BACKGROUND AND PURPOSE: Perioperative stroke remains a devastating complication after surgical procedures, due to hemodynamic and inflammatory changes that increase the risk of strokes within 30 days following surgery. We aimed to assess the incidence of perioperative strokes in patients undergoing various surgical procedures and reach a national estimate. METHODS: A retrospective cohort study was conducted using California State Inpatient Databases, State Emergency Department Databases, State Ambulatory Surgery and Services Databases, and the National Inpatient Sample (NIS) during the period 2008 to 2011 from the Healthcare Cost and Utilization Project. A systematic review was conducted using PubMed, Embase, and Web of Science databases to obtain published articles that reported the incidence of perioperative stroke in various surgical procedures. RESULTS: Analysis of 3,694,410 surgical encounters from the state of California (mean±standard deviation age: 52.4±21.1 years) yielded an overall rate of perioperative stroke of 0.32% (n=11,759). The incidence of perioperative strokes was highest following neurological (1.25%), vascular (1.07%), and cardiac (0.98%) surgeries. The NIS database contained a total of 48,672,974 weighted hospitalizations and yielded a rate of perioperative stroke of 0.42% (n=204,549). The systematic review completed yielded 187 articles, which had an overall sample size of 184,922 and an incidence of perioperative stroke ranging from 0% to 13.86%. It is estimated that in any given year, there would be approximately 40,000 to 55,000 (0.33% to 0.46%) perioperative strokes nationally. CONCLUSIONS: Our findings support further strategies to identify and stratify patients undergoing surgical procedures with a high incidence of perioperative strokes to improve patient counseling and a future potential treatment plan.
Ambulatory Surgical Procedures ; California ; Cohort Studies ; Counseling ; Emergency Service, Hospital ; Health Care Costs ; Hemodynamics ; Hospitalization ; Humans ; Incidence ; Inpatients ; Perioperative Period ; Postoperative Complications ; Retrospective Studies ; Sample Size ; Stroke

Background: and Purpose Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging. Methods: For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification. Results: Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone. Conclusions Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.

Background: and Purpose Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. Methods: From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0–1) and independent outcome (mRS 0–2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. Results: Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3–P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79–1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05–2.12), sICH (aOR 2.87, 95% CI 1.23–6.72), and mortality (aOR 1.77, 95% CI 1.07–2.95). Conclusion Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.