Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-77c89778f8-vsgnj Total loading time: 0 Render date: 2024-07-21T11:08:09.988Z Has data issue: false hasContentIssue false

32 - Cerebrovascular disease

Published online by Cambridge University Press:  12 January 2010

By
Michael R. Frankel  and
Duncan Borland
Edited by
Michael F. Lubin ,
Robert B. Smith ,
Thomas F. Dodson ,
Nathan O. Spell  and
H. Kenneth Walker
Michael R. Frankel
Affiliation:
Emory University, School of Medicine, Atlanta, GA
Duncan Borland
Affiliation:
Portland, OR
Michael F. Lubin
Affiliation:
Emory University, Atlanta
Robert B. Smith
Affiliation:
Emory University, Atlanta
Thomas F. Dodson
Affiliation:
Emory University, Atlanta
Nathan O. Spell
Affiliation:
Emory University, Atlanta
H. Kenneth Walker
Affiliation:
Emory University, Atlanta
Get access

Summary

Stroke affects about 750 000 people each year in the USA and is a leading cause of long-term adult disability. Over the past decade there have been considerable advances in treatment and prevention. This chapter will review many of these advances with emphasis on issues relevant to surgical patients.

There are two types of stroke: ischemic and hemorrhagic. Ischemic events account for about 80% of all strokes. Most of these are related to atherothromboembolic events.

Atherosclerosis is a systemic disease that most prominently affects the aorta, the coronary arteries, the extracranial carotid and vertebral arteries, and the arteries to the extremities. Atherosclerosis causes stroke by producing progressive stenosis, local thrombosis with occlusion, or distal embolization. Any one of these mechanisms can be the primary cause. For example, progressive atherosclerotic occlusion can cause distal hypoperfusion severe enough to result in tissue ischemia and infarction. Mild or moderate atherosclerotic stenosis that does not cause distal hypoperfusion can be the site of thrombosis and cause intra-arterial embolization leading to occlusion of an intracerebral artery downstream.

The relative significance of local thrombosis versus intra-arterial embolization varies according to the site of atherosclerosis. Most strokes resulting from stenosis of the proximal internal carotid artery are caused by distal embolic occlusion of the middle cerebral artery or its branches. Cerebral infarction in the basilar artery territory usually results from occlusion of the small perforating vessels by local thrombosis.

Ischemic strokes are divided into several categories including cardioembolic, lacunar, and atherosclerotic etiologies.

Type
Chapter
Information
Medical Management of the Surgical Patient
A Textbook of Perioperative Medicine
 , pp. 399 - 410
Publisher: Cambridge University Press
Print publication year: 2006

