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Current Geriatrics Reports
Published in: Current Geriatrics Reports 2/2024

23-02-2024 | Stroke | REVIEW

Postoperative Neurologic Complications in the Older Adult

Surgical Care for Current Geriatric Reports (https://www.springer.com/journal/13670)

Authors: Sriharsha Gummadi, Jose L. Pascual L.

Published in: Current Geriatrics Reports | Issue 2/2024

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Abstract

Purpose of Review

The older patient population is at increased risk of postoperative neurologic complications. With an ever-increasing proportion of older adults requiring advanced surgical interventions, surgeons should be knowledgeable in contemporary diagnostic and management paradigms. In this review, we detail neurologic complications common encountered in elderly populations, reviewing relevant literature and practices.

Recent Findings

Common postoperative neurologic complications in the elderly include delirium, cerebrovascular accidents, and seizures. The mainstay of treatment of postoperative delirium is non-pharmacologic management. Postoperative cerebrovascular disorders require prompt diagnosis and evaluation for revascularization (if ischemic) or decompressive (if hemorrhagic) therapies, recognizing certain recent updates have changed guidelines. Preoperative anti-epileptic drug optimization is the most important approach to preventing postoperative seizures in epileptic patients.

Summary

A standardized and systematic approach in managing postoperative neurologic complications is paramount, particularly in the older adult. This includes a comprehensive history (including review of preexisting medications and drug use), physical exam, chemical analysis (glucose, electrolytes, infectious evaluation, blood gas), and axial neurologic imaging, lumbar puncture, or electroencephalogram when indicated. Early expert consultation with a neurologist or neurosurgeon is often warranted.
Literature
1.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. The lancet. 2014;383(9920):911–22.CrossRef
2.
Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, Van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304(4):443–51.PubMedCrossRef
3.
Chang CW, Provencio JJ, Pascual J, Heavner MS, Olson D, Livesay SL, Kaplan LJ. State-of-the-art evaluation of acute adult disorders of consciousness for the general intensivist. Crit Care Med. 2023;51(7):948–63.PubMedCrossRef
4.
5.
Austin CA, O’Gorman T, Stern E, Emmett D, Stürmer T, Carson S, Busby-Whitehead J. Association between postoperative delirium and long-term cognitive function after major nonemergent surgery. JAMA Surg. 2019;154(4):328–34.PubMedPubMedCentralCrossRef
6.
•• Sadeghirad B, Dodsworth BT, Gelsomino NS, Goettel N, Spence J, Buchan TA, et al. Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery: An Individual Patient Data Meta-Analysis. JAMA Network Open. 2023;6(10):e2337239-e. This large scale meta-analysis of 21 studies identifies risk factors for postoperative delirium in surgical patients, providing insight into preventative and interventional measures.
7.
• Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AM, et al. Delirium. Nat Rev Dis Prim. 2020;6(1):90. This excellent review artice on the modern understanding of delirium provides a literature review to date, illustrates potential pathophysiologic mechanisms, and identifies areas of evolving research.PubMedCrossRef
8.
Li T, Li J, Yuan L, Wu J, Jiang C, Daniels J, et al. Effect of regional vs general anesthesia on incidence of postoperative delirium in older patients undergoing hip fracture surgery: the RAGA randomized trial. JAMA. 2022;327(1):50–8.PubMedCrossRef
9.
Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA. Association of duration of surgery with postoperative delirium among patients receiving hip fracture repair. JAMA Netw Open. 2019;2(2):e190111-e.CrossRef
10.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Ann Intern Med. 1990;113(12):941–8.PubMedCrossRef
11.
Wongviriyawong T, Sura-arunsumrit P, Chaiwat O, To-Adithep P, Ramlee R, Srinonprasert V. Diagnosis of postoperative delirium in older adults using the Confusion Assessment Method for the intensive care unit in non-intensive care unit settings: a test modification might improve its diagnostic performance. Geriatr Gerontol Int. 2019;19(8):762–7.PubMedCrossRef
12.
Hufschmidt A, Shabarin V. Diagnostic yield of cerebral imaging in patients with acute confusion. Acta Neurol Scand. 2008;118(4):245–50.PubMedCrossRef
13.
• Acharya R, Kafle S, Shrestha DB, Sedhai YR, Ghimire M, Khanal K, et al. Use of computed tomography of the head in patients with acute atraumatic altered mental status: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(11):e2242805-e. In this meta-analysis of 25 studies, the authors demonstrate limited value of obtaining a CT head indiscriminately for altered mental status.
14.
15.
Rengel KF, Pandharipande PP, Hughes CG. Postoperative delirium. La Presse Médicale. 2018;47(4):e53–64.PubMedCrossRef
16.
Lewis K, Alshamsi F, Carayannopoulos KL, Granholm A, Piticaru J, Al Duhailib Z, et al. Dexmedetomidine vs other sedatives in critically ill mechanically ventilated adults: a systematic review and meta-analysis of randomized trials. Intensive Care Med. 2022;48(7):811–40.PubMedCrossRef
17.
Spence J, LeManach Y, Chan MT, Wang C, Sigamani A, Xavier D, et al. Association between complications and death within 30 days after noncardiac surgery. CMAJ. 2019;191(30):E830–7.PubMedCrossRef
18.
Gaudino M, Angiolillo DJ, Di Franco A, Capodanno D, Bakaeen F, Farkouh ME, et al. Stroke after coronary artery bypass grafting and percutaneous coronary intervention: incidence, pathogenesis, and outcomes. J Am Heart Assoc. 2019;8(13): e013032.PubMedPubMedCentralCrossRef
19.
Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. J Am Soc Anesthesiol. 2011;114(6):1289–96.CrossRef
20.
Group PS. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–47.CrossRef
21.
Wang H, Li S-L, Bai J, Wang D-X. Perioperative acute ischemic stroke increases mortality after noncardiac, nonvascular, and non-neurologic surgery: a retrospective case series. J Cardiothorac Vasc Anesth. 2019;33(8):2231–6.PubMedCrossRef
22.
Tarakji KG, Sabik JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305(4):381–90.PubMedCrossRef
23.
Ng JL, Chan MT, Gelb AW, Warner DS. Perioperative stroke in noncardiac, nonneurosurgical surgery. J Am Soc Anesthesiol. 2011;115(4):879–90.CrossRef
24.
Caplan LR. Clinical diagnosis of stroke subtypes. EE UU: UpToDate. 2014.
25.
Mrkobrada M, Chan MT, Cowan D, Campbell D, Wang CY, Torres D, et al. Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study. Lancet. 2019;394(10203):1022–9.CrossRef
26.
•• Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, et al. Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association. Circulation. 2021;143(19):e923–46. This consensus article provides a comphrensive review of the AHA and ASA’s updated recommendations regarding the initial evaluation, risk mitigation, and further management of perioperative stroke.PubMedCrossRef
27.
Investigators VPS. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study. Open Med. 2011;5(4): e193.
28.
Kikura M, Oikawa F, Yamamoto K, Iwamoto T, Tanaka K, Sato S, Landesberg G. Myocardial infarction and cerebrovascular accident following non-cardiac surgery: differences in postoperative temporal distribution and risk factors. J Thromb Haemost. 2008;6(5):742–8.PubMedCrossRef
