Brooks Daniel C, Schindler Joseph L
Department of Neurology, Yale University, LCI 1005 15 York Street, New Haven, CT, 06510, USA.
Curr Treat Options Cardiovasc Med. 2014 Feb;16(2):282. doi: 10.1007/s11936-013-0282-1.
Numerous risk factors for perioperative stroke have been identified and many are modifiable. Surgical patients with a history of cerebrovascular disease should be evaluated by a neurologist. Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke. The identification and treatment of carotid disease in the context of upcoming surgery has been a source of controversy. Routine carotid revascularization performed with coronary artery bypass graft (CABG) surgery for incidentally discovered carotid stenosis is not recommended. Prior to aortic manipulation during CABG, epiaortic ultrasound should be performed to identify aortic atheromatous plaques. If possible, preoperative aspirin, beta blocker, statin, and angiotensin converting-enzyme (ACE) inhibitor therapy should be continued in the perioperative period. Patients who are prescribed anticoagulation at high risk of thromboembolism should receive bridging anticoagulation during the perioperative period. The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention. CABG patients should be initiated on beta blockade +/- amiodarone to prevent postoperative AF. Many practitioners have been traditionally nihilistic towards acute perioperative stroke treatment. Given the narrow therapeutic window of treatment options, candidacy is dependent on timely recognition. Intravenous and endovascular thrombolysis/therapies are viable options in selected patients under the guidance and expertise of a neurologist. This article will present the epidemiology of perioperative stroke, the pathophysiology, risk assessment and stratification for common surgeries. The article will additionally focus on treatment options including modifiable risk factor reduction and the perioperative management of medications.
围手术期卒中的众多危险因素已被确定，其中许多是可以改变的。有脑血管疾病史的外科手术患者应由神经科医生进行评估。心脏和脑血管检查对于识别围手术期卒中高危患者至关重要。在即将进行手术的情况下，颈动脉疾病的识别和治疗一直存在争议。不建议在冠状动脉旁路移植术（CABG）手术中对偶然发现的颈动脉狭窄进行常规颈动脉血运重建。在CABG手术中进行主动脉操作前，应进行主动脉超声检查以识别主动脉粥样斑块。如果可能，围手术期应继续术前使用阿司匹林、β受体阻滞剂、他汀类药物和血管紧张素转换酶（ACE）抑制剂治疗。有血栓栓塞高风险且正在接受抗凝治疗的患者在围手术期应接受桥接抗凝治疗。识别和预防术后心房颤动（AF）是预防卒中的核心。CABG患者应开始使用β受体阻滞剂+/-胺碘酮以预防术后AF。传统上，许多从业者对围手术期急性卒中治疗持消极态度。鉴于治疗选择的治疗窗狭窄，是否适合治疗取决于及时识别。在神经科医生的指导和专业知识下，静脉内和血管内溶栓/治疗是部分患者可行的选择。本文将介绍围手术期卒中的流行病学、病理生理学、常见手术的风险评估和分层。本文还将重点关注治疗选择，包括降低可改变的危险因素以及围手术期药物管理。
