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*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

145 Scopus citations


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 languageEnglish
Pages (from-to)1022-1029
Number of pages8
JournalThe Lancet
Issue number10203
StatePublished - 21 Sep 2019

Bibliographical note

Funding Information:
EES reports personal fees from Portola Pharmaceuticals and Alnylam Pharmaceuticals, outside the submitted work. MDH reports personal fees from Merck, non-financial support from Hoffmann-La Roche Canada Ltd, and grants from Covidien (Medtronic), Boehringer Ingelheim, Stryker Inc, Medtronic LLC, and NoNO Inc, outside the submitted work. MDH has a patent on Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients issued to US Patent office number 62/086,077, owns stock in Calgary Scientific Incorporated, a company that focuses on medical imaging software, and is a director of the Canadian Federation of Neurological Sciences, a not-for-profit organisation. PJD reports grants from Abbott Diagnostics, Boehringer Ingelheim, Philips Healthcare, Roche Diagnostics, and Siemens, outside the submitted work. All other members of the writing committee declare no competing interests.

Funding Information:
This study was funded by a Foundation Grant from the Canadian Institutes of Health Research (CIHR); CIHR's Strategy for Patient Oriented Research (SPOR), through the Ontario SPOR Support Unit as well as the Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund ( 11120321 ), Food and Health Bureau, the Government of the Hong Kong Special Administrative Region, China; and the Auckland District Health Board Charitable Trust, Neurological Foundation of New Zealand. The Population Health Research Institute was the study-coordinating centre and was responsible for the maintenance of the database, data validation, analyses, and study coordination. The trial committees and their members, participating centres, and investigators are listed in the appendix .

Publisher Copyright:
© 2019 Elsevier Ltd


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