29.
Platzbecker K, Grabitz SD, Raub D, Rudolph MI, Friedrich S, Vinzant N, et al. Development and external validation of a prognostic model for ischaemic stroke after surgery. Br J Anaesth. 2021;127(5):713–21.PubMedCrossRef
30.
Wardlaw JM, Mielke O. Early signs of brain infarction at CT: observer reliability and outcome after thrombolytic treatment—systematic review. Radiology. 2005;235(2):444–53.PubMedCrossRef
31.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418.PubMedCrossRef
32.
Cronin CA, Shah N, Morovati T, Hermann LD, Sheth KN. No increased risk of symptomatic intracerebral hemorrhage after thrombolysis in patients with European Cooperative Acute Stroke Study (ECASS) exclusion criteria. Stroke. 2012;43(6):1684–6.PubMedCrossRef
33.
Menon BK, Buck BH, Singh N, Deschaintre Y, Almekhlafi MA, Coutts SB, et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. Lancet. 2022;400(10347):161–9.PubMedCrossRef
34.
Fayad P. Improved prospects for thrombectomy in large ischemic stroke. N Engl J Med. 2023;388:1326–8.PubMedCrossRef
35.
Sabben C, Charbonneau F, Delvoye F, Strambo D, Heldner MR, Ong E, et al. Endovascular therapy or medical management alone for isolated posterior cerebral artery occlusion: a multicenter study. Stroke. 2023;54(4):928–37.PubMedCrossRef
36.
• Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282–361. This consensus article by the AHA and ASA provides updtated management guidelines for spontaneous (non-traumatic) intracerebral hemorrhage.PubMedCrossRef
37.
Sander J, Hart Y, Shorvon S, Johnson A. Medical science: National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. The Lancet. 1990;336(8726):1267–71.CrossRef
38.
Ramsay RE, Rowan AJ, Pryor FM. Special considerations in treating the elderly patient with epilepsy. Neurology. 2004;62(5 suppl 2):S24–9.PubMed
39.
Faught E, Richman J, Martin R, Funkhouser E, Foushee R, Kratt P, et al. Incidence and prevalence of epilepsy among older US Medicare beneficiaries. Neurology. 2012;78(7):448–53.PubMedPubMedCentralCrossRef
40.
Choi H, Pack A, Elkind MS, Longstreth W, Ton TG, Onchiri F. Predictors of incident epilepsy in older adults: the Cardiovascular Health Study. Neurology. 2017;88(9):870–7.PubMedPubMedCentralCrossRef
41.
Thurman DJ, Logroscino G, Beghi E, Hauser WA, Hesdorffer DC, Newton CR, et al. The burden of premature mortality of epilepsy in high-income countries: a systematic review from the Mortality Task Force of the International League Against Epilepsy. Epilepsia. 2017;58(1):17–26.PubMedCrossRef
42.
Lekoubou A, Bishu KG, Ovbiagele B. Health care expenditures among elderly patients with epilepsy in the United States. Epilepsia. 2018;59(7):1433–43.PubMedCrossRef
43.
Shih T, Schmader KE. Seizures and epilepsy in older adults: Etiology, clinical presentation, and diagnosis. Waltham, MA: UpToDate. 2022.
44.
Sung CY, Chu NS. Status epilepticus in the elderly: etiology, seizure type and outcome. Acta Neurol Scand. 1989;80(1):51–6.PubMedCrossRef
45.
Loiseau J, Loiseau P, Duché B, Guyot M, Dartigues JF, Aublet B. A survey of epileptic disorders in southwest France: seizures in elderly patients. Ann Neurol. 1990;27(3):232–7.PubMedCrossRef
46.
Bladin CF, Alexandrov AV, Bellavance A, Bornstein N, Chambers B, Coté R, et al. Seizures after stroke: a prospective multicenter study. Arch Neurol. 2000;57(11):1617–22.PubMedCrossRef
47.
Niesen AD, Jacob AK, Aho LE, Botten EJ, Nase KE, Nelson JM, Kopp SL. Perioperative seizures in patients with a history of a seizure disorder. Anesth Analg. 2010;111(3):729–35.PubMedCrossRef
48.
Merkler AE, Gialdini G, Lerario MP, Parikh NS, Morris NA, Kummer B, et al. Population-based assessment of the long-term risk of seizures in survivors of stroke. Stroke. 2018;49(6):1319–24.PubMedPubMedCentralCrossRef
