Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study – The Lancet

0
23
Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study – The Lancet


Summary

Background

In non-surgical settings, covert stroke is more common than overt stroke and is associated
with cognitive decline. Although overt stroke occurs in less than 1% of adults after
non-cardiac surgery and is associated with substantial morbidity, we know little about
perioperative covert stroke. Therefore, our primary aim was to investigate the relationship
between perioperative covert stroke (ie, an acute brain infarct detected on an MRI
after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive
decline 1 year after surgery.

Methods

NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries,
in which we assessed patients aged 65 years or older who underwent inpatient, elective,
non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology
experts, masked to clinical data, assessed each MRI for acute brain infarction. Using
multivariable regression, we explored the association between covert stroke and the
primary outcome of cognitive decline, defined as a decrease of 2 points or more on
the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up.
Patients, health-care providers, and outcome adjudicators were masked to MRI results.

Findings

Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study,
78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed
the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%)
of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants
who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20,
absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased
risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute
risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year
follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019).

Interpretation

Perioperative covert stroke is associated with an increased risk of cognitive decline
1 year after non-cardiac surgery, and perioperative covert stroke occurred in one
in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is
needed to establish prevention and management strategies for perioperative covert
stroke.

Funding

Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented
Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and
Medical Research Fund, Government of the Hong Kong Special Administrative Region,
China; and The Neurological Foundation of New Zealand.

To read this article in full you will need to make a payment

References

  1. 1.
    • Devereaux PJ
    • Sessler DI

    Cardiac complications in patients undergoing major noncardiac surgery.

    N Engl J Med. 2015; 373: 2258-2269

  2. 2.
    • Mashour GA
    • Shanks AM
    • Kheterpal S

    Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.

    Anesthesiology. 2011; 114: 1289-1296

  3. 3.
    • Devereaux PJ
    • Yang H
    • Yusuf S
    • et al.

    Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.

    Lancet. 2008; 371: 1839-1847

  4. 4.
    • Debette S
    • Beiser A
    • DeCarli C
    • et al.

    Association of MRI markers of vascular brain injury with incident stroke, mild cognitive impairment, dementia, and mortality: the Framingham Offspring Study.

    Stroke. 2010; 41: 600-606

  5. 5.
    • Longstreth Jr, WT
    • Dulberg C
    • Manolio TA
    • et al.

    Incidence, manifestations, and predictors of brain infarcts defined by serial cranial magnetic resonance imaging in the elderly: the Cardiovascular Health Study.

    Stroke. 2002; 33: 2376-2382

  6. 6.
    • Vermeer SE
    • Prins ND
    • den Heijer T
    • Hofman A
    • Koudstaal PJ
    • Breteler MM

    Silent brain infarcts and the risk of dementia and cognitive decline.

    N Engl J Med. 2003; 348: 1215-1222

  7. 7.
    • Vermeer SE
    • Longstreth Jr, WT
    • Koudstaal PJ

    Silent brain infarcts: a systematic review.

    Lancet Neurol. 2007; 6: 611-619

  8. 8.
    • Lovblad KO
    • Pluschke W
    • Remonda L
    • et al.

    Diffusion-weighted MRI for monitoring neurovascular interventions.

    Neuroradiology. 2000; 42: 134-138

  9. 9.
    • Warach S
    • Gaa J
    • Siewert B
    • Wielopolski P
    • Edelman RR

    Acute human stroke studied by whole brain echo planar diffusion-weighted magnetic resonance imaging.

    Ann Neurol. 1995; 37: 231-241

  10. 10.
    • Nasreddine ZS
    • Phillips NA
    • Bedirian V
    • et al.

    The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.

    J Am Geriatr Soc. 2005; 53: 695-699

  11. 11.
    • Hachinski V
    • Iadecola C
    • Petersen RC
    • et al.

    National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards.

    Stroke. 2006; 37: 2220-2241

  12. 12.
    • Mrkobrada M
    • Chan MTV
    • Cowan D
    • et al.

    Rationale and design for the detection and neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study: a prospective international cohort study.

    BMJ Open. 2018; 8e021521

  13. 13.
    • Salthouse TA

    The role of memory in the age decline in Digit-Symbol Substitution performance.

