Stroke in Surgical Patients: A Narrative Review

Phillip E. Vlisides, M.D.; Laurel E. Moore, M.D.


Anesthesiology. 2021;134(3):480-492. 

In This Article

Clinical Resources and Guidelines

There are many resources available to assist with detection and management of stroke. Several screening tools have been developed for nonspecialists, although none of these scales have been validated in the perioperative setting. An ideal perioperative screening tool should be simple to use, quick to administer, and able to detect neurologic deficits in the setting of residual anesthesia and related confounders (e.g., opioid use, pain). One proposed strategy, the Face, Arm, Anesthesia, Speech, Time (FAAST) stroke scale (Table 3), aims to fulfill these criteria by focusing on signs and symptoms of major stroke.[35] For example, occlusion of a large cerebral vessel can be detected by arm or leg paralysis, aphasia, and/or facial droop. These signs may be present either individually or collectively during a major stroke. This scale prompts the clinician to evaluate for these signs in a simple, efficient manner. Such a scale could be used in the early postoperative setting and administered by nonspecialist clinicians.

For comprehensive assessment and management, the American Heart Association (Dallas, Texas)/American Stroke Association (Dallas, Texas) publish recurrent guidelines for acute ischemic stroke.[22] Similar guidelines are available from the European Stroke Organisation (Basel, Switzerland)[36,37] and the Heart and Stroke Foundation of Canada (Ottawa, Canada).[38] These guidelines contain evidence-based recommendations for prehospital evaluation, in-hospital management, and prevention of stroke-related complications. These guidelines generally align with one another, with similar recommendations for supportive care and emergency management. They also each recommend intravenous alteplase within 4.5 h if criteria are met, although administration beyond 4.5 h can be considered in select cases. Likewise, mechanical thrombectomy is recommended within 6 h of symptom onset, although specific patients may be eligible for up to 24 h after time last known well. Although these guidelines serve as a useful resource for clinicians caring for stroke patients, perioperative considerations are not discussed in great detail. The Society for Neuroscience in Anesthesiology and Critical Care (Richmond, Virginia) publishes complementary guidelines for patients at high risk of stroke undergoing noncardiac, nonneurologic procedures.[24] The main focus of these guidelines is to provide evidence-based recommendations for reducing stroke risk in surgical patients. Overall, there are thus many resources available for stroke assessment and management in the perioperative setting.