Medical Complications in the Surgical Management of Stroke

Abstract

Stroke is an abrupt interruption of blood flow to the brain causing loss of neurological function. In the United States, stroke is the leading cause of disability and the fifth most common cause of death. Yearly stroke expenditures average $45.5 billion USD, making stroke one of the most expensive diseases in the country. Stroke can be ischemic – when caused by thromboembolic obstruction – or hemorrhagic – when caused by a rupture in the cerebral vasculature. For decades, the management of ischemic stroke (IS) was primarily medical, with recombinant tissue plasma activator being the mainstay of treatment. Recently, the value of mechanical thrombectomy for IS management was proved by several randomized studies. Mechanical thrombectomy is now recommended for patients with internal carotid artery or proximal middle cerebral artery occlusion in whom treatment can be initiated within 6 hours of stroke onset. The adoption of endovascular interventions caused a shift in the settings in which IS patients are managed, with IS patients now being common in neurosurgical wards. Understanding the medical complications of IS and their role in the perioperative management of IS patients is of paramount importance for optimizing the surgical care of stroke. In contrast to IS, surgery has been the mainstay of treatment for aneurysmal subarachnoid hemorrhage (aSAH) – a subtype of hemorrhagic stroke. The experience accumulated by generations of cerebrovascular surgeons led to a decrease in surgical complications after aSAH. Because surgical complications of aSAH are highly lethal, reductions in their incidence resulted in increased patient survival. Outcomes of aSAH – however – remain suboptimal, with two-thirds of aSAH patients surviving aneurysm surgery facing death or disability. Medical complications of aSAH may not be as lethal as surgical complications, but they are the main drivers of disability, making their study essential for aSAH outcome improvement.