    J Gerontol. 1978; 33: 232-238

  14. 14.
    • Tombaugh TN

    Trail Making Test A and B: normative data stratified by age and education.

    Arch Clin Neuropsychol. 2004; 19: 203-214

  15. 15.
    • Lawton MP
    • Brody EM

    Assessment of older people: self-maintaining and instrumental activities of daily living.

    Gerontologist. 1969; 9: 179-186

  16. 16.
    • Inouye SK
    • van Dyck CH
    • Alessi CA
    • Balkin S
    • Siegal AP
    • Horwitz RI

    Clarifying confusion: the confusion assessment method. A new method for detection of delirium.

    Ann Intern Med. 1990; 113: 941-948

  17. 17.
    • Tan HH
    • Xu J
    • Teoh HL
    • et al.

    Decline in changing Montreal Cognitive Assessment (MoCA) scores is associated with post-stroke cognitive decline determined by a formal neuropsychological evaluation.

    PLoS One. 2017; 12e0173291

  18. 18.
    • Krishnan K
    • Rossetti H
    • Hynan LS
    • et al.

    Changes in Montreal Cognitive Assessment Scores over time.

    Assessment. 2017; 24: 772-777

  19. 19.
    • Curran D
    • Bacchi M
    • Schmitz SF
    • Molenberghs G
    • Sylvester RJ

    Identifying the types of missingness in quality of life data from clinical trials.

    Stat Med. 1998; 17: 739-756

  20. 20.
    • Simes RJ
    • Greatorex V
    • Gebski VJ

    Practical approaches to minimize problems with missing quality of life data.

    Stat Med. 1998; 17: 725-737

  21. 21.
    • Arnold Fiebelkorn C
    • Vemuri P
    • Rabinstein AA
    • et al.

    Frequency of acute and subacute infarcts in a population-based study.

    Mayo Clin Proc. 2018; 93: 300-306

  22. 22.
    • Newman S
    • Stygall J
    • Hirani S
    • Shaefi S
    • Maze M

    Postoperative cognitive dysfunction after noncardiac surgery: a systematic review.

    Anesthesiology. 2007; 106: 572-590

  23. 23.
    • Mrkobrada M
    • Hill MD
    • Chan MT
    • et al.

    Covert stroke after non-cardiac surgery: a prospective cohort study.

    Br J Anaesth. 2016; 117: 191-197

  24. 24.
    • Daiello LA
    • Racine AM
    • Yun Gou R
    • et al.

    Postoperative delirium and postoperative cognitive dysfunction: overlap and divergence.

    Anesthesiology. 2019; ()

  25. 25.
    • Omiya H
    • Yoshitani K
    • Yamada N
    • et al.

    Preoperative brain magnetic resonance imaging and postoperative delirium after off-pump coronary artery bypass grafting: a prospective cohort study.

    Can J Anaesth. 2015; 62: 595-602

  26. 26.
    • Pendlebury ST
    • Mariz J
    • Bull L
    • Mehta Z
    • Rothwell PM

    MoCA, ACE-R, and MMSE versus the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards neuropsychological battery after TIA and stroke.

    Stroke. 2012; 43: 464-469

  27. 27.
    • Matthey P
    • Finucane BT
    • Finegan BA

    The attitude of the general public towards preoperative assessment and risks associated with general anesthesia.

    Can J Anaesth. 2001; 48: 333-339

  28. 28.
    • Bedford PD

    Adverse cerebral effects of anaesthesia on old people.

    Lancet. 1955; 269: 259-263

  29. 29.
    • Lalmohamed A
    • Vestergaard P
    • Cooper C
    • et al.

    Timing of stroke in patients undergoing total hip replacement and matched controls: a nationwide cohort study.

    Stroke. 2012; 43: 3225-3229

  30. 30.
    • Ng PY
    • Ng AK
    • Subramaniam B
    • et al.

    Association of preoperatively diagnosed patent foramen ovale with perioperative ischemic stroke.

    JAMA. 2018; 319: 452-462

Article Info

Publication History

Published: August 15, 2019

Identification

DOI: https://doi.org/10.1016/S0140-6736(19)31795-7

Copyright

© 2019 Elsevier Ltd. All rights reserved.

ScienceDirect

Access this article on ScienceDirect

Linked Articles

LEAVE A REPLY

Please enter your comment!
Please enter your name here