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 1996; 93(6): 1278–1317.
Caplan, L. R. Diagnosis and the clinical encounter. In Caplan's Stroke: A Clinical Approach. Boston: Butterworth-Heinemann, 2000: 51–71.Google Scholar
Caplan, L. R. Strokes, cerebrovascular disease, and surgery. In Caplan's Stroke: A Clinical Approach. Boston: Butterworth-Heinemann, 2000: 445–462.Google Scholar
Heiss, W.Experimental evidence of ischemic thresholds and functional recovery. Stroke 1992; 23: 1666–1672.CrossRefGoogle ScholarPubMed
Bullock, R., Mendelow, A. D., Bone, T., Patterson, J., Macleod, W. N., & Allardice, G.Cerebral blood flow and CO2 responsiveness as an indicator of collateral reserve capacity in patients with carotid arterial diseases. Br. J. Surg. 1985; 72: 348–351.CrossRefGoogle Scholar
Jansen, C., Ramos, L. M., Heesewijk, J. P., Moll, F. L., Gijn, J., & Ackerstaff, R. G.Impact of microembolism and hemodynamic changes in the brain during carotid endarterectomy. Stroke 1994; 25: 992–997.CrossRefGoogle ScholarPubMed
Henricksen, L., Hjaims, E., & Lindeburgh, T.Brain hyperperfusion during cardiac operations: cerebral blood flow measured in man by intra-arterial injection of xenon 133 – evidence suggestive of intra operative microembolism. J. Thorac. Cardiovasc. Surg. 1983; 86: 202–208.Google Scholar
Karalis, D. G., Chandrasekaran, K., Victor, M. F., Ross, J. J. Jr., & Mintz, G. S.Recognition and embolic potential of intra-aortic atherosclerotic debris. J. Thorac. Cardiovasc. Surg. 1991; 17: 73–78.Google Scholar
Kartchner, M. M. & McRae, L. P.Carotid occlusive disease as a risk factor in major cardiovascular surgery. Arch. Surg. 1982; 117(8): 1086–1088.CrossRefGoogle ScholarPubMed
Rakowski, H. & Pearlman, A.Preventing perioperative stroke: look, but don't touch! Am. Heart. J. 1999; 138(4): 609–611.CrossRefGoogle ScholarPubMed
Stern, A., Tunick, P. A., Culliford, A. T.et al. Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy. Am. Heart J. 1999; 138 (4 Pt 1): 746–752.CrossRefGoogle ScholarPubMed
Barbut, D. & Caplan, L. R.Brain complications of cardiac surgery. Curr. Probl. Cardiol. 1997; 22(9): 449–480.CrossRefGoogle ScholarPubMed
Marshall, W. G. Jr., Barzilai, B., Kouchoukos, N. T., & Saffitz, J.Intraoperative ultrasonic imaging of the ascending aorta. Ann. Thorac. Cardiovasc. Surg. 1989; 48: 339–344.Google ScholarPubMed
Shaw, P. J., Bates, D., Cartlidge, N. E.et al. Neurologic and neuropsychologic morbidity following major surgery: bypass and peripheral vascular surgery. Stroke 1987; 18: 700–707.CrossRefGoogle Scholar
Moody, D. M., Bell, M. A., Challa, V. R., Johnston, W. E., & Prough, D. S.et al. Brain microemboli during cardiac surgery or aortography. Ann. Neurol. 1990; 28: 477–486.CrossRefGoogle ScholarPubMed
Pugsley, W., Klinger, L., Paschalis, C.et al. Microemboli and cerebral impairment during cardiac surgery. Vasc. Surg. 1990; 24: 34–43.CrossRefGoogle Scholar
McKhann, G. M., Grega, M. A., Borowicz, L. M. Jr.et al. Encephalopathy and stroke after coronary artery bypass grafting: incidence, consequences, and prediction. Arch. Neurol. 2002; 59(9): 1422–1428.CrossRefGoogle ScholarPubMed
Reutern, G. M., Hetzel, A., Birrbaum, D., & Schlosser, V.Transcranial Doppler ultrasonography during cardiopulmonary bypass in patients with severe carotid stenosis or occlusion. Stroke 1988; 19(6): 674–680.CrossRefGoogle Scholar
Reed, G. L., 3rd, Singer, D. E., Picard, E. H., & DeSanctis, R. W.Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits. N. Engl. J. Med. 1988; 319(19): 1246–1450.CrossRefGoogle ScholarPubMed
Kamik, R., Valentin, A., Bonner, G., Ziegler, B., & Slany, J.Transcranial Doppler monitoring during percutaneous transluminal aortic valvuloplasty. Angiology 1990; 41: 106–111.Google Scholar
