A patient, in their 70s, was slow to wake in PACU after a 10-hour pelvic exenteration. On extubation, the patient was unable to open their eyes or speak and appeared to have left-sided weakness. The patient was immediately taken for a CT head scan, which confirmed a stroke. Risks of major complications, including stroke, had been explained during preoperative assessment as part of consent for anaesthesia and surgery.

Commentary:

Perioperative stroke is a rare but devastating complication of surgery with an incidence of 0.1 to 0.9% after non-cardiac, non-neurological surgery.¹  The risk of stroke varies by surgical procedure, with the highest risk seen in vascular, thoracic and transplant operations whereas obstetric and gynaecological procedures have the lowest risk, although pelvic exenteration is not mentioned in this dataset.² 

Patients should be screened for risk factors for perioperative stroke.  These include advanced age (> 85 yrs), history of prior stroke (or TIA), atrial fibrillation, hypertension, valvular heart disease, renal disease or congestive heart failure.  Elective surgery should be delayed for 9 months after a previous stroke but emergency surgery should not be delayed.  The decision to delay surgery in cancer patients must be carefully considered and the increased risk of stroke balanced with the risk of delaying surgery.

The choice of anaesthetic modality should be based on clinical indications as there is little evidence that this influences the risk of stroke.³

References

1. Lindberg A, Flexman A Perioperative stroke after non-cardiac, non-neurological surgery BJA Education, 2020; 21, 59-65
2. Al-Hader R, Al-Robaidi K, Jovin T, Jadhav A, Wechsler LR, Thirumala PD. The incidence of perioperative stroke: Estimate using state and national databases and systematic review. J Stroke Korean Stroke Society; 2019; 21: 290–301
3. Saied NN, Helwani MA, Weavind LM, Shi Y, Shotwell MS, Pandharipande PP. Effect of anaesthesia type on postoperative mortality and morbidities: A matched analysis of the NSQIP database. Br J Anaesth; 2017; 118: 105–11