Risk of Ischemic Stroke in Patients With Symptomatic Vertebrobasilar Stenosis Undergoing Surgical Procedures

Abstract

Background and Purpose-There is little information to provide an estimate for stroke risk in patients with established stenosis or occlusion in the basilar or intracranial vertebral arteries undergoing surgical procedures. The objective of this study was to determine the ischemic stroke risk in this specific patient population. Methods-A medical records linkage system retrospectively identified patients with a diagnosis of symptomatic vertebrobasilar stenosis or occlusion matched with surgical procedures. Patients were selected if they had stenosis or occlusion of the basilar or intracranial vertebral arteries identified on vascular imaging before undergoing surgical procedures under general anesthesia. Clinical and radiographic features were reviewed, along with the nature of the surgeries and details of the perioperative management. Records were reviewed for the diagnosis of stroke occurring within 1 month of surgery. Results-Thirty-eight patients with a history of symptomatic vertebrobasilar ischemia underwent 50 operations under general anesthesia, and 3 had ischemic strokes in the vertebrobasilar territory immediately after surgery, a per-procedure rate of 6.0% (95% confidence interval, 1.2 to 16.6) All 3 had episodes of prolonged hypotension (systolic blood pressure Ͻ100 mm Hg for Ͼ10 minutes) during surgery. Conclusions-The risk of perioperative stroke in patients with vertebrobasilar stenosis undergoing surgery under general anesthesia is 6.0%, which is notably higher than the risk for patients with other patterns of cerebrovascular disease.

Effects of Head Position on Cerebral Oxygenation and Blood Flow Velocity During Thyroidectomy

“…However, this magnitude of decrease in blood flow may lead to serious complications in elderly patients with hyperlipidaemia, vertebrobasilar failure or carotid plaques, so this should be taken into consideration. Although general anaesthetics are known to have neuro-protective effects, specified cautions must be taken into consideration in high-risk surgical patients to protect the central nervous system (9). Both propofol and volatile anaesthetics have neuro-protective effects against the damage that may develop as a result of cerebral ischaemia (5).…”

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

“…305 In 11 studies that compared noninvasive imaging with catheter-based angiography for detection of vertebral artery stenosis, CTA and contrast-enhanced MRA were associated with higher sensitivity (94%) and specificity (95%) than ultrasonography (sensitivity 70%). 114 Neither MRA nor CTA reliably delineates the origins of the vertebral arteries, and hence, catheter-based angiography is typically required before revascularization for patients with symptomatic posterior cerebral ischemia.…”

Postoperative coma in a patient with complete basilar syndrome after anterior cervical discectomy

“…12,13 Intracranial vertebrobasilar artery dissection is much more frequent than previously believed, and can be asymptomatic in as many as 10% of patients, 14 while intraoperative malpositioning of the neck has been implicated as a precipitating factor for dissection and/ or thrombosis. [15][16][17][18] Rotation 19 and hyperextension 20 of the neck induce potentially harmful flow changes in the posterior circulation, and is associated with a higher incidence of infarctions in subjects with hypoplastic vertebral arteries (HVA).…”

“…In the patient we report, systolic blood pressure was reduced to about 60% of preoperative values for ten to 15 min. Amongst surgical patients with symptomatic vertebrobasilar stenosis postoperative stroke cases had intraoperative hypotension in common, 12 while anterior cervical spine surgery has been associated with dramatic reductions in carotid artery flow. 29 Therefore, hypotension could have contributed to the evolution of the infarct through decreased collateral supply.…”