Furlan, A. J. & Cracium, A. R.Risk of stroke during coronary artery bypass graft surgery in patients with internal carotid artery disease documented by angiography. Stroke 1985; 16(5): 797–799.CrossRefGoogle ScholarPubMed
Breuer, A. C., Furlan, A. J., Hanson, M. R.et al. Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients. Stroke 1983; 14(5): 682–687.CrossRefGoogle ScholarPubMed
Parikh, S. & Cohen, J. R.Perioperative stroke after general surgical procedures. N Y State J. Med. 1993; 93(3): 162–165.Google ScholarPubMed
Ropper, A. H., Wechsler, L. R., & Wilson, L. S.Carotid bruit and the risk of stroke in elective surgery. N. Engl. J. Med. 1982; 307(22): 1388–1390.CrossRefGoogle ScholarPubMed
Landercasper, J., Merz, B. J., Cogbill, T. H.et al. Perioperative stroke risk in 173 consecutive patients with a past history of stroke. Arch. Surg. 1990; 125(8): 986–989.CrossRefGoogle ScholarPubMed
Limburg, M., Wijdicks, E. F., & Li, H.Ischemic stroke after surgical procedures: clinical features, neuroimaging, and risk factors. Neurology 1998; 50(4): 895–901.CrossRefGoogle ScholarPubMed
Evans, B. A. & Wijdicks, E. F.High-grade carotid stenosis detected before general surgery: is endarterectomy indicated? Neurology 2001; 57(7): 1328–1330.CrossRefGoogle ScholarPubMed
Hise, J. H., Nipper, M. N., & Schnitker, J. C.Stroke associated with CABG. Am. J. Neuroradiol. 1991; 12: 811–814.Google Scholar
Gardner, T. J., Horrieffer, P. J., Manolio, T. A.et al. Stroke following CABG: a 10 year study. Ann. Thorac. Surg. 1985; 12: 574–581.CrossRefGoogle Scholar
Rorick, M. B. & Furlan, A. J.Risk of cardiac surgery in patients with prior stroke. Neurology 1990; 40(5): 835–837.CrossRefGoogle ScholarPubMed
Ascione, R., Reeves, B. C., Chamberlain, M. H., Ghosh, A. K., Lim, K. H., & Angelini, G. D.Predictors of stroke in the modern era of coronary artery bypass grafting: a case control study. Ann. Thorac. Surg. 2002; 74: 474–480.CrossRefGoogle ScholarPubMed
Stamou, S. C., Jablonski, K. A., Pfister, A. J.et al. Stroke after conventional versus minimally invasive coronary artery bypass. Ann. Thorac. Surg. 2002; 74: 394–399.CrossRefGoogle ScholarPubMed
Bendszus, M., Reents, W., Franke, D.et al. Brain damage after coronary artery bypass grafting. Arch. Neurol. 2002; 59(7): 1090–1095.CrossRefGoogle ScholarPubMed
Szabo, Z., Hakanson, E., & Svedjeholm, R.Early postoperative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary artery bypass grafting. Ann. Thorac. Surg. 2002; 74(3): 712–719.CrossRefGoogle ScholarPubMed
American Heart Association. “Guidelines for Carotid Endarterectomy” A Multidisciplinary Consensus Statement From the Ad Hoc Committee. Stroke 1995; 26(1): 188–201.CrossRef
The CASANOVA Study Group. Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke 1991; 22(10): 1229–1235.CrossRef
North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N. Engl. J. Med. 1991; 325(7): 445–453.CrossRef
European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet 1991; 337(8752): 1235–1243.CrossRef
Hobson, R. W., 2nd., Weiss, D. G., Fields, W. S.et al. The Veterans Affairs Cooperative Study Group. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N. Engl. J. Med. 1993; 328(4): 221–227.CrossRefGoogle Scholar
National Institute of Neurological Disorders and Stroke. Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. J. Neurol. Sci. 1995; 129(1): 76–77.CrossRef
Marcinczyk, M. J., Nicholas, G. G., Read, J. F., 3rd., & Nastasee, S. A.Asymptomatic carotid endarterectomy: patient and surgeon selection. Stroke 1997; 82(2): 291–296.CrossRefGoogle Scholar
Hannan, E. L., Popp, A. J., Feustel, P.et al. Association of surgical specialty and processes of care with patient outcomes for carotid endarterectomy. Stroke 2001; 32(12): 2890–2897.CrossRefGoogle ScholarPubMed
