Central Nervous System Risk Assessment: Preventing Postoperative Brain Injury

Perioperative complications involving the central nervous system (brain and spinal cord) are common, particularly postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). Attention to these syndromes is increasingly important as the population of elderly patients undergoing both elective and urgent surgery grows and as more studies shed light on the morbidity associated with POD and POCD. Perioperative action plans for prevention and management are receiving increasing attention. Focus on identification and optimization of modifiable factors is the cornerstone of current approaches, as effective pharmacologic prevention or cure remains elusive. Patients with prior stroke are at surprisingly high risk for perioperative stroke. New data suggest that elective surgery should be delayed 9 months after an ischemic stroke. Patients with seizure disorders are prone to injury in the perioperative period from recurrent seizures caused by factors such as missed medications and epileptogenic drugs. In patients with recent concussion, as for those with prior stroke, timing of elective surgery should be considered carefully by a multidisciplinary team. Patients with implanted neurostimulator devices are increasingly common and may need special arrangements for perioperative device management. Centers performing procedures with high risk for cardiac arrest (such as cardiac surgery, aortic surgery, and interventional electrophysiologic procedures) should have specific plans for the care of the patient with a periprocedural anoxic brain insult, specifically critical care with targeted temperature management. Similarly, these procedures carry a risk for ischemic stroke; acute stroke care, including thrombolysis and endovascular thrombectomy, should be immediately available.