay elective surgery for at least three months after stroke. Consider a multidisciplinary approach to perioperative optimization and planning for high-risk patients. For patients with symptoms concerning for perioperative stroke, emergent evaluation is critical, with early engagement of a multidisciplinary team. Before we wrap up for today, we are going to hear from Nadler again. I also asked him what he hopes to see going forward. Let's take a listen now.

Speaker 3:

I can imagine several developments that would significantly improve our perioperative outcomes. Enhanced risk stratification tools, possibly incorporating artificial intelligence and machine learning or individual patient multiomics, will improve our ability to identify high-risk patients. Better bleeding risk profiles will let us develop more personalized anticoagulation management protocols In the OR we might see personalized blood pressure targets based on individual real-time cerebral monitoring technologies. And I don't know if we'll ever find the holy grail, a neuroprotective drug that can prevent damage in the setting of hypoperfusion. But research into the mechanisms of hibernation and ischemia reperfusion injury might allow us to precondition our at-risk patients or, post-condition, our patients who do end up having a stroke.

Speaker 2:

Thank you so much to Nadler for contributing to the show today. We are looking forward to the future with more tools to improve perioperative outcomes and help prevent perioperative stroke going forward. If you have any questions or comments from today's show, please email us at podcast at APSForg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes for links to all the topics we discussed today.

Speaker 2:

Thank you for tuning in and if you found this episode valuable, please share it with your colleagues, friends or anyone interested in improving anesthesia, patient care and safety. Your support helps us reach more listeners and spread awareness about the importance of safety in anesthesia. We're excited to share that the podcast is available on Spotify and YouTube, so it's easier than ever to listen and share. If you're on Spotify, make sure you click the bell icon to subscribe so that you don't miss an episode. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.