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RISK FACTORS FOR PERIOPERATIVE STROKE
DEVELOPMENT IN CARDIAC SURGERY
Aripov Dilshodbek Murodilloevich
https://orcid.org/ 0009-0004-1840-0819
Bukhara State Medical Institute named after Abu Ali ibn Sino,
Uzbekistan, Bukhara.
Abstract
Risk factors for perioperative stroke development are diverse and can
be divided into patient-related factors and factors directly related to surgical
intervention. This review discusses risk factors, potential mechanisms, prevention
strategies, and the impact of stroke on clinical outcomes in the postoperative period.
Keywords:
stroke, cardiac surgery, pathogenesis, cardiovascular complications.
ФАКТОРЫ РИСКА РАЗВИТИЯ ПЕРИОПЕРАЦИОННОГО ИНСУЛЬТА
ПРИ КАРДИОХИРУРГИЧЕСКИХ ВМЕШАТЕЛЬСТВАХ
Арипов Дилшодбек Муродиллоевич https://orcid.org/ 0009-0004-1840-0819
Бухарский государственный медицинский институт имени Абу Али ибн
Сино, Узбекистан, г. Бухара.
Аннотация
Факторы риска развития периоперационного инсульта
многообразны, и они условно могут быть разделены на факторы, связанные с
пациентом, и факторы, связанные непосредственно с оперативным
вмешательством. Данный обзор посвящен обсуждению факторов риска,
потенциальных механизмов, стратегий профилактики, а также влиянию
инсульта на клинические исходы в послеоперационном периоде.
Ключевые слова
: инсульт, кардиохирургия, патогенез, сердечно-
сосудистые осложнения.
YURAK JARROHLIGIDA PERIOPERATIV INSULT
RIVOJLANISHI XAVF FAKTORLARI
Aripov Dilshodbek Murodilloevich https://orcid.org/ 0009-0004-1840-0819
Abu Ali ibn Sino nomidagi Buxoro davlat tibbiyot instituti, O‘zbekiston, Buxoro.
Annotatsiya
Perioperativ insult rivojlanishi uchun xavf omillari xilma-xil bo'lib,
ularni bemor bilan bog'liq omillarga va jarrohlik aralashuvga bevosita bog'liq bo'lgan
omillarga bo'lish mumkin. Ushbu sharhda xavf omillari, potentsial mexanizmlar, oldini
olish strategiyalari va operatsiyadan keyingi davrda insultning klinik natijalarga ta'siri
muhokama qilinadi.
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Kalit so'zlar:
insult, kardiojarrohlik, patogenez, yurak-qon tomir asoratlari.
Relevance of the research
Perioperative stroke is the most severe complication of surgical interventions. The
risk of developing this complication depends on the type of intervention. If in non-
cardiac surgical interventions it is 0.1–2.0%, then in high-risk cardiac surgery it can
reach 10% [1]. Perioperative stroke leads to an increase in mortality and disability of
patients, and also contributes to the overexpenditure of financial and human resources.
Clinically hidden (asymptomatic) strokes also contribute to the deterioration of
neurocognitive dysfunction in the long term, as well as the development of clinically
significant strokes [2].
A consensus document of the Society for the Neurosciences of Anesthesiology
and Critical Care defines perioperative stroke as a cerebral infarction of ischemic or
hemorrhagic etiology that occurs during surgery or 30 days after surgery, including the
development of stroke after awakening from anesthesia. Perioperative Stroke Rate and
Its Impact on Clinical Outcomes Despite advances in medical technology and drug
development, perioperative neurological complications remain a major cause of
increased hospital stay, disability, and mortality. A minority of all perioperative strokes
occur intraoperatively; 30% occur within the first 2 days; approximately 50% occur by
the 5th postoperative day; and 20–25% develop during hospitalization [3].
According to the American College of Surgeons database, the stroke rate in
patients undergoing low-risk surgery is 0.14% [4]. In the prospective VISION study,
which included 40,004 patients over 45 years of age undergoing non-cardiac surgery
(28 centers from 14 countries), the stroke rate was 0.3% [5]. This study showed that
ischemic stroke was much more common than hemorrhagic stroke. The prospective
cohort multicenter NeuroVISION study included 1114 patients over 65 years of age
who underwent elective non-cardiac surgery [6]. All patients underwent MRI in the
immediate postoperative period to assess latent (clinically "silent") stroke. In addition,
all patients underwent neurocognitive status and delirium assessment. It was shown
that the incidence of latent stroke was 7% (78 patients). Moreover, the development of
this complication was accompanied by an increased risk of postoperative delirium (by
2.2 times) and deterioration of neurocognitive function 1 year after surgery (by 2
times). The risk of transient ischemic attack within 1 year after surgery in patients with
latent stroke increased 4-fold. Cardiac surgery patients are at high risk for perioperative
stroke due to underlying comorbidities and invasive technologies used to provide
surgeries. The incidence of clinically significant stroke in cardiac surgery ranges from
1 to 6% [7].