Hannan, E. L., Popp, A. J., Tranmer, B., Feustel, P., Waldman, J., & Shah, D.Relationship between provider volume and mortality for carotid endarterectomies in New York State. Stroke 1998; 29(11): 2292–2297.CrossRefGoogle ScholarPubMed
Barnett, H. J., Taylor, D. W., Eliasziw, M.et al. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N. Engl. J. Med. 1998; 339(20): 1415–1425.CrossRefGoogle ScholarPubMed
Paciaroni, M., Eliasziw, M., Kappelle, L. J., Finan, J. W., Ferguson, G. G., & Barnett, H. J.Medical complications associated with carotid endarterectomy. Stroke 1999; 30: 1759–1763.CrossRefGoogle ScholarPubMed
Streifler, J. Y., Eliasziw, M., Benavente, O. R.et al. Prognostic importance of leukoaraiosis in patients with symptomatic internal carotid artery stenosis. Stroke 2002; 33(6): 1651–1655.CrossRefGoogle ScholarPubMed
Gorelick, P. B.Carotid endarterectomy; where do we draw the line? Stroke 1999; 30: 1745–1750.CrossRefGoogle Scholar
Sacco, R. L.Extracranial carotid stenosis. N. Engl. J. Med. 2001; 345(15): 1113–1118.CrossRefGoogle ScholarPubMed
Albers, G. W., Amarenco, P., Easton, J. D., Sacco, R. L., & Teal, P.Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 2001; 119: 300S–320S.CrossRefGoogle ScholarPubMed
Wolf, P. A., Clagett, G. P., Easton, J. D.et al. Preventing ischemic stroke in patients with prior stroke and transient ischemic attack. A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 1999; 30: 1991–1994.CrossRefGoogle ScholarPubMed
Hirsch, J., Anand, S. S., Halperin, J. L., & Fuster, V.Guide to anticoagulant therapy: heparin: a statement for healthcare professionals from the American Heart Association.
Hirsh, J.et al. Guide to anticoagulant therapy: heparin. A Statement From the American Heart Association. Circulation 2001; 103: 2994–3018.CrossRefGoogle ScholarPubMed
International Stroke Trial Collaborative Group: The International Stroke Trial: a randomized trial of aspirin, subcutaneous heparin, both or neither among 19,435 patients with acute ischemic stroke. Lancet 1997; 349: 1569–1581.CrossRef
The Publication Committee for the Trial of Org 10172 in Acute Stroke Treatment (TOAST) Investigators: Low molecular weight heparinoid, ORG 10172 (danaperoid) an outcome after acute ischemic stroke: a randomized controlled trial. J. Am. Med. Assoc. 1998; 279: 1265–1272.CrossRef
Chimowitz, M. I., Kokkinos, J., Strong, J.et al. The warfarin– aspirin symptomatic intracranial disease study. Neurology 1995; 45: 1488–1493.CrossRefGoogle ScholarPubMed
Caplan, L. R. Treatment. In Caplan's Stroke: A Clinical Approach. Boston: Butterworth-Heinemann, 2000: 115–161.Google Scholar
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N. Engl. J. Med. 1995; 333: 1581–1587.CrossRef
Furlan, A., Higashida, R., Wechsler, L.et al. Intra-arterial pro-urokinase for acute ischemic stroke: The PROACT II Study: a randomized controlled trial. J. Am. Med. Assoc. 1999; 282: 2003–2011.CrossRefGoogle ScholarPubMed
Katzan, I. L., Masaryk, T. J., Furlan, A. J.et al. Intra-arterial thrombolysis for perioperative stroke after open heart surgery. Neurology 1999; 52(5): 1081–1084.CrossRefGoogle ScholarPubMed
Bladin, C. F.et al. What causes seizures after stroke? Stroke 1994; 25: 245.Google Scholar
Bosch, J., Yusuf, S., Pogue, J.et al. Use of ramipril in preventing stroke: double blind randomised trial. Br. Med. J. 2002; 324: 1–5.CrossRefGoogle ScholarPubMed
MacMahon, S., Neal, B., Tzourio, C.et al. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischemic attack. Progress Collaborative Group. Lancet 2001; 358: 1033–1041.Google Scholar
Dahlof, B., Devereinx, R. B., Kjeldsen, S. E.et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359: 995–1003.CrossRefGoogle ScholarPubMed
Neal, B., MacMahon, S., & Chapman, N.Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet 2000; 355: 1955–1964.Google Scholar
