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

Marko Mrkobrada, Matthew T.V. Chan, David Cowan, Douglas Campbell, Chew Yin Wang, David Torres, German Malaga, Robert D. Sanders, Manas Sharma, Carl Brown, Alben Sigamani, Wojciech Szczeklik, Mukul Sharma, Gordon Guyatt, Eric E. Smith, Ronit Agid, Adam A. Dmytriw, Jessica Spence, Nikesh R. Adunuri, Flavia K. BorgesTimothy G. Short, Michael D. Hill, Feryal Saad, Ingrid Copland, Shirley Pettit, Quazi Ibrahim, Shrikant I. Bangdiwala, Salim Yusuf, Scott Tsai, Demetrios J. Sahlas, Arun Mensinkai, Luciano A. Sposato, Sara Hussain, Steven Yang, Deborah Siegal, Alexander Khaw, Jennifer Mandzia, Sara Simpson, Manoj Raval, Ahmer Karimuddin, P. T. Phang, Vincent CT Mok, William KK Wu, Simon CH Yu, Tony Gin, Pui San Loh, Mun Thing Liew, Norlisah Ramli, Yee Lein Siow, Maite Fuentes, Victor Ortiz-Soriano, Ellen Waymouth, Jonathan Kumar, Divya Sadana, Lenimol Thomas, Bogusz Kaczmarek, Heidi Lindroth, Daniel Sessler, Sarah Apolcer, Amelia Trombetta, Stephanie Handsor, Monidipa Dasgupta, John M. Murkin, Shun Fu Lee, P. J. Devereaux

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41 Scopus citations

Abstract

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.
Original languageAmerican English
Pages (from-to)1022-1029
Number of pages8
JournalThe Lancet
Volume394
Issue number10203
DOIs
StatePublished - 21 Sep 2019

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