According to a meta-analysis of 42 studies (2632 patients), the incidence of occult
stroke in patients undergoing CABG is 25% [8]. In a small prospective study, A.
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Browne et al. (2020) showed that occult stroke developed in 39% of patients after
CABG surgery. Despite the apparent harmlessness of occult stroke, the risk of
developing dementia, cognitive impairment, and clinically significant strokes in the
future increases. Stroke risk factors can be divided into modifiable, conditionally
modifiable, and non-modifiable. Patient age (especially over 65 years) is one of the
most important risk factors for stroke in the postoperative period, with the risk
increasing with each additional year of life. The presence of concomitant pathology in
the patient, such as chronic kidney disease, arterial hypertension, diabetes mellitus,
ischemic heart disease, stroke in history, as well as smoking increase the risk of stroke
[9].
Today, the development of predictive models for the development of
perioperative cardiovascular complications, including stroke, is of particular relevance.
Identification of patients at high risk for the development of this complication can
potentially improve outcomes by changing the tactics of patient management. In
addition, the detection of new markers of brain damage in the blood, such as the light
chain of neurofilament in the blood, can be a useful method for screening for ischemic
neuronal damage [10].
Postoperative atrial fibrillation (AF) is one of the most common cardiovascular
complications after non-cardiac surgery, and the frequency of AF depends on the extent
of the surgical intervention. In turn, AF increases the risk of stroke in the postoperative
period by 2-4 times; the risk of stroke also increases in the late periods after surgery.
The presence of an open oval window in a patient increases the risk of paradoxical
embolism when changing the bypass from the right to the left sides of the heart. A
systematic review of non-cardiac surgery patients showed that the risk of stroke
increases by 4 times [11].
However, the most common and most recognized factor in the development of
perioperative stroke is hypotension. Analysis of the POISE-I study results showed that
clinically significant hypotension was the most significant predictor of postoperative
stroke [12]. One of the largest retrospective studies, which included 358,391 patients,
demonstrated that intraoperative hypotension (a decrease in SBP <55 mmHg or a
decrease in SBP by 30% compared with baseline values) is a predictor of stroke within
7 days after surgery. SBP less than 55 mmHg was also associated with the development
of postoperative delirium [13].
Perioperative bleeding can also lead to hemodynamic disturbances and
deterioration of the oxygen transport function of the circulatory system. An analysis of
651,775 non-cardiac surgery patients showed that in patients with significant bleeding
(bleeding requiring transfusion of more than 4 units (about 1 liter) of packed red blood
cells) the risk of stroke increases by 2.7 times within 30 days after surgery. In addition,
the development of bleeding also leads to a delay in the resumption of antithrombotic
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therapy in the postoperative period, which also increases the risk of stroke [14].
The main intraoperative causes of stroke during cardiac surgery include
thromboembolism, cerebral hypoperfusion (low mean arterial pressure, carotid artery
stenosis, cerebral atherosclerosis) and systemic inflammatory response syndrome when
blood comes into contact with the foreign surface of the artificial blood circulation
circuits. In the early postoperative period, risk factors for stroke include AF, low
cardiac output syndrome and bleeding. The source of thromboembolism can be an
atherosclerotic aorta, heart and artificial blood circulation circuits. Manipulations on
the aorta are associated with its cannulation, clamping of the aorta, as well as with the
imposition of distal anastomoses during CABG surgery. Atherosclerosis of the
ascending aorta occurs in more than 50% of patients with coronary heart disease [15].
Doppler analysis of microembolic signals showed their maximum frequency at
the beginning of artificial circulation, as well as during application and removal of the
clamp from the aorta.
Most strokes in cardiac surgery during the first week are associated with
hemodynamic instability and cardiac arrhythmias. Newly occurring AF in the
postoperative period is a risk factor for recurrent AF in the late postoperative periods,
and, consequently, stroke. Formation of blood clots in the left atrium in the absence of
adequate anticoagulant therapy is also one of the factors contributing to the
development of stroke.
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