Perioperative Stroke and Associated Mortality after Noncardiac, Nonneurologic Surgery

Background:Stroke is a leading cause of morbidity and mortality in the United States and occurs in the perioperative period. The authors studied the incidence, predictors, and outcomes of perioperative stroke using the American College of Surgeons National Surgical Quality Improvement Program. Methods:Data on 523,059 noncardiac, nonneurologic patients in the American College of Surgeons National Surgical Quality Improvement Program database were analyzed for the current study. The incidence of perioperative stroke was identified. Logistic regression was applied to a derivation cohort of 350,031 patients to generate independent predictors of stroke and develop a risk model. The risk model was subsequently applied to a validation cohort of 173,028 patients. The role of perioperative stroke in 30-day mortality was also assessed. Results:The incidence of perioperative stroke in both the derivation and validation cohorts was 0.1%. Multivariate analysis revealed the following independent predictors of stroke in the derivation cohort: age ≥62 yr, history of myocardial infarction within 6 months before surgery, acute renal failure, history of stroke, dialysis, hypertension, history of transient ischemic attack, chronic obstructive pulmonary disease, current tobacco use, and body mass index 35–40 kg/m2 (protective). These risk factors were confirmed in the validation cohort. Surgical procedure also influenced the incidence of stroke. Perioperative stroke was associated with an 8-fold increase in perioperative mortality within 30 days (95% CI, 4.6–12.6). Conclusions:Noncardiac, nonneurologic surgery carries a risk of perioperative stroke, which is associated with higher mortality. The models developed in this study may be informative for clinicians and patients regarding risk and prevention of this complication.

[1]  J. Mathew,et al.  Perioperative stroke: where do we go from here? , 2011, Anesthesiology.

[2]  Eric Boerwinkle,et al.  The Atherosclerosis Risk in Communities (ARIC) Study , 2011 .

[3]  A. Folsom,et al.  Race- and Sex-Specific Associations of Obesity Measures With Ischemic Stroke Incidence in the Atherosclerosis Risk in Communities (ARIC) Study , 2010, Stroke.

[4]  C. Ko,et al.  Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. , 2010, Journal of the American College of Surgeons.

[5]  J. Horrow,et al.  Perioperative management of acute ischemic stroke: a case report. , 2009, Journal of clinical anesthesia.

[6]  L. Fleisher,et al.  Perioperative Strokes and &bgr;-Blockade , 2009, Anesthesiology.

[7]  L. Fleisher,et al.  Effect of chronic beta-blocker use on stroke after noncardiac surgery. , 2009, The American journal of cardiology.

[8]  B. Ovbiagele,et al.  The Impact of Body Mass Index on Mortality After Stroke , 2009, Stroke.

[9]  K. Tremper,et al.  Development and Validation of an Acute Kidney Injury Risk Index for Patients Undergoing General Surgery: Results from a National Data Set , 2009, Anesthesiology.

[10]  Shuang Wang,et al.  Perioperative Acute Ischemic Stroke in Noncardiac and Nonvascular Surgery: Incidence, Risk Factors, and Outcomes , 2009, Anesthesiology.

[11]  Denis Xavier,et al.  Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial , 2008, The Lancet.

[12]  C. Hui Perioperative Stroke , 2008 .

[13]  M. Weintraub,et al.  Perioperative stroke. , 2007, The New England journal of medicine.

[14]  M. Kikura,et al.  Preexisting morbidity as an independent risk factor for perioperative acute thromboembolism syndrome. , 2005, Archives of surgery.

[15]  Volkmar Falk,et al.  Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. , 2003, The Annals of thoracic surgery.

[16]  W. Knaus,et al.  Prediction of Survival for Older Hospitalized Patients: The HELP Survival Model , 2000, Journal of the American Geriatrics Society.

[17]  G. Y. Wong,et al.  Risk of Surgery and Anesthesia for Ischemic Stroke , 2000, Anesthesiology.

[18]  M. Limburg,et al.  Ischemic stroke after surgical procedures , 1998, Neurology.

[19]  R. Calcroft,et al.  Peri‐operative stroke in general surgical patients , 1997, Anaesthesia.

[20]  F. Harrell,et al.  Prognostic/Clinical Prediction Models: Multivariable Prognostic Models: Issues in Developing Models, Evaluating Assumptions and Adequacy, and Measuring and Reducing Errors , 2005 .

[21]  Daniel B. Mark,et al.  TUTORIAL IN BIOSTATISTICS MULTIVARIABLE PROGNOSTIC MODELS: ISSUES IN DEVELOPING MODELS, EVALUATING ASSUMPTIONS AND ADEQUACY, AND MEASURING AND REDUCING ERRORS , 1996 .

[22]  Camilo R. Gomez,et al.  Perioperative Stroke in Patients Undergoing Head and Neck Surgery , 1993, The Annals of otology, rhinology, and laryngology.

[23]  J. Cohen,et al.  Perioperative stroke after general surgical procedures. , 1993, New York state journal of medicine.

[24]  Gates Pc,et al.  Watershed cerebral infarction associated with perioperative hypotension. , 1993 .

[25]  P. Gates,et al.  Watershed cerebral infarction associated with perioperative hypotension. , 1993, Clinical and experimental neurology.

[26]  T. Cogbill,et al.  Perioperative stroke risk in 173 consecutive patients with a past history of stroke. , 1990, Archives of surgery.

[27]  G. Boysen,et al.  Postoperative cerebrovascular accidents in general surgery , 1988, Acta anaesthesiologica Scandinavica.

[28]  B. Hindman,et al.  Mechanisms of perioperative cerebral infarction. , 1982, Stroke.

[29]  J. Hanley,et al.  The meaning and use of the area under a receiver operating characteristic (ROC) curve. , 1982, Radiology.

[30]  P. Parseval,et al.  Structure of the { 001 } talc surface as seen by atomic force 1 microscopy : Comparison with X-ray and electron diffraction 2 results 3 4 , 2006 .