Previous stroke may increase risk of complications after major surgery

1. Patients who had a stroke within the last 24 months had a higher risk of post-operative complications.

2. 30 day in-hospital mortality rate in this population was twice that seen in patients without prior stroke.

Evidence Rating Level: 2 (Good)

Study Rundown: Stroke incidence is on the decline but still remains a leading cause of adult disability and death. Patients with prior stroke face multiple problems once they survive the episodes including dementia, traumatic brain injury (TBI), depression, pneumonia, urinary tract infections, decubitus ulcers from paralysis and loss of sensation, and even hip fractures. In this study, patients with a stroke within the 24 months prior to major non-neurosurgery procedures were evaluated to assess for any increased rate of post-operative complications. Complications assessed included pneumonia, septicemia, AKI (acute kidney injury), acute myocardial infarction (MI), pulmonary embolism (PE) and 30 day in hospital mortality. Patients with prior stroke who had any of these complications pre-operatively were excluded. Severity of stroke history was also evaluated including intracerebral hemorrhage, ICU treatment of stroke, stroke-related neurosurgery, and high stroke related medical expenditure.

The strengths of this study include using a large nationalized database that comprises more than 99% of the total patient population, using matched control populations, including all cause non-neurosurgery, and accounting for the severity of stroke history as it relates to post-operative complications. The limitations of the study, as is inherent with utilizing medical billing codes, include the lack of patient level data on socioeconomics and lifestyle, lack of stroke related clinical scores or lesion characteristics, and uncertainty about the validity of post-operative co-morbidity or complications as determined by using these codes.

Click to read the study in The British Journal of Surgery

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Relevant Reading: Medical complications after stroke

In-Depth [retrospective cohort]: 1.4 million patients, age >20, from the Taiwan National Health Insurance Research Database undergoing major non-neurosurgery between 2008 and 2010, were evaluated based on the presence or absence of any stroke within prior 24 months. Of these patients 45,420 patients had a documented history of stroke and met study criteria. Major non-neurosurgery included any surgery requiring general, spinal or epidural anesthesia and hospital length of stay (LOS) >1 day. Controls were matched across multiple variables and also propensity matched based on pre-existing co-morbidities considered to be associated with adverse events after surgery. As expected, the patients in this study with prior stroke are mostly older (>50 yrs old) with multiple underlying co-morbidities including hypertension, diabetes mellitus, and depression. The top five post-op complications in order were pneumonia (ARR 1.93, CI 1.80-2.07), septicemia (ARR 1.83 CI 1.75-1.92), 30-day in-hospital mortality (ARR 1.79 CI 1.61-1.99), AKI (ARR 1.71 CI 1.57-1.86) and PE (ARR 1.70 CI 1.20-2.41), respectively. Most importantly, in subgroup analysis, stroke severity (hemorrhagic was highest risk- ARR 3.41 CI 2.97-3.91) and stroke within the prior 1-6 months (ARR 3.31 CI 2.91-3.75) had the highest complication rates. This study is the first of its kind to include a whole population, all cause non-neurosurgery and assess multiple primary outcomes with propensity matching owing to the large sample size. These results and other follow-up studies will help better categorize stroke patients, using improved complication scoring criteria, and may promote the delay of surgery if stroke was within the prior 1-6 months.

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