Intraoperative Ischemic Stroke in Elective Spine Surgery

A Retrospective Study of Incidence and Risk

Basem Ishak, MD; Amir Abdul-Jabbar, MD; Amit Singla, MD; Emre Yilmaz, MD; Alexander von Glinski, MD; Wyatt L. Ramey, MD; Ronen Blecher, MD; Zane Tymchak, MD; Rod Oskouian, MD; Jens R. Chapman, MD


Spine. 2020;45(2):109-115. 

In This Article

Abstract and Introduction


Study Design: Retrospective study.

Objective: To determine incidence, risk factors, complications, and early postoperative outcome in patients with intraoperative ischemic stroke during elective spine surgery.

Summary of Background Data: Overall, stroke is the fifth leading cause of death in the United States and the second leading cause of death worldwide. It can be a catastrophic event and the main cause of neurological disability in adults.

Methods: A retrospective review of the electronic medical records of patients who underwent elective spine surgery between January 2016 and November 2018 at a larger tertiary referral center was conducted. Patients with infection and neoplastic disease were excluded. Patient demographics, pre- and postoperative neurological status, surgical treatment, surgical time, blood loss, intraoperative abnormalities, risk factors, history of stroke, medical treatment, diagnostics, hospital stay, complications, and mortality were collected.

Results: Out of 5029 surgically treated patients receiving elective spine surgery, a total of seven patients (0.15%) were identified who developed an ischemic stroke during the surgical procedure. Patients were predominantly females (n = 6). Ischemic pontine stroke occurred in two patients. Further distributions of ischemic stroke were: left caudate nucleus, left posterior inferior cerebellar artery, left external capsule, left middle cerebral artery, and acute ischemic supratentorial spots. The main risk factors identified for intraoperative ischemic stroke include hypertension, diabetes, smoking, dyslipidemia, and possibly major intraoperative CSF leak. Three patients (43%) had neurological deficits which did not improve during hospital stay. Two patients recovered fully and two patients died. Therefore, in-hospital mortality rate of this subset of patients was 29%.

Conclusion: With the increase of spinal procedures, it is important to identify patients at risk for having an ischemic stroke and to optimize their comorbidities preoperatively. Patients with intraoperative ischemic stroke carry a higher risk for morbidity and mortality during the index hospitalization.

Level of Evidence: 4


Perioperative stroke can be a devastating and an unexpected complication of spine surgery but has only rarely been addressed. For hemorrhagic stroke several case reports surrounding spine surgery exist, in contrast to intraoperative ischemic strokes. One nationwide database of patients with spinal fusion procedures reported an incidence of 0.4% with perioperative ischemic stroke surrounding the index surgery.[1]

In contrast, ischemic stroke during or after cardiac and certain vascular surgical procedures is a well-known complication and has been reported to occur in arrange of 2% to 10% with a subsequent mortality rate of 22.2%.[2–4] The main risk factors for perioperative ischemic stroke during these procedures have been reported to include hypotension, dehydration, cerebral arteriosclerosis, atrial fibrillation with cardiac thrombi, valvular disease, acute myocardial infarction, carotid disease, hypercoagulability and prior stroke.[5,6]

Causes of stroke are often multifactorial, and can include a number of patient comorbidities, anesthetic complications or surgical events. While perioperative hemorrhagic stroke is more commonly reported, indexed literature reports of ischemic stroke after spine surgery are sparse. Although the specific pathophysiologic mechanisms leading to perioperative hemorrhagic stroke remain controversial, most case reports have attributed hemorrhagic stroke to be associated to an intraoperative CSF leak leading to intracranial hypotension.[7,8] In contrast, risk factors specific for perioperative ischemic stroke are less well defined and are presently unknown for intraoperative ischemic stroke. Current literature on this serious patho-entity is limited and consists of case reports and epidemiological database searches.[9–12]

The aim of this study was to establish incidence, early outcome, mortality, pertinent risk factors, and investigate possible pathophysiologic events which may contribute to intraoperative ischemic stroke during elective major spine reconstructive surgery. We also conducted a comprehensive review of the literature to identify the incidence and risk factors for perioperative stroke in general as to the best of our knowledge intraoperative ischemic stroke in elective spine surgery has not been studied before.