AbstractPerioperative stroke is rare; however, patients undergoing cardiovascular surgery are considered to be at high risk for perioperative stroke. Here, we outline a case where perioperative stroke occurred following total hip replacement surgery. The risk factors and possible causes of the stroke in this patient are discussed. In addition, we reiterate the appropriate management approaches needed to prevent perioperative stroke. Briefly, the importance of precise preoperative evaluation and of proper intraoperative and postoperative management should not be overlooked. Finally, it is important to realize that decreasing perioperative strokes and the disabilities associated with them will lower the financial burden on families and the community

Chen, Tsung-Ying

Huang, Chia-Chun

Lee, Chia-Ling

Ong, Jimmy

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Perioperative Stroke Following General Surgery 

available at http://www.tzuchimedjnl.com/
Tzu Chi Medical Journal
 TZU CHI MED J  December 2009  Vol 21  No 4
© 2009 Buddhist Compassion Relief Tzu Chi Foundation
Case Report
Perioperative Stroke Following General Surgery
Chia-Chun Huang1,2,3, Jimmy Ong1,2, Chia-Ling Lee1,2, Tsung-Ying Chen1,2,3*
1Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
2Department of Anesthesiology, Tzu Chi University, Hualien, Taiwan
3Graduate Institute of Clinical Medicine, Tzu Chi University, Hualien, Taiwan
Abstract
Perioperative stroke is rare; however, patients undergoing cardiovascular 
surgery are considered to be at high risk for perioperative stroke. Here, 
we outline a case where perioperative stroke occurred following total hip 
replacement surgery. The risk factors and possible causes of the stroke in 
this patient are discussed. In addition, we reiterate the appropriate man-
agement approaches needed to prevent perioperative stroke. Briefly, the 
importance of precise preoperative evaluation and of proper intraopera-
tive and postoperative management should not be overlooked. Finally, it 
is important to realize that decreasing perioperative strokes and the dis-
abilities associated with them will lower the financial burden on families 
and the community. [Tzu Chi Med J 2009;21(4):345–347]
Article info
Article history:
Received: October 3, 2008
Revised: November 10, 2008
Accepted: December 10, 2008
Keywords:
General surgery
Ischemic
Perioperative stroke
Risk factors
*Corresponding author. Department of Anesthesiology, Buddhist Tzu Chi General Hospital, 
707, Section 3, Chung-Yang Road, Hualien, Taiwan.
E-mail address: chenyting@mail.tcu.edu.tw
1. Introduction
The reported incidence levels of perioperative stroke 
following general surgery indicate that it is rare [1]. 
No matter what the consequence, a perioperative 
stroke does impose a heavy financial burden on the 
family and the community. Therefore, this problem 
deserves to be paid more vigorous attention by the 
medical community. Here, we report a case of peri-
operative stroke following total hip replacement sur-
gery and discuss the possible etiologies and available 
preventive strategies.
2. Case report
A 72-year-old female was admitted to our hospital to 
receive total hip replacement for right hip osteoarthri-
tis. The operation was proposed as suitable in view 
of the patient’s stable vital signs and neurological con-
dition. She was 144 cm in height and weighed 52 kg. 
Preoperative anesthetic assessment showed that she 
had a past history of diabetes mellitus and hyperten-
sion, both of which had been under medical control 
for a number of years. In addition, she had received 
stenting to her left circumflex coronary artery about 
5 years previously. A complete electrocardiography 
examination and chest X-ray were normal and her lab-
oratory data, including hemogram and coagulation 
time, were also within the normal ranges.
General anesthesia combined with epidural analge-
sia was planned for the operation. Anesthesia was in-
duced with thiamylal 5.7 mg/kg and fentanyl 1 μg/kg, 
after which a 3# size laryngeal mask airway was 
inserted. The patient breathed spontaneously dur-
ing the operation period. Next, an epidural catheter 
was placed 6 cm cephalad via the L2–3 interspace. 
Anesthesia was maintained with sevoflurane 2–3% in 
346 TZU CHI MED J  December 2009  Vol 21  No 4
100% oxygen at a flow rate of 1 L/min oxygen. In ad-
dition, an epidural bolus consisting of 5 mL 1% xy-
locaine was introduced every 30 minutes. Standard 
intraoperative monitoring was in place, including elec-