Sacks, F. M., Pfeffer, M. A., Move, L. A.et al. Cholesterol and Recurrent Events Trial investigators. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N. Engl. J. Med. 1996; 335(14): 1001–1009.CrossRefGoogle Scholar
White, H. D., Simes, R. J., Anderson, N. E.et al. Pravastatin therapy and the risk of stroke. N. Engl. J. Med. 2000; 343(5): 317–326.CrossRefGoogle ScholarPubMed
Executive summary of the third report of the National Cholesterol Education program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). J. Am. Med. Assoc. 2001; 285: 2486–2497.CrossRef
Blacker, D. J., Flemming, K. D., Link, M. J.et al. The preoperative cerebrovascular consultation: common cerebrovascular questions before general or cardiac surgery. Mayo Clin. Proc. 2004; 79: 223–229.CrossRefGoogle ScholarPubMed
Blacker, D. J., Wijdicks, E. F., & McClelland, R. L.Stroke risk in anticoagulated patients with atrial fibrillation undergoing endoscopy. Neurology 2003; 61: 964–968.CrossRefGoogle ScholarPubMed
Gorelick, P. B.New horizons for stroke prevention: PROGRESS and HOPE. Lancet Neurology 2002; 1: 149–156.CrossRefGoogle ScholarPubMed
The Heart Outcome Prevention Evaluation Study Investigators (HOPE). Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N. Engl. J. Med. 2000; 342: 145–153.CrossRef
PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033–1041.CrossRef
Gorelick, P.Stroke prevention therapy beyond antithrombotics. Stroke 2002; 33: 862.CrossRefGoogle ScholarPubMed
MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo controlled trial. Lancet 2002; 360: 7–22.CrossRef
Taylor, D. W., Barnett, H. J., Haynes, R. B.et al. ASA and Carotid Endarterectomy (ACE) Trial Collaborators. Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. Lancet 1999; 353: 2179–2184.CrossRefGoogle ScholarPubMed
Hass, W. K., Easton, J. D., Adams, H. P. Jr. et al. A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. N. Engl. J. Med. 1989; 321: 501–507.CrossRefGoogle ScholarPubMed
CAPRIE Steering Committee. A randomized, blinded, trial of clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE). Lancet 1996; 348: 1329–1339.CrossRef
Diener, H. C., Cunha, L., Forbes, C.et al. European Stroke Prevention Study 2 (ESPS-2). Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J. Neurol. Sci. 1996; 143: 1–13.CrossRefGoogle Scholar
The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) Trial Investigators. N. Engl. J. Med. 2001; 345: 494–502.
Mohr, J. P., Thompson, J. L. P., Lazar, R. M.et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke (WARSS). N. Engl. J. Med. 2001; 345: 1444–1451.CrossRefGoogle Scholar
Homma, S., Sacco, R. L., Di Tullio, M. R.et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in cryptogenic stroke study. Circulation 2002; 105: 2625–2631.CrossRefGoogle ScholarPubMed
The APASS Investigators. Antiphospholipid antibodies and subsequent thrombo-occlusive events in patients with ischemic stroke. J. Am. Med. Assoc. 2004; 291: 576–584.CrossRef
Chobanian, A. V., Bakris, G. L., Black, H. R.et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. J. Am. Med. Assoc. 2003; 289: 2560–2571.CrossRefGoogle ScholarPubMed
Coull, B., Williams, L. S., Goldstein, L. B.et al. Anticoagulants and antiplatelets in acute ischemic stroke. Stroke 2002; 33: 1934–1942.CrossRefGoogle Scholar
Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. J. Am. Med. Assoc. 1998; 279: 1265–1272.CrossRef
Bath, P. M. W., Lindenstrom, E., Boysen, G.et al. Tinzaparin in acute ischaemic stroke (TAIST): a randomized aspirin-controlled trial. Lancet 2001; 358: 702–710.CrossRefGoogle ScholarPubMed
HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet 2000; 355: 1205–1210.

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×