49.
Zehtabchi S, Silbergleit R, Chamberlain JM, Shinnar S, Elm JJ, Underwood E, et al. Electroencephalographic seizures in emergency department patients after treatment for convulsive status epilepticus. J Clin Neurophysiol. 2022;39(6):441–5.PubMedCrossRef
50.
Cock H, Schapira A. A comparison of lorazepam and diazepam as initial therapy in convulsive status epilepticus. QJM. 2002;95(4):225–31.PubMedCrossRef
51.
Silbergleit R, Lowenstein D, Durkalski V, Conwit R, Investigators NETT. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. 2011;52:45–7.PubMedPubMedCentralCrossRef
52.
Hoffman RS, Weinhouse GL, Traub SJ, Grayzel J. Management of moderate and severe alcohol withdrawal syndromes. UpToDate Waltham (MA): UpToDate. 2011.
53.
Schuckit MA. Management of withdrawal delirium (delirium tremens). N Engl J Med. 2015;372(6):580–1.PubMed
54.
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–7.PubMedCrossRef
55.
DeCarolis DD, Rice KL, Ho L, Willenbring ML, Cassaro S. Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit. Pharmacotherapy: J Hum Pharmacol Drug Ther. 2007;27(4):510–8.CrossRef
56.
McClelland S III, Hall WA. Postoperative central nervous system infection: incidence and associated factors in 2111 neurosurgical procedures. Clin Infect Dis. 2007;45(1):55–9.PubMedCrossRef
57.
Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, et al. 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017;64(6):e34–65.PubMedPubMedCentralCrossRef
58.
Lozier AP, Sciacca RR, Romagnoli MF, Connolly Jr ES. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2008;62:SHC-688-SHC-700.
59.
Reynolds F. Neurological infections after neuraxial anesthesia. Anesthesiol Clin. 2008;26(1):23–52.PubMedCrossRef
60.
Fritz BA, King CR, Mehta D, Somerville E, Kronzer A, Abdallah AB, et al. Association of a perioperative multicomponent fall prevention intervention with falls and quality of life after elective inpatient surgical procedures. JAMA Netw Open. 2022;5(3):e221938-e.CrossRef
61.
Church S, Robinson TN, Angles EM, Tran ZV, Wallace JI. Postoperative falls in the acute hospital setting: characteristics, risk factors, and outcomes in males. Am J Surg. 2011;201(2):197–202.PubMedCrossRef
62.
Gardner RC, Dams-O’Connor K, Morrissey MR, Manley GT. Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions. J Neurotrauma. 2018;35(7):889–906.PubMedPubMedCentralCrossRef
63.
Kehoe A, Rennie S, Smith J. Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients. Emerg Med J. 2015;32(8):613–5.PubMedCrossRef
64.
Goode T, Young A, Wilson SP, Katzen J, Wolfe LG, Duane TM. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? Am Surg. 2014;80(2):182–4.PubMedCrossRef
65.
Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510–8.PubMedCrossRef
66.
Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery. 2017;80(1):6–15.PubMedCrossRef
67.
TQIP A. Best practices in the management of traumatic brain injury. ACS Committee on Trauma. 2015:3–23.
68.
Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, et al. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965–9.PubMedCrossRef
69.
Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, et al. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2023;54(7):e314-e70.
70.
Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28(1):14–20.PubMedCrossRef
Metadata
Title
Postoperative Neurologic Complications in the Older Adult
Surgical Care for Current Geriatric Reports (https://www.springer.com/journal/13670)
Authors
Sriharsha Gummadi
Jose L. Pascual L.
Publication date
23-02-2024
Publisher
Springer US
Published in
Current Geriatrics Reports / Issue 2/2024
Electronic ISSN: 2196-7865
DOI
https://doi.org/10.1007/s13670-024-00409-8

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