trocardiography, nasal temperature, a noninvasive 
blood pressure monitoring system, end-tidal CO2, and 
pulse oximetry. During the 2.5 hours of the operation, 
her systolic blood pressure was maintained at 140–
180 mmHg, and her diastolic blood pressure at 90–
110 mmHg, except for two episodes of hypotension 
(80–85/50–55 mmHg), which persisted for less than 
3 minutes and which were promptly corrected by in-
travenously administered ephedrine (8 mg each time). 
There was no significant blood loss. The patient re-
covered smoothly from the anesthesia after the op-
eration and her consciousness and activity remained 
normal in the postanesthesia recovery room.
Seven hours after being transferred to the ward, 
the patient developed a sudden onset change in con-
sciousness. Immediate physical examination at the 
bedside found that the patient’s eyes showed devia-
tion to the right and that right facial palsy was 
present. There was also muscle weakness in the right 
upper and lower extremities. Babinski sign was posi-
tive on the right side but her pupil reflex was intact. 
The patient’s vital signs were relatively stable. None-
theless, her Glasgow coma scale score was deter-
mined to be just E2V1M5. Laboratory analysis showed 
no abnormal findings, except for a mild decrease in 
hemoglobin level (11.2 g/dL postoperatively compared 
to 13.8 g/dL preoperatively). A neurologist on con-
sultation indicated a suspected left brain infarction. 
Brain magnetic resonance imaging later confirmed a 
diagnosis of acute ischemic infarction of the left fron-
tal lobe (Fig. 1). Heparin infusion was initiated and 
warfarin was given. Carotid Doppler was performed 
on the second day and this showed atherosclerosis 
of bilateral common carotid arteries, especially on 
the left side where there was nearly total occlusion. 
Cardiac echocardiography revealed preserved left 
ventricular function and no patent foramen ovale. 
Though the postoperative course after stroke was 
complicated by a urinary tract infection, this was re-
solved after a course of antibiotics. Fortunately, the 
patient underwent gradual recovery and started a re-
habilitation program 1 week after the stroke for the 
sequelae of right hemiparesis, impaired cognition and 
global aphasia. She was able to perform her daily 
activities with moderate assistance at the time of 
discharge.
3. Discussion
Perioperative stroke is defined as an episode of focal 
or global loss of cerebral function with symptoms last-
ing more than 24 hours or leading to death that oc-
curs intraoperatively or in the postoperative period 
[2]. The postoperative period is not clearly defined, 
but a duration of 3–30 days is usually considered 
acceptable. The incidence of perioperative stroke 
varies with the type and complexity of the surgical 
procedure [3]. However, the reported risk of periop-
erative stroke associated with general surgery is low 
and has been reported to range from 0.08% to 0.7% 
[1]. Although perioperative stroke is considered rare, 
it does have a significant financial impact on the 
family and the community.
Many risk factors for perioperative stroke have been 
identified. In a matched case-control study of 61 pa-
tients who developed ischemic stroke after various 
general surgical procedures, Limburg et al found three 
major factors to be significantly associated with peri-
operative stroke: previous cerebrovascular disease, 
chronic obstructive pulmonary disease, and periph-
eral vascular disease [4]. Other identified factors that 
increase the risk of perioperative stroke in patients 
undergoing general surgery include age, hypertension, 
atherosclerosis, smoking, previously existing neuro-
logical symptoms, diabetes mellitus, and cardiac ar-
rhythmia [1,5,6]. Our patient presented with a history 
of diabetes mellitus, hypertension, and coronary ar-
tery disease, all of which are included in the above 
previously identified risk factors.
Although the exact mechanism of perioperative 
stroke remains uncertain, the major sources of peri-
operative stroke are considered to be either ischemic 
or embolic [2,3]. In this context, this may provide a 
basis for the event in our patient; specifically, post-
operative carotid Doppler ultrasonography showed 
that there was severe stenosis in the left common 
carotid artery. Thus, it is possible that manipulation 
Fig. 1 — Magnetic resonance imaging (diffusion-weighted 
imaging) of the left frontal infarction (arrow) that had 
developed in front of the left central sulcus.
