Elsevier

The Lancet

Volume 394, Issue 10203, 21–27 September 2019, Pages 1022-1029
The Lancet

Articles
Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study

https://doi.org/10.1016/S0140-6736(19)31795-7Get rights and content

Summary

Background

In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery.

Methods

NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results.

Findings

Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019).

Interpretation

Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke.

Funding

Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.

Introduction

Although non-cardiac surgery can improve and prolong quality and duration of life, it is associated with complications.1 The American College of Surgeons National Surgical Quality Improvement Program showed that among 350 031 patients undergoing low-risk non-cardiac surgeries (ie, not including patients undergoing major vascular surgery and neurosurgery), 485 (0·14%) patients had a perioperative overt stroke (ie, acute brain infarct with clinical manifestation lasting >24 h).2 An international randomised trial3 that included patients undergoing all types of inpatient non-cardiac surgery showed that 60 (0·7%) of 8351 adults had an overt stroke, and these strokes were associated with a high risk of mortality (32%) and disability (59%).

Covert strokes represent brain infarcts that are not recognised acutely because of unappreciated, subtle, or misclassified manifestations but are detected on brain imaging. In the non-operative setting, covert stroke is more common than overt stroke and is associated with the development of dementia, cognitive decline, decline in psychomotor speed, and an increased risk of subsequent overt stroke.4, 5, 6, 7 These findings in the non-operative setting raise the possibility that prognostically important covert strokes occur after non-cardiac surgery.

Brain MRI with diffusion-weighted imaging enables detection of acute brain infarction that has occurred within the preceding 10 days.8, 9 This technology allows patients to undergo a single brain MRI after surgery to establish the presence of an acute perioperative brain infarct. The Montreal Cognitive Assessment (MoCA) evaluates multiple cognitive domains, including executive function,10 and is used for assessing vascular cognitive impairment.11

Research in context

Evidence before this study

We searched MEDLINE, from database inception until June 20, 2019, using the search terms “stroke”, “noncardiac”, “non-cardiac”, “postoperative”, “perioperative” and “surgery”, restricted to publications in English, to identify studies in people aged 18 years or older evaluating the epidemiology or the impact of covert stroke after non-cardiac surgery. Less than 1% of adults having major non-cardiac surgery have an overt stroke. Although there are several studies showing that covert stroke is frequent after carotid artery procedures, we did not identify any study outside this population that examined the incidence or effect of covert stroke, with the exception of the NeuroVISION pilot study. We did not identify any study examining the relationship between perioperative covert stroke after non-cardiac surgery with 1-year cognitive decline.

Added value of this study

In this international, prospective cohort study of 1114 participants aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery, perioperative covert stroke occurred in 7% of participants. Patients who had a perioperative covert stroke showed an increased risk of perioperative delirium, overt stroke, or transient ischaemic attack at 1 year, and cognitive decline (primary outcome) 1 year after surgery, compared with patients who did not have a perioperative covert stroke.

Implications of all the available evidence

Perioperative covert stroke occurs in a substantial number of patients aged 65 years or older and is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke.

We did the neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study to inform the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery.

Section snippets

Study design and participants

NeuroVISION was an international (ie, centres from five continents), prospective, cohort study of a representative sample of adults who underwent elective, non-cardiac surgery to establish the association between perioperative covert stroke and cognitive decline 1 year after surgery. We have previously published details of the study objectives, design, and methods.12

Eligible patients were aged 65 years or older; underwent elective, non-cardiac surgery under general or neuraxial anaesthesia; had

Results

We recruited patients from March 24, 2014, to July 21, 2017, at 12 academic centres in nine countries (ie, Canada, Chile, China, India, Malaysia, New Zealand, Peru, Poland, and the USA). Of the 1627 patients who were eligible for NeuroVISION, 511 (31%) patients did not participate (appendix p 9). The most common reason for not participating was patient refusal to have an MRI (423 [26%] patients). Two patients were ineligible because they had an overt stroke on postoperative days 2 or 3, before

Discussion

In this international, prospective cohort study of a representative sample of 1114 participants aged 65 years and older who underwent elective, non-cardiac surgery, we showed that 78 (7%, 95% CI 6–9) of 1114 patients had a perioperative covert stroke. Perioperative covert stroke was observed across all types of non-cardiac surgeries. Cognitive decline occurred frequently in individuals without covert stroke (29%) and even more frequently in those with covert stroke (42%). The primary analysis

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