Stroke surgery

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Stroke Surgery: Current Insights and Developments

Neurotransplantation for Motor Stroke Recovery

Neurotransplantation has emerged as a potential treatment for restoring lost brain function following a stroke. A phase 2 randomized trial investigated the efficacy of human neuron transplantation in patients with substantial fixed motor deficits due to basal ganglia stroke. The study involved 18 patients who were randomized to receive either 5 or 10 million neuronal cells followed by a 2-month rehabilitation program, or to serve as a control group receiving rehabilitation alone. The primary measure of efficacy was the change in the European Stroke Scale (ESS) motor score at 6 months. While some patients showed measurable improvements in motor function and daily activities, the study did not find significant benefits in motor function as determined by the primary outcome measure, indicating the need for further research to establish the effectiveness of this treatment.

Risk Factors for Stroke After Cardiac Surgery

Stroke remains a significant complication following cardiac surgery. A comprehensive analysis of 16,184 patients undergoing various cardiac procedures identified several independent predictors of postoperative stroke. These include a history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operations, prolonged cardiopulmonary bypass (CPB) time, intraoperative hemofiltration, and high transfusion requirements. Notably, beating heart coronary artery bypass grafting (CABG) was associated with a lower incidence of stroke, suggesting it may improve patient outcomes.

Ischemic Stroke Post-General Surgery

Ischemic strokes can occur after general surgical procedures, with risk factors including previous cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD). A case-control study highlighted that these strokes often occur after an asymptomatic interval, with a median procedure-to-stroke interval of 2 days. The study emphasized that major comorbidities are more critical risk factors than intraoperative events, underscoring the importance of preoperative assessment and management.

Acute Surgical Interventions in Stroke

Surgical interventions in acute stroke cases are becoming more aggressive, with current standards focusing on decompressive surgery for large ischemic strokes and surgical removal of intracranial hematomas. Decompressive surgery has been shown to significantly reduce mortality and improve outcomes in patients with large ischemic strokes. However, the benefits of surgical removal of intracranial hematomas remain debated, and new approaches for treating intraventricular hemorrhage are being explored .

Perioperative Stroke in Noncardiac, Nonneurosurgical Surgery

Perioperative stroke in noncardiac, nonneurosurgical procedures is more common than previously acknowledged, with an incidence of 0.05-7%. These strokes are predominantly thrombotic and often occur after discharge from the post-anesthetic care unit. Key predisposing factors include age, previous stroke, atrial fibrillation, and vascular and metabolic diseases. The mortality rate for perioperative strokes is significantly higher than for strokes occurring outside the hospital, highlighting the need for increased awareness and management of risk factors.

Covert Stroke in Surgical Patients

Covert strokes, which are not clinically apparent, are a significant concern in the perioperative setting. A study involving 1,114 patients undergoing non-cardiac surgery found a high incidence (7%) of covert strokes, which were associated with cognitive decline one year post-surgery. This finding suggests that covert strokes may contribute to postoperative cognitive decline, emphasizing the need for improved detection and preventive strategies.

Surgical Correction of Gait Abnormalities Post-Stroke

Surgical interventions can effectively address lower extremity abnormalities in stroke patients, such as equinovarus, toe curling, excessive hip and knee flexion, and limb scissoring. These procedures are typically recommended 6 to 9 months post-stroke, provided the patient's disability is not so severe that they cannot walk.

Conclusion

Stroke surgery encompasses a range of interventions from neurotransplantation to acute surgical treatments and perioperative management. While some treatments show promise, such as decompressive surgery for large ischemic strokes, others require further research to establish their efficacy. Identifying and managing risk factors remain crucial in reducing the incidence and improving the outcomes of stroke-related surgical complications.