 TZU CHI MED J  December 2009  Vol 21  No 4 347
of the patient’s neck during or after surgery led to 
atheroma dislodgement and this became a source of 
emboli. Despite the fact that fat emboli from ortho-
pedic procedures may have provided another source 
for emboli [7], the patient’s presentation did not meet 
the criteria for this [8]. In addition, the postoperative 
cardiac echocardiography failed to identify the pres-
ence of a patent foramen ovale. Hence, in this case, 
the possibility of fat embolism syndrome is lower. 
Although it has been reported that hypoperfusion 
itself is generally not a major cause of perioperative 
stroke [3,4], we are unable to exclude the possibility 
that the two episodes of intraoperative hypotension 
might be the main cause of this tragedy. Even though 
the duration of each hypotensive episode was short, 
they might have drastically affected the supply of oxy-
gen to the fragile brain in a patient with a history of 
hypertension and carotid artery stenosis. In addition, 
the trauma of surgery, the presence of associated tis-
sue injury, the general anesthesia, patient dehydra-
tion, together with the fact that the patient underwent 
bed rest, and thus did not move a great deal, all might 
render the patient subject to hypercoagulability. We 
believe that multiple factors contributed to the peri-
operative stroke in our patient, among which the hy-
potensive episodes and/or atheroma dislodgement 
may have contributed the most.
Several studies have suggested preoperative, in-
traoperative, and postoperative preventive measures 
in order to prevent a minor reversible neurological 
deficit from becoming a major irreversible disability 
[1,2]. First of all, it is important that the patient should 
have received a proper and thorough preoperative 
evaluation [9]. History taking should include the above-
mentioned significant risk factors for perioperative 
stroke as well as any transient ischemic attack-like 
symptoms in the past. If there have been any symp-
toms that are suggestive of transient ischemic attack, 
carotid Doppler should be performed. Furthermore, 
any preoperative coexisting medical conditions should 
be optimized and it is suggested that elective surgery 
be postponed for 4–6 weeks after a moderately large 
ischemic stroke [7]. In the case of any exacerbated 
neurological damage, the patient’s blood glucose 
level should be checked and maintained [1]. Finally, 
in the postoperative period, it is recommended that 
hypotension and dehydration be avoided in order to 
lessen the possibility of surgical factors inducing a 
change in the hypercoagulation status.
In conclusion, we report a patient who developed 
a stroke 7 hours after surgery and anesthesia. This 
patient had a history of diabetes mellitus, hyperten-
sion, and coronary artery disease. We reiterate the 
importance of a full preoperative evaluation in order 
to allow the identification of any possible risk factors 
for a perioperative stroke. At the same time, it is 
important that hemodynamic stability is maintained 
during the perioperative period. We believe that de-
tailed evaluation and careful management during and 
after surgery will result in perioperative strokes being 
successfully kept to a minimum.
References
1. Kam PC, Calcroft RM. Peri-operative stroke in general surgi-
cal patients. Anaesthesia 1997;52:879–83.
2. Menon U, Kenner M, Kelley RE. Perioperative stroke. Expert 
Rev Neurother 2007;7:1003–11.
3. Selim M. Perioperative stroke. N Engl J Med 2007;356:
706–13.
4. Limburg M, Wijdicks EF, Li H. Ischemic stroke after surgical 
procedures: clinical features, neuroimaging, and risk fac-
tors. Neurology 1998;50:895–901.
5. Parikh S, Cohen JR. Perioperative stroke after general surgi-
cal procedures. N Y State J Med 1993;93:162–5.
6. Wong DH. Perioperative stroke. Part I: General surgery, 
carotid artery disease, and carotid endarterectomy. Can J 
Anaesth 1991;38:347–73.
7. Blacker DJ, Flemming KD, Link MJ, Brown RD Jr. The preop-
erative cerebrovascular consultation: common cerebrovas-
cular questions before general or cardiac surgery. Mayo 
Clin Proc 2004;79:223–9.
8. Kuo CP, Lu CC, Chueng CM, et al. Post-operative stroke after 
dynamic hip screw fixation in a patient with old cerebral 
infarction and atrial fibrillation. Acta Anaesthesiol Taiwan 
2004;42:223–6.
9. Kelley RE. Stroke in the postoperative period. Med Clin 
North Am 2001;85:1263–76.


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